Knowledge and Awareness of Cancer Screening Among the Public in Saudi Arabia: A Cross-Sectional Study.

Introduction
Cancer ranks second as the most common cause of death worldwide, following ischemic heart disease [1]. The International Agency for Research on Cancer (IARC) reported that the global cancer burden had risen to 18.1 million cases and 9.6 million deaths in 2018 [2]. The Global Cancer Observatory, a constituent of the IARC, projects that the future incidence of cancer and cancer-related deaths will rise to 29.5 million cases worldwide and approximately 16.4 million deaths by 2040 [3]. This trend was demonstrated by the World Health Organization (WHO), which indicated that more than 9,000 deaths were caused by cancer in the Kingdom of Saudi Arabia (KSA) in 2014 [4], increasing to 10,518 deaths in 2018 [5]. According to data from the Global Burden of Disease study, colon cancer is the leading cause of cancer-related mortality, accounting for 1.6% of deaths worldwide and 1.43% of deaths in Saudi Arabia. In contrast, breast cancer accounts for 1.09% of deaths worldwide and 0.96% in Saudi Arabia, while prostate cancer accounts for 0.74% of deaths among the global male population and 0.58% among Saudi men.
Numerous preventive strategies and early diagnostic techniques have been suggested in a bid to curb the prevalence of certain forms of cancer [6-10]. Early detection of abnormal tissue, hyperplasia, or cancer through screening modalities increases the chances of treatment or cure at an earlier stage, before the disease manifests itself [11]. When a patient is diagnosed with cancer, it is usually at a later stage, after sufficient cellular growth has occurred to cause symptoms [12]. This may adversely impact cancer treatment and reduce curability rates [12,13]. Therefore, screening tests are undertaken in individuals who have no cancer symptoms [13]. Furthermore, other researchers have established that screening programs undertaken at an early age are economical when compared with non-screening approaches [14,15].
Screening modalities for cancer ought to be affordable, non-invasive, and capable of reducing mortality rates through early diagnosis [10]. Low-dose computed tomography (LDCT) is a screening method advised for adults who are at high risk of developing lung cancer. Mammograms are screening X-rays carried out in asymptomatic women [5]. Screening mammograms aim to detect breast cancer at a stage when it is so small that it cannot be felt by a woman or physician. Early detection of small breast cancers using screening mammography significantly reduces cancer-related mortality and morbidity [5]. Polyps or cancer in the colon can be detected using several tests. These include stool-based tests (including stool DNA and RNA tests), flexible sigmoidoscopy, colonoscopy, and CT colonography [12,14].
It is of crucial importance that the public be familiar with and aware of the various screening methods and programs, which will aid in reducing mortality rates [12]. The aim of this study is to assess the knowledge of the Saudi community regarding these screening programs, an evaluation that would assist health authorities in enhancing health screening programs and campaigns.

Materials and methods
A community-based cross-sectional study was conducted among the general population of Saudi Arabia, using a sample of 451 participants. Participants were recruited using a convenience sampling method via an anonymous online survey distributed through social media (WhatsApp and Twitter/X). Participants represented the general public and were not selected based on high-risk status for specific cancers. Recruitment was not restricted to guideline-eligible screening age groups, and detailed high-risk eligibility variables (e.g., hereditary cancer syndromes, strong family history, or defined high-risk smoking exposure such as pack-years) were not used to define inclusion. Accordingly, the findings primarily reflect awareness in a general population sample rather than a high-risk cohort. This approach, while efficient for reaching a broad audience, introduces inherent selection bias, as it favors younger, tech-savvy individuals. Data were collected through an anonymous online survey addressing sociodemographic information and awareness of cancer screening. Statistical analysis was conducted using IBM SPSS Statistics for Windows, Version 26 (Released 2018; IBM Corp., Armonk, NY, USA), with categorical variables expressed as percentages and frequencies, and numerical data presented as means and standard deviations. The Chi-square test was used to assess correlations, with degrees of freedom calculated based on contingency table dimensions. Effect sizes for Chi-square tests were calculated using Cramér’s V to assess the strength of associations. A p-value of < 0.05 was considered statistically significant.
