Colorectal cancer (CRC) continues to be one of the principal global health care issues where recent studies have shown that it ranks second to breast cancer among females and third after lung and prostate cancers among males [1] [2]. In 2018 CRC was responsible for about 9.2% of all worldwide deaths caused by cancer ranking second with around 881,000 deaths worldwide [3]. As for Lebanon, in 2018, 1463 (8.5%) CRC cases out of 17,298 new cancer cases were reported for both sexes thus ranking in fifth place after breast, bladder, lung and prostate cancers [4] [5]. Specifically, CRC ranked fourth among males (8.8%) after prostate, bladder and lung cancers; and ranked second among females (8.1%) after breast cancer. In addition, CRC accounted for 7.1% of the number of cancer mortalities with 8976 deaths out of the total number of 41,843 cancer deaths in Lebanon [4].

It is noticeable that the global cancer burden has continuously been increasing whereby in 2012, there were 14.1 million new cancer cases and around 8.2 million deaths due to cancer, then the CRC cases were around 1.36 million (9.7% for both sexes) [6]. Later, the International Agency for Research on Cancer’s press release indicated that “The global cancer burden is estimated to have risen to 18.1 million new cases and 9.6 million deaths in 2018. One in 5 men and one in 6 women worldwide develop cancer during their lifetime, and one in 8 men and one in 11 women die from the disease” [7]. In fact, the global burden of the CRC trend is expected to increase by 60% to more than 2.2 million new cases and 1.1 million deaths by 2030 [8]. Likewise, in the USA, the cases of CRC continue to increase yearly by 1% to 2.4% among people in the age range 20 to 40 years, and by 0.55% to 1.3% among people aged 40 to 55 years, respectively. This trend continues to prevail since 1980 [9] [10]. Along the aforementioned facts, Lebanon is not an exception where the incidence of different types of cancer is 179 new cases per 100,000 inhabitants and digestive cancers account for 14.1% of all types of cancer, with more than 50% of them located in the rectum and colon [11]. Further projection studies have revealed that by 2020, overall cancer will reach 361 and 312 cancer cases per 100,000 persons for males and females, respectively [12]. In fact, reported information indicates that both cancer incidence and mortality are expected to increase dramatically in the near future [5] [13].

Among those rising trends, the subject of CRC awareness remains a topic of major importance among both the medical and social communities. Indeed, various studies have shown that increasing the levels of awareness leads to an increased rate in screening for CRC and thus reduction in mortality rates [14] [15]. CRC is known to be curable if detected early, when it begins as a simple benign polyp at the interior wall of the colon [16] [17]. There is also a reduction in the medical and financial burdens of treatment [18].

CRC awareness has developed over the years and different nations have adopted campaigns and procedures to encourage people especially at ages above 45 years to undergo screening. Simple screening tests like FOBT (fecal occult blood test) and FIT (fecal immunochemical test) that look for occult blood (blood that cannot be seen with the naked eye) are becoming both very popular and affordable to identify blood in the stool which is a strong predictor to the presence of polyps or cancers in the digestive tract [19]. Thus undergoing an FOBT or FIT test can lead to the early detection of CRC cases which can be prevented or at least downstaged through colonoscopy. However, it has been reported that despite the ability to prevent the development of CRC and downstage the disease, the participation in CRC screening lags behind screening for other types of cancer [20] [21]. Screening through fecal testing, mainly fecal Occult blood test (FOBT) and fecal Immunochemical test (FIT) followed by colonoscopy for positive cases has led to an approximately 16% reduction in mortality caused by CRC [9] [22].

The usefulness of CRC screening in terms of reduction of incidence and mortality rates has been shown in randomized controlled trials since the nineties of the past century where early screening procedures were associated with a substantial reduction of CRC incidence and mortality [23] - [29]. In fact, it is well agreed that medical organizations and practice clinical guidelines highly recommend screening in average-risk populations [30] [31] [32].

