Knowledge Regarding Early Detection of Cancer among Romanian Women having Relatives with Cancer

Early detection of cancer greatly increases the chances for successful treatment and thus for survival. Early diagnosis is particularly relevant for cancers of the breast, cervix, skin, mouth, larynx, colon and rectum (World Health Organization, 2014). Cancers can be detected by awareness of suspicious symptoms (passive detection) or by specific actions undertaken by individuals or participation to medical checks or screening programmes (active detection). Early symptoms of cancer include lumps in the breast or other parts of the body, sores that fail to heal, abnormal bleeding from any orifice of the body, persistent indigestion or difficulty in swallowing, nagging coughing and hoarseness, unexplained weight loss, appearance or change in a wart or mole (de Nooijer et al., 2004; Keeney et al., 2014; World Health Organization, 2014; Singapore Cancer Society, 2014). Some symptoms are specifically associated with a particular type of cancer, while others may be caused


Introduction
Lucia Maria Lotrean 1 *, Roxana Ailoaiei 1 , Monica Popa 1 , Hein de Vries 2 by several types of cancer or other diseases. A major problem with the interpretation of these symptoms is the non specific nature of many of the warning signals in apparently healthy people. Hence possible cancer symptoms may be easily attributed to common diseases and medical check could be delayed. Recognizing possible warning symptoms of cancer and taking prompt action leads to early diagnosis. Different organizations underline the importance of identifying these symptoms and recommend that a physician should be consulted immediately or within a few weeks (de Nooijer et al., 2004;Gultekin et al., 2011;Yilmaz et al., 2013;World Health Organization, 2014;Singapore Cancer Society, 2014).
At the same time, several types of cancer can be detected in asymptomatic people by mean of self examination like breast self examination and examination of the skin as well as regular check-ups and physical examination by a physician and screening tests. Screening refers to the use of simple tests across a healthy population in order to identify individuals who have disease, but do not yet have symptoms. Examples include breast cancer screening using mammography, cervical cancer screening using cytology screening methods, including Pap smears and colo-rectal cancer screening using faecal immunochemical test or colonoscopy (de Nooijer et al., 2004;Palmer et al., 2007;Gultekin et al., 2011;Andreeva et al., 2013;Yilmaz et al., 2013;World Health Organization, 2014;Singapore Cancer Society, 2014).
Studies from different countries showed that increased awareness of possible warning symptoms of cancer and methods of early diagnoses among physicians, nurses and other health care providers as well as among the general public, can have a great impact on the disease (de Nooijer et al., 2004;Akhta et al., 2008;Akhal et al., 2010;Chin Che et al., 2011;International Agency for Research on Cancer, 2012;Luszczynska et al., 2012;Al-Sharbatti et al., 2013;Kamzol et al., 2013;Grimes et al., 2014;World Health Organization, 2014;Singapore Cancer Society, 2014). Nevertheless, in Romania there are few information with regard to the level of knowledge of different population groups regarding these issues.
Hence, this paper has three objectives. The first one is to assess the knowledge of Romanian women who have relatives with cancer with regard to cancer symptoms and detection methods. Second, it intends to identify sociodemographics factors which might influence their level of knowledge. Third, it aims to get information regarding the attitude of the women from the study regarding medical help seeking in case of any symptom which might be associated with cancer.

Sample and procedure
The study was performed between October 2010-February 2011 in the state oncological institute, Ion Chiricuta' from Cluj-Napoca, a town with approximately 330 000 inhabitants from North-West Romania. It offer medical care to oncological patients from North-West Romania and, sometimes, also from other Romanian regions. Institutional approval for the study was obtained from the hospital directorate. The study involved female first degree relatives of patients diagnosed with various types of cancer, who came to different departments of oncological institute (Surgery, Radiotherapy, Chemotherapy, Oncological pediatry) for treatment or medical checks. The study subjects were contacted for participation in the study during their presence in the oncological institute for accompanying or visiting their cancer relatives (Lotrean et al., 2013).
Informed oral consent for participation was obtained from all participants. A number of 160 women were included in the study (the refusal rate was 8.5%).
They were asked by a member of the research team to fill in a self-administered anonymous questionnaire, which investigated several components of their lifestyle as well as knowledge regarding cancer prevention and detection. Each participant filled in the questionnaire and the member of the research team collected it.