For some screening tests, result data were missing for a small number of participants, which accounts for minor discrepancies between the number of individuals reporting having undergone screening and those reporting test results. Follow-up questions regarding test results were analyzed only for participants who answered “Yes” to having undergone the test, and the total number of respondents (N) is indicated, for clarity.
The sample size was calculated to provide 80% power to detect a small-to-medium effect size (Cohen's d = 0.2), with a significance level (alpha) of 0.05, using a two-tailed test. This calculation indicated a required sample size of approximately 400 participants. We ultimately recruited 451 individuals to account for potential incomplete responses and to enhance the statistical power of our study.
Questionnaire development and validation
The study questionnaire was meticulously developed based on an extensive review of current literature concerning cancer screening awareness and knowledge. It was structured into several key domains: sociodemographic characteristics, general knowledge about cancer, awareness of specific cancer screening modalities (e.g., mammography, colonoscopy, and Papanicolaou (Pap) test), and attitudes toward screening practices. To ensure clarity, comprehensibility, and cultural appropriateness, the questionnaire underwent pilot testing with a cohort of 25 individuals from the target population. Feedback from this pilot phase was instrumental in refining question wording and optimizing the survey flow. The internal consistency reliability of the knowledge-based items within the questionnaire was subsequently assessed using Cronbach's alpha, which yielded a coefficient of 0.78, indicating acceptable reliability.
Ethical considerations
The study protocol received full ethical approval from the Institutional Review Board (IRB) of the University of Jeddah (no. HAP-02-J-094) Research Ethics Committee. Prior to participation, all prospective respondents were directed to a dedicated informed consent page. This page provided a comprehensive overview of the study, explicitly detailing its objectives, the voluntary nature of participation, the estimated time commitment for survey completion, and a firm assurance of the anonymity and confidentiality of all submitted responses. Participants were also provided with contact information for the principal investigator, should they have any questions or concerns. By proceeding to complete the online questionnaire, participants were understood to have provided their implied consent to participate in the study. No personally identifiable information was collected, further safeguarding the privacy and anonymity of all participants. Statistical analysis was conducted using IBM SPSS Statistics for Windows, Version 26 (Released 2018; IBM Corp., Armonk, NY, USA), with categorical variables expressed as percentages and frequencies, and numerical data presented as means and standard deviations. The Chi-square test was used to assess correlations, with a statistically significant p-value of less than 0.05.

Results
This study included a total of 451 participants. The sociodemographic characteristics of the study population are detailed in Table 1. Briefly, the most prevalent age group was 18-29 years (n = 373, 82.7%), and males constituted a slightly higher percentage than females (n = 246, 54.5% vs. n = 205, 45.4%).
Regarding knowledge and awareness, a significant majority of participants (n = 369, 81.8%) were aware of tests for various types of cancer and tumors. Furthermore, 94.5% (n = 426) agreed that early detection aids in cancer treatment, and 69% (n = 311) believed it improves treatment outcomes. Breast cancer was the most recognized cancer for screening (n = 424, 94%), followed by prostate (n = 271, 60.1%), and colon cancer (n = 270, 59.9%).
Despite high awareness, the prevalence of actual screening uptake was notably low. For colorectal cancer, only 3.5% (n = 16) of all participants (N = 451) reported having undergone colonoscopy or sigmoidoscopy (95% CI: 1.8%-5.3%), and 4.9% (n = 22) had other forms of colorectal testing (95% CI: 2.9%-6.9%). However, these screening prevalence estimates were calculated using the entire study population as the denominator; given that the cohort was predominantly young, they should not be interpreted as screening coverage among age-eligible individuals. Among female participants (n = 205), mammogram uptake was 4.4% (n = 9; 95% CI: 1.6%-7.2%), other breast tests were 7.3% (n = 15; 95% CI: 3.8%-10.9%), and Pap test uptake was 2.4% (n = 5; 95% CI: 0.3%-4.6%). This low uptake, particularly for age-specific screenings like mammograms, is largely attributable to the predominantly young demographic of our study population, in which the majority (82.7%) were aged 18-29 years, and only a small proportion (n = 21, 4.6%) were aged 40 years or older, the recommended age for many screenings.