A recent study by Dénes et al. [9], suggested that awareness efforts should go beyond the general public and extend specifically to health professionals who should be involved in CRC screening educational programs. The aforementioned study performed in Romania on a sample of 275 CRC patients showed that 41.5% of the patients declared that they have heard about cancer screening and only 6.5% about specific CRC screening procedures. Among those who have heard about screening, 85.1% perceived the information through mass media while the rest 14.9% got it from family, friends or colleagues. Unfortunately, the outcomes of the study indicated that health professionals did not contribute at all to informing about screening.

Another study performed in South Carolina, USA by Brandt et al. [21], reported that even though the levels of CRC knowledge and awareness were high, overall participation in CRC screening was modest. Thus, an essential step is to elaborate on mechanisms to transform public awareness and knowledge into real screening participation because recommended screening and especially colonoscopy has prevented or downstaged CRC [33] [34]. Also Inadomi and Sonnenberg [35] assessed the effect of screening for colorectal cancer on life expectancy, and showed that CRC decreases the life expectancy of U.S. residents aged 50 to 54 years by 292 days and those aged 70 to 74 years by 70 days. Moreover, the study demonstrated that screening with fecal occult blood tests (FOBT) extends expected lifetime of the two age groups by 51 and 12 days, respectively, whereas screening with Sigmoidoscopy leads to increases of 86 and 21 days, and Colonoscopic screening increases expected lifetime by 170 and 41 days, respectively.

By the end of the first 20 years of the twentieth first century, the issue of CRC awareness continues to be a major topic of research among medical and social professionals. A recent study regarding knowledge, practice and attitude towards CRC and its screening procedures among people of Hong Kong showed that 60.9% of the people were unaware that CRC is a very common type of cancer and 91.5% responded that there wasn’t any case of CRC in their family [36]. Even in first world countries like England, a recent study among English population showed that only 10% of the participants were aware of the fact that CRC is ranked third among common type of cancers and merely 46% of the people knew some symptoms and risk factors of CRC [37].

Another study done in Kuwait demonstrated that among 675 respondents, 75% of the participants had heard about CRC [38]. A similar CRC study carried out among the population of Perak state of Malaysia concluded that 38% of the 2379 participants of the study had no knowledge regarding CRC [39]. Likewise a study performed in Saudi Arabia indicated that 53.5% of the 385 surveyed Makkah residents were unaware of CRC symptoms and 92.2% never had a CRC screening test [40]. Actually, it has been reported that CRC is one of the most common cancers in Saudi Arabia being the first most common cancer among Saudi males and third among females [41]. A study conducted among people of Oman suggested that 59.6% of them were unaware of basic symptoms and risk factors of CRC and others had poor understanding of screening procedures [42]. It can be easily concluded that around the globe there is a significant fact that people lack basic knowledge regarding CRC. This trend is also very common in western countries. In reality, the lack of knowledge on CRC happens to be a noticeable barrier to screening adherence [43].

Moreover, in a study conducted in Iran assessing the practice of Iranian physicians towards CRC showed that for 71 out of 123 physicians (57.7%), colonoscopy is the first-step screening test in average-risk individuals above 50 years; and only 22 physicians (17.9%) designated FOBTs as the first step for the above 50 years age group. In fact, 89.4% of the physicians recommended screening for CRC among people above the age of 50 with symptoms suggestive of CRC [44]. It is noticeable that even though Iran is experiencing a significant rise in the incidence of CRC over the recent decades [45] the aforementioned Iranian physicians study which was performed in 2018 did not include any reference to FIT CRC screening tests which are nowadays very popular in the health sectors. Despite its relatively high financial cost in comparison to other CRC pre-screening procedures, the surveyed physicians cited colonoscopy in first place followed by FOBT’s. Actually, this information is similar to the Saudi physicians’ survey where most of the physicians considered colonoscopy as the most effective screening test while only one-third of them agreed with FOBT [46]. Here, it is worth mentioning that the 5-year survival for persons with colorectal cancer is 64% in the United States. If the disease is detected at an early stage, the 5-year survival rate increases to 90%. However, because of lack of screening programs in many countries, only 39% of colorectal cancers are diagnosed at this stage [47].

