|Year : 2021 | Volume
| Issue : 1 | Page : 27-32
Thyroid cancer awareness among women in the asir region of Saudi Arabia
Majed Saad Al Fayi
Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, King Khalid University; Central Research Laboratory, College of Applied Medical Sciences, King Khalid University, Abha, Saudi Arabia
|Date of Submission||23-Feb-2021|
|Date of Acceptance||24-May-2021|
|Date of Web Publication||31-Jul-2021|
Majed Saad Al Fayi
Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, King Khalid University, Abha
Source of Support: None, Conflict of Interest: None
Background: Thyroid cancer (TC) is one of the most common malignancies among females in Saudi Arabia, accounting for approximately 11% of newly diagnosed cancers in the kingdom. Over the past few decades, an increasing prevalence of TC has been documented in the kingdom. In Saudi Arabia, and especially in the Asir region, no studies have been conducted to address TC awareness among females. Objectives: This study aims to assess the level of TC awareness among women in the Asir region of Saudi Arabia. This study focuses on knowledge of the risk factors, signs, prevalence, treatment, and diagnosis of TC. Materials and Methods: This study uses a cross-sectional survey design. An online survey was conducted among 310 females in the Asir region of Saudi Arabia over 3 months. The questionnaire was divided into four subsections, namely, a demographic section, a knowledge score section, an awareness section, and practices to detect TC section. Results: A total of 75 (24.8%) participants had a low level of knowledge about TC, while only five (1.7%) participants had a high level of knowledge about TC, with the remainder having a moderate level of knowledge. The knowledge scores of participants were found to be significantly correlated with their education levels (0.048), while knowledge of TC did not significantly correlate with their age group (0.790), marital status (0.471), or number of visits to a health center per year (0.211). The majority of the respondents claimed that TC is uncommon in Saudi Arabia (54.6%), more common in males/females (75.2%), and more common in those aged over 40 years. Conclusion: The study depicted the suboptimal awareness levels of women regarding TC in the Asir region and its association with education levels. Women's awareness of TC in routine practice is urgently required.
Keywords: Awareness, female, knowledge, Saudi Arabia, thyroid cancer
|How to cite this article:|
Al Fayi MS. Thyroid cancer awareness among women in the asir region of Saudi Arabia. King Khalid Univ J Health Sci 2021;6:27-32
|How to cite this URL:|
Al Fayi MS. Thyroid cancer awareness among women in the asir region of Saudi Arabia. King Khalid Univ J Health Sci [serial online] 2021 [cited 2021 Nov 28];6:27-32. Available from: https://www.kkujhs.org/text.asp?2021/6/1/27/322885
| Introduction|| |
One of the most common endocrine malignancies in the world is thyroid cancer (TC), and its incidence has been continuously increasing over the past 40 years.,,,, No justifiable explanation has been provided regarding the reason for this escalation, but newer and improved detection technologies are thought to be the cause.,,, Recent retrospective epidemiological studies utilizing the United States Surveillance, Epidemiology, and End Results-9 Program have shown a steep increase of 3%/year in the incidence of TC.
According to the Saudi Cancer Registry, the most common cancer types found among Saudi females are breast, thyroid, and colorectal cancer outnumbering, respectively. In Saudi Arabia, the ASR for male was 2.5/100,000 whereas for female was 7.8/100,000. The Asir region of Saudi Arabia was the third highest ASR among all regions after Riyadh and Eastern region. TC comprises 8.8% of all cancer types and 12% of malignant cancers in females. It is less common among males than females, with the female-to-male ratio being 1:0.3., Saudi literature has reported a 26-fold increase in the incidence of TC when comparing its incidence from 1990 to 2016. The reason for this elevated incidence in females is not well understood, but one of the main causes is thought to be the exposure of thyroid cells to the endogenous estrogen hormone. The most common histological subtype of TC is papillary cancer, followed by the follicular subtype. TC transpires from two main cells – the follicular cell, which is endodermally derived and causes papillary and follicular carcinomas, and the calcitonin-producing C-cell type, which causes medullary thyroid carcinomas., In Weir et al.'s research conducted from the US Center for Disease Control and Prevention, it was anticipated that, by the year 2020, the immense escalations in registered cancer cases in females annually would be due to malignancies of the breast, thyroid, lung, and uterus. In another study by Davies and Welch, the absolute increase in the incidence of TC in women was determined as being four times higher than for men. The incidence of TC peaks in the third and fourth decades of life.