Accordingly, age-stratified prevalence (e.g., among participants aged ≥40 years for colorectal and breast cancer screening) provides a more appropriate estimate of uptake in the eligible population, and some screening among younger participants may have occurred due to high-risk indications, such as family history, which were not separately assessed in this analysis.
Associations between sociodemographic characteristics and knowledge regarding cancer screening tests were investigated. A significant association was found between gender, educational level, and employment status with general knowledge and awareness (p < 0.05). Specifically, females demonstrated significantly higher knowledge than males (p < 0.001), and respondents with higher educational levels and students also exhibited a higher level of knowledge compared with other groups (p = 0.003 and 0.02, respectively).​​
Overall knowledge and awareness
The majority of participants (n = 369, 81.8%) knew that there are tests for various types of cancer and tumors (Figure 1).
Additionally, 94.5% (n = 426) agreed that early detection of cancer helps in its treatment, and 69% (n = 311) agreed that early detection helps in improving treatment outcomes (Figure 2). 
Awareness of cancers that can be screened for reported breast cancer as the most known (n = 424, 94%), followed by prostate (n = 271, 60.1%) and colon cancer (n = 270, 59.9%) (Figure 3).
Sources of information varied among participants, with the internet (n = 294, 65.2%) and social media (n = 236, 52.3%) being the most popular (Figure 4).
Knowledge regarding breast cancer screening
Over half of respondents, 53.2% (n = 109), correctly identified age 40 as the recommended starting age for mammography. Additionally, mammography was recognized by 39.5% (n = 81) as the best approved screening method; only 4.4% (n = 9) reported having undergone a mammogram, and 7.3% (n = 15) reported other breast cancer-related tests. This low proportion reflects the calculation across all female participants, the majority of whom were below the recommended screening age for mammography. Among those screened, most results were negative (n = 7, 77.8% for mammography and n = 11, 73.3% for other breast cancer tests). Two-thirds of participants (n = 140, 68.3%) showed willingness to visit the doctor and discuss the possibility of undergoing preventive breast screening (Table 2).
Knowledge regarding cervical cancer screening
Only 30.7% (n = 63) of participants correctly identified age 21 as the recommended starting point for cervical cancer screening. Knowledge of the approved screening methods was also limited, with only 43.4% (n = 89) identifying human papillomavirus (HPV) Pap smear as the best method, while over one-third were unsure (n = 77, 37.6%). When calculated across all female participants, reported cervical cancer screening uptake appeared low; however, many respondents were younger than the recommended screening age, which likely influenced this finding. Only 2.4% (n = 5) had ever undergone a Pap test, and 2.9% (n = 6) had undergone other forms of cervical cancer testing. Among the small number of participants who reported undergoing testing, most reported positive results (n = 4, 80.0%); however, this finding should be interpreted cautiously due to the limited number of screened individuals. Regarding willingness to engage in preventive care, 65.4% (n = 134) expressed readiness to consult their doctor about HPV vaccination, and 69.3% (n = 142) were open to discussing recommended screening based on age and health status (Table 3).
Knowledge regarding prostate cancer screening
Data showed that 30.9% (n = 76) of participants identified 45 years as the recommended prostate screening age, while 35.8% (n = 88) were not sure. Awareness of approved screening methods was also limited, with only 25.2% (n = 62) selecting the prostate-specific antigen (PSA) test as the best method, while half of the respondents were uncertain. When calculated across all male participants, only 4.1% (n = 10) reported having undergone a PSA test. Among those who reported being screened, 22.2% of participants (n = 2) had positive results, while 77.8% (n = 7) had negative results. However, most participants were below the recommended age for prostate cancer screening. A digital rectal examination was reported by 4.1% (n = 10) of participants, with the majority yielding negative findings (n = 6, 85.7%). Prostate biopsy rates were almost negligible, with only 1.2% (n = 3) having undergone the procedure, of whom 66.7% (n = 2) had positive results. Only 44.7% (n = 110) expressed readiness to consult a doctor about PSA testing, while 55.3% (n = 136) were not ready for this (Table 4).