Once more, in the Middle East and specifically in Oman, a study was carried out to specifically explore nurses’ and physicians’ (82 nurses and 60 physicians who are clinically experienced with mean service time 9.39 years and standard deviation 6.13 years) attitudes and knowledge regarding CRC screening. The findings showed that both nurses and physicians working in primary care settings have inadequate knowledge regarding CRC screening (more than 55% did not know the frequency of performing specific screening procedures, the upper age limit at which screening is not recommended, and the patients at high-risk for CRC).

Almost the same results were found in a Jordanian study where the knowledge of CRC among the majority (69.1%) of nurses and physicians working in primary care settings was very poor [48]. Actually, it looks that a principal barrier to undertake CRC screening by eligible patients is the inadequate knowledge among health care professionals.

According to Tfaily et al. [49], in a study performed in Lebanon among 371 participants (more than half of them had a university level education) who were surveyed in a major health care medical center showed that 83% and 67% of participants were not aware of CRC risk factors and warning signs, respectively, 15% have previously undergone CRC screening, 56% were aware of the necessity for screening, and 43% were willing to undergo screening. Once again, the aforementioned study did ignore existence of the popular FIT screening test where it was reported “50% of patients who were planning to get screened in the future selected FOBT as their preferred method of screening and 42% preferred colonoscopy. The remaining 8% chose neither or no preference”.

In a study performed in eight Louisiana federally qualified health centers [50] among 975 patients who were 50 years or older not up to date with CRC screening (52% of them had low literacy, i.e. less than a 9^th grade level); the majority of participants had positive beliefs about the benefits of CRC screening using FOBTs, but only slightly over a third of all participants stated ever receiving a physician recommendation for CRC screening and fewer recalled being given an FOBT kit. These outcomes did not vary by literacy and clearly pointed to the limited physician recommendations.

In Hungary, the results of a study conducted among 1150 adults between the ages of 40 and 70 using quota sampling showed that 81.2% of the respondents were not well-informed about the risk factors of CRC; likewise, 79.0% were not well-informed about the symptoms of CRC, and 27.0% of respondents had not heard of CRC screening methods before [51].

In a survey administered to a representative population of the United States of America formed of 6349 participants, the term “Colonoscopy” was recognized by 80% of participants (over the age of 35); however, only 35% of the respondents perceived it as a major method for colon cancer screening. Gender played a major role in colon cancer knowledge. Women (42%) were more likely than men (27%) to understand that colonoscopy tests were for colon cancer. More women than men were aware of colonoscopy (64% versus 36%). Age did not play a major role in cancer knowledge. Older patients were more likely to know that colonoscopy detects colon cancer (50 - 64 years 45%, 35 - 49 years 33%). The youngest age group (18 - 34 years, 65%) was less likely to have heard of colonoscopy (82% - 88% in the older age groups). Employment status did not influence colon cancer knowledge [52].

“The American Cancer Society (ACS) [19] has recently issued a qualified recommendation to initiate colorectal cancer (CRC) screening starting at age 45 years in average-risk individuals. The rationale for this recommendation is that 1) US epidemiologic data show an increase in CRC incidence in individuals younger than 50 years, 2) there is concern about a birth cohort effect with individuals aged 45 to 49 showing increasing CRC incidence rate ratios since 1949, and 3) updated simulation models show a favorable balance of benefit of risk from initiating screening at an earlier age” [53].

It is well known that behind CRC screening there are two main objectives: to reduce the incidence of CRC by detecting and removing adenomas and to reduce mortality by detecting CRC at an early stage [54]. The study performed by Larsen et al. [54] completed in Denmark aimed at assessing the effectiveness of FIT tests as an early screening tool for CRC. The reported results indicated that the FIT-based CRC screening program detects CRC in earlier stages and thereby secures a better prognosis for the patients.

In order to increase awareness and direct higher percentages of the Lebanese population towards early CRC screening, the authors in conjunction with the SAID NGO CRC awareness organization exposed the citizens to a new tool of spreading awareness being a giant inflatable, walk-through colon model equipped with physical depictions of healthy tissue, polyps and CRC [55]. The research findings showed that upon comparing results before and after making the inflatable colon tour, that the use of such a tool does increase the knowledge of colorectal cancer and its corresponding screening practice by 49.6%. A similar activity was also reported by Baasiri et al. [56] and results showed that “participants demonstrated that the inflatable colon increased participants’ knowledge about CRC and its screening. It also improved their attitude toward discussing and undergoing CRC screening” (p. 171).