Many previous researchers have depicted early detection with advanced techniques as the reason behind the escalating cases of TC in recent years.,, Although its incidence has increased, its mortality has decreased., However, many researchers have questioned whether the overdiagnosis of TC could be the main cause of its increased incidence in recent years; they argued that improved detection techniques could not be the only explanation for it.,, Many other factors, such as increased knowledge regarding the causes of TC, age, marital status, gender, lifestyle factors, the levels of the thyroid hormone in the blood, genetics, thyroid swelling, and so on, might have played a role in the increased incidence.
We tried to determine the epidemiological and other causes of TC to discover their relationship to the actual factors that have led to this increased incidence. Therefore, we conducted a survey among women in the Asir region of Saudi Arabia aiming to discover the causes of this increased incidence.
| Materials and Methods|| |
This study used a cross-sectional design. To collect the responses from the participants about their knowledge, awareness, and practices regarding TC, a close-ended, structured questionnaire was designed based on previous studies conducted in various countries. The validity and reliability of the questionnaire and its instruments were pretested. The questionnaire was translated into Arabic (local) to get accurate responses from the participants. The accuracy of the Arabic translation was checked by retranslating the Arabic version of the questionnaire into English.
Instruments and assessment of the outcome
The questionnaire was divided into four subsections, namely, a demographic section, a knowledge score section, an awareness section, and a practices to detect TC section. The demographic section included questions regarding the participant's age, marital status, and education level, as well as how often they visited a health center per year. The knowledge scores for TC were calculated based on the correct answers of the participants. The proportion of correct answers ranged from 0% to 50%, which was characterized as a low level of knowledge, whereas 51% to 75% was characterized as a moderate level of knowledge and more than 75% was characterized as a high level of knowledge, as demonstrated in [Table 1]. The awareness level was determined by a further division of its items into three subcategories, namely, general perception and awareness of TC, awareness of the risk factors of TC, and awareness of the diagnosis and treatment of TC. The last section included a question about practices to detect TC, as depicted in [Table 2].
|Table 1: The categorization of knowledge based on the thyroid cancer scores of the participants|
Click here to view
|Table 2: Practices for detecting thyroid cancer according to the participants|
Click here to view
Sampling techniques and sample size
Residents from across the region of Saudi Arabia were considered as the target population for this study. Nonprobability convenience sampling techniques were used to screen participants. To determine the minimum number of samples required to meet the desired statistical constraints, online software (www.calculator.net) was used. The minimum required sample size of 267 participants was calculated with a 95% confidence interval (CI), a 6% margin of error, and a 50% population proportion when the population was considered infinite.
The method of data collection
The primary method of data collection was online surveys through Google Forms. Written consent was obtained from the participants before the final survey. The link to the online survey was distributed among the normal population across the region of Saudi Arabia. Data were collected over 3 months from the beginning of October 2020 to the end of December 2020. Participants were strictly monitored and followed up on, and they were provided with multiple reminders during the period of the survey. A total of 310 responses were received during the 3-month period. A total of 302 responses were included due to their completeness, while eight incomplete responses were excluded from the study.
Statistical tools for data analysis
Data were converted into an Excel Spreadsheet from the Google survey after getting the minimum required number of responses. The responses were coded numerically. With respect to the questions related to TC perception, accurate responses were allocated a score of 1 (denoting “aware”), whereas an inaccurate response was allocated a score of 0 (denoting “not aware”). An overall score for every participant was calculated by aggregating the number of accurate responses. After cleaning and scrutinizing the data for uniformity, the data were exported into analytical software utilizing IBM Statistical Product and Service Solutions Version 20 (Armonk, NY, USA) for analytical purposes. To check for and appraise the correlations between the sociodemographic variables and TC perception scores, Pearson Chi-square tests were utilized. Statistical significance was estimated at P < 0.05. Bivariate analysis and multivariate logistic regression were utilized to discover the correlations between the TC awareness scores and different factors, which provided odds ratios and 95% CIs.
| Results|| |
A total of 302 participants participated in the study and provided information to assess their knowledge, awareness, and practices regarding TC. The majority of the participants (93%) belonged to the age group of 21–50 years, while only a few (4%) were under the age of 20 years and (3%) above the age of 50 years. Most of the participants (72.5%) were married. In the education category, there were more university graduates (37.1%) than university and high-school graduates (27.8%), whereas high-school graduates were the least (7.3%). The majority of the participants (47%) visited a health-care center once a year, followed by 32% who visited more than twice a year and 21% who visited twice a year [Table 3].
|Table 3: Distribution of sociodemographic factors and their association with awareness scores among the 302 participants in the Asir region|
Click here to view
Knowledge of TC was determined by the knowledge score, which was calculated based on the correct answers of the participants. The proportion of correct answers ranged from 0% to 50%, which was characterized as a low level of knowledge, whereas 51% to 75% was characterized as a moderate level of knowledge and more than 75% was characterized as a high level of knowledge [Table 1].