Knowledge regarding colorectal cancer screening
A high percentage of participants (n = 179, 39.7%) did not know the recommended age to begin screening for colorectal cancer. Knowledge of approved screening methods was low, with almost half of the respondents (n = 217, 48.1%) being unsure, while colonoscopy every 10 years was the most frequently selected option (n = 133, 29.5%). When calculated across the entire study population, reported colorectal cancer screening uptake appeared low, with 3.5% (n = 16) of participants having undergone colonoscopy or sigmoidoscopy and 4.9% (n = 22) reporting other forms of colorectal testing. Among respondents who answered the follow-up question regarding test results, 11.4% (n = 5) reported positive results and 88.6% (n = 39) reported negative results; the denominator reflects respondents to the results item rather than exclusively those who reported undergoing testing. Among the 16 participants who reported undergoing lower endoscopy, only 13 provided a response to the follow-up question on test results, of whom 38.5% (n = 5) reported positive findings and 61.5% (n = 8) reported negative findings (denominator = 13 respondents to the results item, not the full n = 16). Similarly, among those who reported other colorectal tests (n = 22), only 16 reported test results, of whom 25.0% (n = 4) were positive and 75.0% (n = 12) were negative (denominator = 16).
However, this finding is strongly influenced by the young age distribution of the sample, as most participants were below the recommended age for colorectal cancer screening. Despite the low uptake of screening tests, half of the respondents (n = 228, 50.6%) expressed willingness to consult a physician regarding colonoscopy or other similar screening methods (Table 5).
Knowledge regarding lung cancer screening
The vast majority (n = 191, 42.4%) were not sure about the recommended age for lung cancer screening. Knowledge of approved screening methods was similarly limited; only 26.4% (n = 119) correctly identified LDCT as the preferred screening modality, whereas more than half of respondents (n = 239, 53%) were unsure. Only 2.9% (n = 13) had undergone LDCT previously. Regarding willingness to seek screening, 51% (n = 230) expressed readiness to consult a physician about LDCT, while 49.0% (n = 221) were unwilling. Interpretation of LDCT uptake is limited, as eligibility for lung cancer screening depends on both age and smoking history, the latter of which was not assessed in this study (Table 6).
Screening uptake among participants aged >40 years
Among the study participants who were more than 40 years old (n = 21), the uptake of breast cancer screening was higher than in the overall study population. One-fifth of women (n = 3, 18.8%) reported having undergone mammography, and one-fourth (n = 4, 25.0%) stated they had other breast cancer screening tests, mostly with negative results. A large number of participants (n = 13, 81.3%) reported being ready to talk to a doctor about undergoing breast screening for prevention.
On the other hand, no prostate cancer screening was conducted among male participants who were age-eligible; none of them had previously undergone a PSA blood test, digital rectal examination, or prostate biopsy. However, more than half of the respondents (n = 3, 60.0%) expressed readiness to talk to their physicians about PSA screening.
For colorectal cancer, a group of the oldest participants had undergone lower endoscopy (n = 3, 14.3%), but none had had any other colorectal screening tests. Notwithstanding, half (n = 11, 52.4%) indicated willingness to consult a doctor regarding colonoscopy.
Regarding lung cancer screening, very few participants reported having undergone LDCT screening in the past (n = 2, 9.5%); however, more than half (n = 12, 57.1%) stated they would be willing to talk to a doctor about LDCT. The uptake of lung cancer screening was restricted by eligibility based on smoking history, which was not evaluated in this study (Table 7). 