So, the main objective of the present study is to assess the levels of CRC awareness in Lebanon and how these levels were influenced by the massive NGO awareness campaigns that took place in a time span of three years, more precisely from the beginning of 2016 till the end of 2018. In reality, and as far as the authors know, this current study is a unique “Repeated Cross-Sectional” study that compares the Lebanese CRC public awareness over a span of three years. The newest part of this current study was administered over the Lebanese territory during the last quarter of 2018. Data was collected using a simple questionnaire via face to face interviews with more than 1000 randomly selected people. The resultant figures of the 2018 study are compared with their respective counterpart figures obtained from a study realized in 2016 [57]. The target is to assess the levels of CRC awareness improvement over 3 years (2016-2018), whereby the impact of 2017 is not tested per se but assumed to accumulate to the year after, knowing that during this period of time, continuous and massive interventions from the SAID NGO foundation, in particular, took place through direct contact lectures and demonstrations, mass media interviews, fairs, festivals, fund rising events and marathons.

This paper has its first merit from the comparative assessment of the collected and analyzed data and facts from the two studies performed in 2016 and 2018, whereby findings are statistically validated to offer a strong parametric analysis which may act as a platform for further research. The second merit is in the fact that results and outcomes enrich the current scarcity of information about the topic in Lebanon and the region. Finally, the third merit is the fact that reported improvements in CRC knowledge and awareness as presented in the previous two studies have led to materialize the government support and put into action a national campaign during the year 2019.

This study adapts a Repeated Cross-Sectional research design. In longitudinal research studies participants are largely or entirely different on each sampling occasion and may analyze multiple variables at a given instance. Nonetheless, cross-sectional studies require less time to be set up, and may be considered for preliminary evaluations of association prior to embarking on cumbersome longitudinal-type studies [58]. Such a study is useful since it adds a dynamic component to the study of cross-sectional units and allows the investigation of time-varying relationships.

Thus, the aim of this study is to perform a recent cross-sectional study of Lebanese residents’ CRC awareness and compare the findings with those from an earlier study [55] [57]. Repeated cross-sectional surveys are designed to give good estimates for the current population and the changes or movements that have occurred since the last survey or previous surveys.

Based on the two 2016 and 2018 cross-sectional samples, we demonstrate an increase in awareness of CRC among the Lebanese population. The percentage of those who have heard about CRC has increased significantly from 40.4% in 2016 to 78.7% in 2018. In fact, it looks that the efforts of SAID NGO (118 different major activities in the span of 3 years) did make a significant difference in what relates to CRC awareness among the participant Lebanese population. However, among those who are aware of CRC, the percentage of those acquainted with CRC screening presented no improvement where the 2016 figure of 57.3% decreased significantly to 48.0% in 2018. This result may be due to the fact that no organized screening is performed in Lebanon rather opportunistic screening is offered [1] (pp. 284-285).

In addition, the results of the research showed that the proportion of respondents who believed that family history is the major risk factor for CRC did increase significantly from 47.7% in 2016 to 90.8% in 2018. This high percent for 2018 fits the finding by Baasiri et al. [56] who reported 70.1% of the respondents “knew that the risk for developing CRC increases if they have a family member with CRC” (p. 171). In addition to the findings reported by IARC [1] whereby results from several European nations lead to the stated outcome, “There is a large body of evidence from observational studies, most of which have been summarized in meta-analyses, which consistently found an approximately 2-fold increased risk of CRC in people with a first degree relative with CRC compared with people with no such family history” (p. 264). Likewise, the proportions of respondents who believed that overweight, age, and stress are among the major risk factors for CRC increased from 26.9%, 26.7% and 11.3% in 2016 to 86.2%, 52.1% and 21.51% in 2018, respectively. On the other hand, the proportions for the risk factors related to alcohol and smoking have dropped from 37.7% and 37.3% to 27.4% and 24.2%, respectively.