Associations between thyroid cancer knowledge and sociodemographic factors
The relationship between the knowledge scores and the various sociodemographic factors was calculated, and the results are presented in [Table 3]. Participants were categorized as having low, moderate, or high levels of TC knowledge based on their sociodemographic factors. A total of 75 (24.8%) participants had a low level of knowledge about TC, whereas only five (1.7%) participants had a high level of knowledge about TC. The remaining participants had a below-moderate level of knowledge. The knowledge scores of the participants were found to be significantly correlated with their education levels (0.048), while knowledge of TC was not significantly correlated with their age group (0.790), marital status (0.471), or number of visits to a health center per year (0.211) [Table 3].
The prevalence of awareness regarding the various aspects of thyroid cancer
The prevalence of awareness of TC was separated into three categories, namely, (1) general perception and awareness of TC, (2) awareness of the risk factors of TC, and (3) awareness of the diagnosis and treatment of TC [Table 4].
|Table 4: The number and proportion of women who are aware of the various aspects of thyroid cancer among the 302 participants in the Asir region|
Click here to view
General perception and awareness of thyroid cancer
As depicted in [Table 4], 85.1% of the participants were aware that TC can be cured, and 99.7% of the participants believed that TC is not contagious. However, only a few participants (7.6%) believed that TC can be prevented. The majority of the respondents were aware that TC is uncommon in Saudi Arabia (54.6%). Moreover, 75.2% believed that TC is more common in males/females. Further, 58.6% of the participants thought that TC is more common in those aged 40 years or older. In response to the importance of early detection, 98.7% of the participants were aware that, when TC is detected early, it can be treated appropriately and adequately. Only 8.3% of the participants had ever attended or watched the effectiveness or special awareness campaign for TC [Table 4].
Awareness of the risk factors of thyroid cancer
In response to the risk factors of TC, 68.5% of the participants reported that they were aware that TC is often genetic, 49.3% of the participants were aware that physical activity reduces the risk of TC, and 51.7% of the participants believed that obesity increases the risk of TC [Table 4].
Awareness of the diagnosis and treatment of thyroid cancer
Questions related to the diagnosis and treatment of TC were asked in the survey to check the awareness level of participants. The majority of the participants (95%) were aware that TC appears in the form of a lump or knot in the neck, 96% of the participants were aware that the presence of swelling in the neck is useful for the early detection of TC, and 91.4% agreed with the statement that finding a lump or knot in the thyroid area would encourage them to visit the doctor for a consultation.
Practices for detecting thyroid cancer
The awareness of participants regarding the practice and detection procedures for TC was determined. There were 60 (19.9%) participants who had had a thyroid hormone analysis, 33 (10.9%) who had undergone an ultrasound or computed tomography scan of the thyroid gland, and only 13 (4.3%) who had attended or watched the effectiveness or special awareness campaign for TC.
| Discussion|| |
An increasing incidence of TC has been reported in Saudi Arabia over recent decades. TC affects adults at a comparatively young age, and a female predominance has been seen. Papillary carcinomas are the most frequently seen TC variety and affect male patients at an older age than female participants, while no age variance relating to gender can be seen in the other types. Further, nearly all patients present during preliminary TC stages. No trend toward smaller-sized tumors has been seen in the last few years compared to the past years.
In this study, the majority of the participants were 21–50 years old. Of the participants, 24.8% had a low level of knowledge about TC, while 1.7% had a high level of knowledge about TC. The remaining participants had a below-moderate level of knowledge about TC. Precise comparable median ranges have been proclaimed in a study from the same institution, with the median age being 35 years for women and 48 years for men. More recently, a study that examined all patients attended to between 2000 and 2010 proclaimed a median age of 38 years and the maximum incidence being in the age range of 30–39 years.
Two-and-a-half percent of cases were confirmed to have ATC. Despite this rate showing a low incidence, it is higher than the universal international rate, which is approximately 1%–2%., Only 4.5% of the reported cases were FTC in this cohort, which is <10% universal international incidence, but some similar rates were proclaimed in earlier studies from the same institution. Equal incidences of TC occurrence were reported in the course of the third, fourth, and fifth decades of life. However, differences arose when gender was taken into consideration, with major cases of TC in females taking place in the third decade of life (20–30 years) and the majority of TC cases in males taking place in the fifth decade of life (40–50 years). This dissimilitude with the current research, in which 35 years is the median age of diagnosis and the interquartile range is 21–50 years, indicates an earlier detection of cases, a better awareness of health, or the existence of a true deviation in the pattern of the disease with a younger age of commencement, which is juxtaposed to what has been found in the past.