Measures
This study relies on several questions which were developed based on a questionnaire used previously in a Dutch study (de Nooijer et al., 2004). They have got information regarding demographics characteristics (age, educational level, residence in urban or rural area), level of knowledge regarding symptoms of cancer, level of knowledge regarding methods for cancer detection and attitude regarding medical help seeking behaviour in case of having a symptom which might suggest cancer. The level of knowledge about cancer symptoms was evaluated with one question; participants were asked to choose from a list the symptoms they thought that could be related to cancer. Another question assessed the level of knowledge about cancer detection, the participants being asked to choose from a list the methods they know to contribute to cancer detection.
At the same time, the study sample were asked to indicate if they would have a symptom of cancer how quick they will address this problem to a physician (less than one week; more than one week, but less than one month; one month; more than one month; only if the symptom is getting worst).

Analyses
First, data analysis included basic descriptive statistics of the respondents with regard to socio-demographics characteristics.
Second, the percentages of women who identified each symptom of cancer, respectively each method for cancer detection were calculated.
Third, two new variables were created: one variable was the number of symptoms identified by each participant (minimum0-maximum8), the other was the number of methods for cancer detection identified by each woman (minimum 0-maximum 7). Percentages of participants who identified all symptoms or less (from 0 to 7), respectively all detection methods or less (from 0-to 6) were calculated.
Fourthly, univariate linear regression analyses were used to assess the socio-demographics factors associate with higher level of knowledge regarding cancer related symptoms and methods for cancer detection. The dependent variables were the number of symptoms identified by each participant, respectively the number of methods for cancer detection identified by each woman. Independent variables were age, residence in rural (0) or urban area (1), educational level (0-low, 1-medium, 2-high).
Fifthly, there were included descriptive statistics of the respondents with regard to attitudes regarding medical help seeking behaviour in case of a presence of a symptom which might be associated with cancer.
Data were analysed using SPSS 20.0 statistical program. Significant results are reported at p<0.05.

Socio-demographic characteristics
The study involved 160 women having relatives with cancer with age between 18-70 years, mean age 42 (SD=12.8). The educational level of the sample was as Asian Pacific Journal of Cancer Prevention, Vol 16, 2015 1093 DOI:http://dx.doi.org/10.7314/APJCP.2015.16.3.1091 Knowledge Regarding Early Detection of Cancer among Romanian Women having Relatives with Cancer following: 15.6% with low educational level (only junior high school or less), 42.5% with medium educational level (only high school), 41.9% with high educational level (university studies). A percentage of 38.1% of the women were living in rural areas, and 61.9% from urban areas. Table 1 presents the results regarding the cancer symptoms mentioned by the respondents. The symptoms which were more frequently mentioned by the participants were thickenings or lumps, unusual weight loss and abnormal bleeding, which were known by more than two thirds of the women. All the other symptoms were known by less than 40% of the study sample, the percentage varying between 20.6% for swallowing problems and 36.9% for sores that do not heal. Moreover, Table 3 shows that only around 10% of the participant recognised all the 8 symptoms of cancer, while 60% of the participants identified maximum 4 cancer symptoms.

Knowledge regarding symptoms of cancer
The results of the linear regression analyses pointed out that younger women (B=-0.390, p<0.01), persons from urban areas (B=0.872, p<0.01) and those having higher educational level (B=0.883, p<0.001) had statistically significant higher level of knowledge with respect to cancer symptoms. Table 2 lists the cancer detection methods mentioned by the respondents. It show that the most recalled methods for detection of cancer were breast self examination, having a mammography and a Pap test as well as regular medical check-ups, which were known by more than two thirds of the subjects. Skin examination was mentioned by 15.6% of the women, while checking for the presence of blood in the stool and colonoscopy were known by 33.1%, respectively 43.1% of the study sample. Table 3 shows that 10% of the participants identified all the methods for cancer detection, and around half of the women mentioned a maximum 4 methods. Almost 6% of the participants were unable to recall any method for cancer detection.