Along the same line, the non-readiness and unwillingness for CRC screening has shown a decrease from 29.3% in 2016 down to 16.4% in 2018 (13.2% did not agree that they are ready for CRC screening and 3.2% strongly did not agree). Again, Baasiri et al. [56] report a 30.5% of the respondents being unwilling before the giant colon visit. In addition, the proportion of those who believe that they may reduce CRC risk has increased from 78.7% in 2016 to 96.0% in 2018 (70.9% strongly agreed that they can lower their risk of and 25.1% agreed that they can).

Furthermore, the proportion of CRC aware respondents who have relatives diagnosed with CRC has dropped significantly from 22.8% to 9.9%. This could indicate that NGO awareness campaigns have widened their target population to include more populations with undiagnosed CRC in their families. The proportion of those who intend to undergo a FIT test did increase significantly from 22.0% in 2016 to 66.5% in 2018, which is a reassuring result.

The research outcomes showed that the proportion of those who intend to do nothing in relation to CRC screening became 16.8% of those aware of CRC (In 2016, 77.3% of the sample refused colonoscopy, 84.2% of the sample refused virtual colonoscopy and 78.0% of the sample refused the FIT) and the proportion of those who intend to undergo a colonoscopy did decrease significantly from 22.7% in 2016 to 11.4% in 2018. The aforementioned attitude is also observed in Baasiri et al. [56] finding who reported that “although the majority of the participants > 50 years of age and eligible for CRC screening were willing to get screened (74.2%), we found that only 14.2% reported having undergone CRC screening test in the previous years” (p. 171). Noteworthy as well the study performed by EL Kaddoum et al. [64], who concluded “while it was hard for us to quantify people for whom a free FIT was proposed, the low restitution rate among those who accepted to undergo the test shows the urgent necessity of establishing sensitization and screening campaigns” (p. S23).

The most important source of information for CRC was friends where the percentage of respondents who indicated this choice was 18.4% in 2016 which did increase considerably to 73.8% in 2018. In second place came family (18.7% chose family in 2016 which went up to 56.7% in 2018). Physicians occupied the third place as sources of information (18.9% in 2016 and 40.2% in 2018), well this is not an encouraging outcome since physician recommendation happens to be the most important factor that influences “being up to date with screening and intending to be screened” [65]. This could indicate a low level of engagement with the healthcare system when it comes to preventative care.

As for media as a source of information, the research showed that media occupies a low position as a CRC information source where in 2016 only 22.6% of the respondents relied on media as a source of information on CRC, this percentage dropped to 13.7% in 2018. The aforementioned outcome is possibly due to three factors, the recurring stressful political events in Lebanon, the COVID-19 situation and the habit of reading less [62] [63]. Such an observation must be taken in consideration when awareness campaigns are designed for the future to come.

As for gender differences, it looks that from 2016 to 2018, the population understanding of CRC has grown where back in 2016 females were more familiar than males, then by 2018 males have caught up.

In conclusion, CRC awareness is increasing over time and there is a trend towards more FIT CRC early screening tests. In addition, it looks that more masses are aware of CRC risk factors (overweight, age, and stress). It is noticeable that the proportion of those who believe that family history is a major CRC factor has almost doubled in the time interval between 2016 and 2018. It looks that the awareness campaigns are fortifying CRC knowledge.

This paper is the first contemporary research in Lebanon to perform a cross-sectional study of Lebanese residents’ CRC awareness and compare the findings with those from an earlier study.

The justification of such a study emanates from the continuous flow of reports and studies addressing the importance of Colorectal Cancer Screening.

The basis for the current research was two papers reporting the use of several tools to motivate, create, increase and sustain the Lebanese population awareness about the great benefits of preventive screening for Colon Cancer. Among these tools, are public gatherings, conferences, workshops, visitations to rural communities, sport activities [marathons], university and school lectures, meetings with government officials, meetings with the Minister of Health, and the use of a giant Inflatable Colon (similar to [56] as a support vivid-tool for spreading awareness of Colorectal Cancer Screening [66] [67]. Further, this paper has its first merit from the comparative assessment of the collected and analyzed data and facts from all the aforementioned events; in addition, results and outcomes enrich the current scarcity of information about the topic.