Our research has several strengths and limitations. A large sample from the Asir region of Saudi Arabia was used, where the standardization of the detection and management of TC according to the international standards has been ongoing for some time. Without prejudice, it has long-term outcome data that have not been reported previously for the Asir region. In addition, all of the data collected were retrospective, and all patients did not have each data. However, since any retrospective data provide this particular problem, we were fortunate that there were minimal deficient data in any of the parameters.
In this study, we found that 85.1% of the participants were aware that TC can be cured, and 99.7% of the participants believed that TC is not contagious. However, only a few participants (7.6%) believed that TC could be prevented. The majority of the respondents were aware that TC is uncommon in Saudi Arabia (54.6%). Moreover, 75.2% believed that TC is more common in males/females. Further, 58.6% of the participants thought that TC is more common in those who are older than 40 years. In response to the importance of early detection, 98.7% were aware that, when TC is detected early, it can be treated appropriately and adequately. Previous differentiated research concerning TC has depicted that females are affected more often than males, which is compatible with our results., In addition, this study showed that only 8.3% of the participants had ever attended or watched the effectiveness or special awareness campaign for TC. Therefore, further efforts to improve the special awareness campaign for TC are essential to encourage health-related behavioral changes.
The cause of the higher TC incidence in females is still not well understood, but a conceivable theory is the subjection of the thyroid tumor cells to the endogenous estrogen hormone. As various experimental studies have perceived, the mediation of estrogen's action on thyroid cells is through estrogen's alpha and beta receptors. The upregulation of alpha regulators is demonstrated by TC cells, which triggers the process of tumorigenesis, and similarly, the downregulation of beta receptors, which possibly act as tumor suppressors, leads to tumorigenesis.
In the present study, it was observed that 68.5% of the participants reported that they were aware that TC is often genetic, 49.3% of the participants were aware that physical activity reduces the risk of TC, and 51.7% of the participants believed that obesity increases the risk of TC. One of the limitations of our study is its retrospective nature over a long period; the other limitation is the small sample size since all cases were from one region and focused on one gender. Thus, it may be said that our findings might not apply to the general population. It is only possible to conjecture about the probable explications for the noticeable TC trends, particularly due to the descriptive nature of this study. Registries were unable to capture individual-level environmental exposure and lifestyle-related factors. In addition, the current study did not evaluate the influences of treatment on these trends.
| Conclusion|| |
The present study covered a diverse sample of women, particularly from the community level, from the Asir region of Saudi Arabia. The study depicted the suboptimal awareness level of these women regarding TC and its association with age groups and education levels. Less than half of the women were aware of TC detection methods, but the prevalence of practice was much lower, especially for clinical breast examination or mammography. There is an urgent need to increase the awareness of women regarding TC in routine practice.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Siegel RL, Miller KD, Jemal A. Cancer statistics, 2016. CA Cancer J Clin 2016;66:7-30.
”Cancer Basic Facts.” American Cancer Society, 2018.
Mao Y, Xing M. Recent incidences and differential trends of thyroid cancer in the USA. Endocr Relat Cancer 2016;23:313-22.
Simard EP, Ward EM, Siegel R, Jemal A. Cancers with increasing incidence trends in the United States: 1999 through 2008. CA Cancer J Clin 2012;62:118-28.
Alzahrani AS, Alomar H, Alzahrani N. Thyroid cancer in Saudi Arabia: A histopathological and outcome study. Int J Endocrinol 2017;8423147.
Pellegriti G, Frasca F, Regalbuto C, Squatrito S, Vigneri R. Worldwide increasing incidence of thyroid cancer: Update on epidemiology and risk factors. J Cancer Epidemiol 2013;965212.
Grodski S, Brown T, Sidhu S, Gill A, Robinson B, Learoyd D, et al.
Increasing incidence of thyroid cancer is due to increased pathologic detection. Surgery 2008;144:1038-43.
Brito JP, Kim HJ, Han SJ, Lee YS, Ahn HS. Geographic distribution and evolution of thyroid cancer epidemic in South Korea. Thyroid 2016;26:864-5.
Lee WJ. Can screening effects explain increased risk of thyroid cancer among population living near nuclear power plants in Korea? Environ Health Toxicol 2015;30:e2015013.