Screening uptake among participants aged >30 years
In the case of female participants above the age of 30 (n = 60), the prevalence of cervical cancer screening was higher than that of the overall female study population. One out of six respondents (n = 4, 17.4%) reported having a cervical smear, and most of the results were positive (n = 3, 75.0%). A smaller number of women (n = 2, 8.7%) stated that they had undergone related tests, which yielded mixed results. The majority of participants (n = 13, 56.5%) expressed interest in discussing the HPV vaccination with their doctors, whereas more than two-thirds (n = 16, 69.6%) were open to talking about the recommended preventive and diagnostic cervical screening examinations according to their age and health condition (Table 8). 
Sociodemographic factors associated with overall knowledge and awareness regarding cancer screening
Investigating the association between sociodemographic characteristics of participants and knowledge regarding tests used for cancer screening revealed a significant association between gender, educational level, and employment status with general knowledge and awareness regarding tests used for cancer (p < 0.05), with females being more knowledgeable than males (p < 0.001). Similarly, respondents with higher educational levels and students had a higher level of knowledge than other respondents (p = 0.003 and 0.02, respectively) (Table 9).
Association between knowledge of tests used for cancer screening and awareness of screening age and utilization of screening tests
The association between awareness of the availability of cancer screening tests and having undergone a mammogram was significant (p = 0.01). Interestingly, participants who had previously undergone mammography demonstrated lower awareness compared to those who had never been screened. Another significant association was found between awareness and knowledge of the recommended age for lung cancer screening among high-risk individuals (p < 0.001). No other significant associations were observed (Table 10).

Discussion
This study investigated the public's awareness and knowledge of cancer screening in Saudi Arabia, revealing important insights into current understanding and screening practices. In this study of 451 predominantly young Saudi adults (n = 373, 82.7% aged 18-29), we found a notable disparity between high awareness of cancer screening benefits and significantly low actual screening rates. We observed a high level of awareness about cancer screening in general (81.8% knew screening exists; 94.5% agreed that early detection helps treatment), but very low self-reported uptake of specific cancer screening tests. While this might initially appear as a discordance between knowledge and behavior, it is consistent with patterns seen in previous research, where awareness does not reliably translate into preventive action without addressing structural, psychosocial, and eligibility barriers [16]. It is crucial to consider the demographic characteristics of our cohort.
Given that 82.7% of participants were aged 18-29 years, the low uptake of cancer screening tests should be interpreted cautiously. Many routine screening programs (e.g., mammography, colorectal cancer screening, and prostate cancer screening discussions) primarily target older age groups; therefore, a substantial proportion of our respondents were likely not eligible for routine screening at the time of participation. Accordingly, the low prevalence of self-reported screening in our cohort may reflect guideline ineligibility as much as behavioral or access-related barriers.
A key factor contributing to the low screening rates in our sample is indeed the young age distribution. Many standard screening recommendations, for example, mammography, colorectal screening, and prostate cancer discussions, are primarily targeted at older age groups. Consequently, a substantial portion of the participants in this study would not yet be eligible for routine screening based on age-related guidelines. Therefore, while general awareness is high, the observed low prevalence of test uptake in our cohort is, to a significant extent, an expected outcome given the age profile of our participants, rather than solely a failure of knowledge translation.
Breast cancer was the most widely recognized screening-eligible cancer (n = 424, 94%), followed by prostate (n = 271, 60.1%) and colon cancer (n = 270, 59.9%). This aligns with previous Saudi and regional studies; for example, a large community-based Saudi survey also found that breast cancer is the most recognized cancer for screening [17]. The dominance of breast cancer in public consciousness is likely driven by sustained national public-health messaging and female-centered screening campaigns, which may not yet be mirrored in public awareness of other cancers.
Only 4.4% (n = 9) of participants reported having had a mammogram, and just 2.4% (n = 5) had a Pap smear, while only 4.1% (n = 10) had ever undergone a PSA test. These low rates are concerning, but they reflect broader trends in Saudi Arabia. For instance, in prostate cancer screening, prior studies in the Asir region found good general knowledge (82.5%) but much lower awareness of specific screening methods (49.4%) and actual PSA testing [18]. Similarly, in Najran, only 30.5% were aware of PSA testing, and just 3.2% had seen a specialist [19].