According to Mamlouk et al. [16], CRC is naturally developed, as a malignant transformation of a benign adenoma in the majority of cases. Therefore, Bonnington and Rutter [17] argue that the aforementioned fact gives hope that the detection of adenomas and polyps with malignant potential could reduce the mortality rate. Thus, there is a continuous and urgent need to launch population-wide campaigns that assist to inform the Lebanese residents about cancer, the underlying risk factors, and the promising remedies [5] [55] [56] [57].

This study presents significant evidence that the cumulative use of more than 135 different activities by SAID NGO [68] including the use of a giant inflatable colon [tunnel like] increases knowledge of colorectal cancer and its corresponding screening practice. According to SAID’s president, “These activities have directly affected 8000 people of all ages. A total of 1200 free FIT tests were performed and 95 colonoscopy procedures were performed, by the association, to anyone whose results were positive” [61]. The study shows that awareness of the importance of CRC screening did increase significantly from 40.4% in 2016 [57] [69] to 78.7% in 2018 [55] [70]. Furthermore, since 2018, the implications of the dynamism of SAID NGO and other associations continued to produce more awareness campaigns based on the fact that the lack of awareness on CRC and its common risks and symptoms terminology is a barrier to CRC screening. Accordingly, the issue needs to be more highlighted among members of the society. Consequently, SAID NGO organized a walkathon [5 km march] on March 10, 2019 under the slogan “be fit, do FIT” and an event’s motto “March in Blue,” in reference also to Colon Cancer Awareness Month and the blue color of the campaign’s ribbons [71] [72]. See Figure 3.

The knowledge and the facts presented and gained from this study will continue to guide public policy makers in formulating and adjusting policies to promote awareness and support NGOs that are active in this field. It is worth mentioning that the previous extensive campaigns across the Lebanese territory and the continuous communication with health authorities in hospitals, NGOs, clinics, and political figures beside the Ministry of Public Health resulted in the launching of the first “National Colon Cancer Awareness Campaign 2019” supported by Dr. Jamil Jabbak, Minister of Public Health, and in cooperation with Merck Sharp and Dom, the Syndicate of Physicians, the Syndicate of Pharmacists, the Syndicate of Hospitals, the Lebanese Association of Oncologists, SAID NGO and other civil associations, and Medical Laboratory Owners In Lebanon [73].

Dr. Jamil Jabbak, Minister of Public Health, announced that the Rafik Hariri hospital will be presenting 1000 free FIT tests to those benefiting from the Ministry of Public Health’s services (those without insurance). This grant is provided by Fuji Film International. Also, this is the first time that the Ministry of Public Health has launched a national campaign to raise awareness on colon cancer, something that was deemed necessary given the increasing numbers of patients. At the end of the announcement, an educational film prepared by the Ministry of Health, was screened, urging citizens to carry out FIT examinations every year. Furthermore, an informational pamphlet (see Figure 4) was launched to the public supported by the Lebanese Association of Gastroenterology, the Lebanese Society of Medical Oncology, the Ministry of Public Health, and surely SAID NGO (the only civil society organization in Lebanon that is specialized in raising awareness on the early detection of colon cancer) [61].

This study reflects current health education of several community groups,

which could help guide establishing local screening protocols, in addition, to inclusion in health provider curricula. Moreover, as the study guides policy makers in making and adjusting policies to achieve a more effective performance, it will help the specialized NGOs to grow, resulting in enhanced standards of living of the community at large. There is a continuous and urgent need to launch population-wide campaigns that assist to inform the Lebanese residents about cancer, the underlying risk factors, and treatments.

The authors declare no conflicts of interest regarding the publication of this paper.

Hejase, A.J., Hejase, H.J., Nemer, H.A., Hejase, C.A. and Trad, M.-A.M. (2020) Repeated Cross-Sectional Survey of Knowledge and Attitudes to Colorectal Cancer Screening in Lebanon. Journal of Biosciences and Medicines, 8, 178-210. https://doi.org/10.4236/jbm.2020.812017