Lim H, Devesa SS, Sosa JA, Check D, Kitahara CM. Trends in thyroid cancer incidence and mortality in the United States, 1974-2013. JAMA 2017;317:1338-48.
King Faisal Specialist Hospital Tumor Registry Annual Report. Riyadh, Saudi Arabia, 2018.
Hussain F, Iqbal S, Mehmood A, Bazarbashi S, ElHassan T, Chaudhri N. Incidence of thyroid cancer in the Kingdom of Saudi Arabia, 2000-2010. Hematol Oncol Stem Cell Ther 2013;6:58-64.
Althubiti MA, Nour Eldein MM. Trends in the incidence and mortality of cancer in Saudi Arabia. Saudi Med J 2018;39:1259-62.
Pambinezhuth F, Al Busaidi N, Al Musalhi H. Epidemiology of thyroid cancer in Oman. Ann Endocrinol Metab 2017;1:11-7.
Kilfoy BA, Devesa SS, Ward MH, Zhang Y, Rosenberg PS, Holford TR, et al.
Gender is an age-specific effect modifier for papillary cancers of the thyroid gland. Cancer Epidemiol Biomarkers Prev 2009;18:1092-100.
Weir HK, Thompson TD, Soman A, Møller B, Leadbetter S. The past, present, and future of cancer incidence in the United States: 1975 through 2020. Cancer 2015;121:1827-37.
Davies L, Welch HG. Current thyroid cancer trends in the United States. JAMA Otolaryngol Head Neck Surg 2014;140:317-22.
Oh CM, Kong HJ, Kim E, Kim H, Jung KW, Park S, et al.
National Epidemiologic Survey of Thyroid cancer (NEST) in Korea. Epidemiol Health 2018;40:e2018052.
Davies L, Welch HG. Increasing incidence of thyroid cancer in the United States, 1973-2002. JAMA 2006;295:2164-7.
Cho BY, Choi HS, Park YJ, Lim JA, Ahn HY, Lee EK, et al.
Changes in the clinicopathological characteristics and outcomes of thyroid cancer in Korea over the past four decades. Thyroid 2013;23:797-804.
Park S, Oh CM, Cho H, Lee JY, Jung KW, Jun JK, et al.
Association between screening and the thyroid cancer “epidemic” in South Korea: Evidence from a nationwide study. BMJ 2016;355:i5745.
Morris LG, Myssiorek D. Improved detection does not fully explain the rising incidence of well-differentiated thyroid cancer: A population-based analysis. Am J Surg 2010;200:454-61.
Pandeya N, McLeod DS, Balasubramaniam K, Baade PD, Youl PH, Bain CJ, et al.
Increasing thyroid cancer incidence in Queensland, Australia 1982-2008 – True increase or overdiagnosis? Clin Endocrinol (Oxf) 2016;84:257-64.
Yoo F, Chaikhoutdinov I, Mitzner R, Liao J, Goldenberg D. Characteristics of incidentally discovered thyroid cancer. JAMA Otolaryngol Head Neck Surg 2013;139:1181-6.
Al-Nuaim AR, Ahmed M, Bakheet S, Abdul Kareem AM, Ingmenson S, al-Ahmari S, et al.
Papillary thyroid cancer in Saudi Arabia. Clinical, pathologic, and management characteristics. Clin Nucl Med 1996;21:307-11.
Hundahl SA, Fleming ID, Fremgen AM, Menck HR. A National Cancer Data Base report on 53,856 cases of thyroid carcinoma treated in the US, 1985-1995. Cancer 1998;83:2638-48.
Hundahl SA, Cady B, Cunningham MP, Mazzaferri E, McKee RF, Rosai J, et al.
Initial results from a prospective cohort study of 5583 cases of thyroid carcinoma treated in the United States during 1996. U.S. and German Thyroid Cancer Study Group. An American College of Surgeons Commission on Cancer Patient Care Evaluation study. Cancer 2000;89:202-17.
Aschebrook-Kilfoy B, Grogan RH, Ward MH, Kaplan E, Devesa SS. Follicular thyroid cancer incidence patterns in the United States, 1980-2009. Thyroid 2013;23:1015-21.
Ahmed M, Al-Saihati B, Greer W, Al-Nuaim A, Bakheet S, Abdulkareem AM, et al
. A study of 875 cases of thyroid cancer observed over a fifteen-year period (1975-1989) at the King Faisal Specialist Hospital and Research Centre. Ann Saudi Med 1995;15:579-84.
[Table 1], [Table 2], [Table 3], [Table 4]