Knowledge regarding methods for cancer detection
The results of the linear regression analyses show that the level of knowledge regarding the detection was higher among younger ages (B=-0.260; p<0.01), women living in urban areas (B=0.676; p<0.01) and among those having a higher educational level (B=0.536; p<0.001).

Attitudes regarding seeking medical help for symptoms which might suggest cancer
A percentage of 55% of the study sample declared that in case they would have a symptom which might be associated with cancer they would seek medical help in less than one week, while 22.5% would address the problem to a physician in more than one week, but less than one month and 9.3% in one month. Only 6.9% of the participants intend to consult a physician if confronted with such a problem in more than one month and 6.3% of the women only if the symptom gets worst.

Discussion
In the North-West part of Romania 351.7 people per 100,000 of the population were diagnosed with cancer in the 2008. The most common types of cancer among women were breast cancer followed by cervix, colo-rectal, uterus, ovary, lung, stomach, tyroide, leukemias and liver cancer (Oncological Institute I Chiricuta, 2008).
This study offers information regarding the level of knowledge of Romanian women who have relatives with cancer regarding detection of cancer, as well as about their attitude regarding medical help seeking in case of a symptom which might be associated with cancer.
The results show that the majority of the participants understand the importance of looking for medical help within weeks up to one month in case that a symptom which might be associated with cancer is observed.
Nevertheless, only around 10% recognised all 8 listed symptoms. More than two thirds of the women knew that symptoms like thickenings or lumps in the breast or other parts of the body, bleeding, unusual weight loss might be associated with cancer, but other cancer symptoms such as nagging cough or hoarseness, swallowing problems, appearance or change in a wart or mole, were recognised to a less extent.  At the same time, the results showed that more than two thirds of participants were familiar with methods for detection of breast and cervical cancer. This might be the result of the information and education campaign developed in Romania with respect to these issues, as well as the implementation of screening programs for cervical cancer in different regions of Romania (Oncological Institute I Chiricuta, 2008). On the other side, it might be also positively associated with the type of cancer among participants' relatives, since the participants might be more aware about methods for diagnoses used for this particular type of cancer. The breast and cervical cancer are the most common types of cancer among women and thus it is conceivable that many participants had relatives with these pathologies. Nevertheless, since this information was not included in the questionnaire, we can not confirm this hypothesis.
On the other side, much fewer participants recognised the methods for detection of colo-rectal cancer (less than 44%) and skin cancer (less than 16%). One explanation could be the fact the in Romania there are less information and education actions with respect to these issues than for breast and cervical cancer, while no screening programs are available for these types of cancers.
Moreover, only 10% recognised all listed methods for detection. The level of knowledge regarding both symptoms and methods for detection was lower among older women, among those living in rural areas and having lower educational level. These results are similar with studies from other developing countries investigating similar issues (Palmer et al., 2007;Kumar et al., 2011;Matejic et al., 2011;Radi, 2013;Adakan et al., 2014;Jo et al., 2014). At the same time, other studies from Romania also underlined the gap between different groups with respect to health related knowledge and health literacy among Romanian population based on residence and educational level (Stativa and Anghelescu, 2005;Center for Health Policies and Services, 2007;Eurobarometru, 2012).
The study is subject of several limitations. First, it did not include a national representative sample and the sample size limited the analyses of the results separately based on age, residence and education level. Second, the data relied on participants' self-reports. Although some respondents may have not reported truthfully, the likelihood of honest responses is maximized in this survey by having it conducted anonymously. Third, because of ethical issues (some of the participants' relatives might be not aware about their cancer diagnosis), the questionnaire did not include questions about the type of cancer presented among participants' relatives.
Despite these limitations, the study underline that much more information should be given to the women who have relatives with cancer about what they can do to detect cancer in an early stage. This is specially needed for older women, women living in rural areas and women having low educational level. Different channels tailored to different sections of the population should be taken into account. They include education and counselling offered by health professionals, health education materials on early detection of cancer disseminated via waiting rooms in primary health care and hospitals but also more general and non-medical media in order to reach the most disadvantaged groups of population as well (Vrscaj et al., 2008;Chukmaitov et al., 2012;Jackowska et al., 2012;Luszczynska et al., 2012;Grimes et al., 2014).