Regarding barriers to screening, the findings suggest that a lack of detailed, actionable knowledge may be one barrier. For cervical cancer screening, only 30.7% (n = 63) correctly identified 21 years as the starting age, and only 43.4% (n = 89) selected HPV Pap smear as the best; over a third were unsure. These gaps mirror international evidence, with low socioeconomic status, lack of physician recommendation, and embarrassment or fear identified as key deterrents [20]. In Saudi Arabia, especially, cultural sensitivity, lack of public campaigns, and limited screening infrastructure have been flagged as obstacles, particularly for colorectal cancer [21,22].
Correlation testing found that females, those with higher education, and students had significantly higher levels of screening knowledge. This aligns with the theory that health literacy, socioeconomic status, and regular exposure to health messaging influence preventive behavior. Cognitive factors (e.g., perceived behavioral control and subjective norms) have also been shown to mediate screening intentions and uptake [21]. These demographic patterns suggest that targeted educational interventions could be beneficial, focusing on groups with lower awareness levels.
While general awareness of screening benefits was high, there were gaps in actionable knowledge (which test to take, when to start, recommended intervals, and where to access services). Public health messaging should, therefore, be clearer, age-specific, and risk-focused, emphasizing evidence-based eligibility criteria and pathways for accessing screening. Targeted educational interventions may be particularly beneficial for groups with lower awareness levels and should be aligned with guideline-eligible age groups and individuals at increased risk.
In conclusion, despite high awareness of cancer screening benefits among predominantly young Saudi adults, uptake of specific screening tests was low, likely reflecting both guideline ineligibility and other barriers. Future efforts should prioritize improving practical knowledge and facilitating access among guideline-eligible populations and high-risk individuals to maximize the effectiveness of screening programs.
Limitations of the study
A major limitation relates to the age distribution of the sample. The study population was predominantly young, with 82.7% of participants aged 18-29 years, while individuals in higher-risk age groups for most cancer screening programs (≥45 years) constituted only a very small proportion of the sample. As a result, the findings regarding screening uptake and eligibility may be skewed toward lower observed screening rates and may not accurately reflect behaviors or knowledge among older adults, who are more likely to meet screening criteria.
In addition, self-reported screening behavior may suffer from recall bias or social desirability bias. Furthermore, the cross-sectional design prevents assessment of causality (e.g., whether knowledge leads to future screening). Finally, the snowball sampling technique may have introduced selection bias. Data collection through an anonymous online survey may also introduce selection bias, as individuals with greater internet access or a predisposition to participate in health-related surveys might be overrepresented.
Future studies should employ age-stratified sampling and longitudinal designs to better assess determinants of screening uptake. Additionally, a limitation of this study is the potential for sampling bias due to the online distribution method via social media platforms and snowball sampling. This approach may have led to an overrepresentation of individuals who are active on these platforms, particularly those in the 18-29 age group and within specific social networks. This demographic characteristic is a notable weakness, as this population typically does not qualify for routine cancer screening, potentially limiting the generalizability of our findings regarding screening awareness and uptake to the broader Saudi population. Future studies could employ stratified sampling or other methods to ensure broader age and demographic representation.

Conclusions
This study demonstrates that, among a predominantly young adult sample in Saudi Arabia, general awareness of cancer screening and its perceived benefits is relatively high, while detailed knowledge of recommended screening methods, eligibility criteria, and actual screening uptake remains limited. The low prevalence of screening observed should be interpreted in the context of the participants’ young age distribution, as many were not eligible for routine screening according to current guidelines. Sociodemographic factors - particularly gender, education level, and employment status - were significantly associated with awareness levels within this population. Accordingly, these findings are most applicable to younger adults and should not be generalized to guideline-eligible older populations or high-risk groups.
Future research using age-stratified, nationally representative sampling and explicit risk stratification is warranted to better characterize screening knowledge and behaviors across eligible and high-risk populations in Saudi Arabia, and to inform targeted public health interventions.