Evaluation of Head and Neck Cancer Awareness and Screening Status in Jeddah, Saudi Arabia

Head and neck cancer (HNC) is the current designation for oral cancer, which includes cancers that originate from the oral and nasal cavities, sinuses, lips, salivary glands, throat, and larynx(http://globocan.iarc.fr, Accessed 7-2015). HNC is the ninth most common cancer worldwide (http://globocan.iarc.fr, Accessed 7-2015), and in Saudi Arabia, it is the third most common cancer after lymphoma and leukemia and as such, represents a significant public health concern (Al-Balawi and Nwoku, 2002). Moreover, the prevalence of HNC is dependent on geographic location; the incidence is highest in the southern region (Al-Ghamdi et al., 1994; Tandon et al., 1995; Al-Balawi and Nwoku, 2002). The 5-year survival rate is poor, averaging around 50%, not changing for decades (http://www.cancer.org/Accessed 7-2015). Alcohol and tobacco use are the main risk factors for HNC (Galbiatti et al., 2013; http://www.cancer. org/, Accessed 7-2015). However, infection with human papilloma virus (HPV), human immunodeficiency virus (HIV), poor oral hygiene, ill-fitting oral appliances that injure the mucosa, and family history also seem to play a role (Galbiatti et al., 2013; http://www.cancer.org/, Accessed 7-2015), while 25% of all HNC patients have no obvious risk factors, highlighting the complexity of the disease (http://www.cancer.org/, Accessed 7-2015). Risk factors specific to the population of Saudi Arabia are the use of smokeless tobacco such as shammah and alqat, which are associated with carcinogenesis, especially in

It is worth noting that not all patients experience pain as part of the disease process (Scharpf et al., 2009), which presents a challenge for early detection; indeed, the widely held misconception in the general population that cancer is associated with pain must be dispelled. The lack of awareness about HNC among patients as well as health professionals can delay diagnosis, referral, and hence treatment. The present study evaluated the level of awareness about HNC as well as screening status in the general population of Jeddah, Saudi Arabia.

Materials and Methods
An e-questionnaire was developed using Google forms and accessed using tablet devices; it included questions that assessed both knowledge and screening status of HNC in a random sample of the population in Jeddah, Saudi Arabia. The study was conducted during our 3rd HNC awareness campaign in April 2015 at the Red Sea Mall, the largest mall in Jeddah.
The questionnaire was explained to all participants. Written, informed consent was obtained from all participants. The study was approved by the research ethical committee board from King Abdulaziz University, Faculty of Dentistry and Red Sea Mall Administration, and was in full accordance with the World Medical Association Declaration of Helsinki.

Results
A total of 400 adults participated in the HNC awareness campaign; of these, 112 individuals (28%; 40% male and 60% female) participated in the study. Most of the participants were 20-30 years old (45%) or 30-40 years old (28%) ( Figure 1A); 43% were employed, 27% were students, and 27% were housewives ( Figure   1B). The majority held bachelor degrees, whereas few had post-graduate education ( Figure 1C). Unexpectedly, 68% of visitors indicated that they had never received any information about HNC ( Figure 2A); those who had received information (32%) had obtained it mostly from social media (39%) or dentists (33%), through educational lectures (28%), or from television (28%) ( Figure 2B).    Only 26% and 28% of participants identified the tongue and floor of the mouth, respectively, as the most common locations of HNC, while 32% thought it could occur anywhere in the oral cavity ( Figure 3A). The majority of participants (84%) correctly identified cigarette smoking, and use of shammah, hoka, and alcohol as HNC risk factors, while only 10% identified cigarette smoking alone as a major factor ( Figure 3B). In addition, 53% thought that HNC is always painful; while the remaining participants either did not know (20%) or did not think pain was a typical presentation of HNC (27%) ( Figure 3C). Only 19% of participants had heard of HPV (data not shown), but only 18% identified it as a risk factor for HNC ( Figure 4A). In contrast, the percentages of individuals who thought or did not think HIV was a risk factor or who did not know were similar ( Figure 4B). Interestingly, 59% of participants cited poor oral hygiene as a risk factor, while 26% believed it was irrelevant ( Figure 4C). Most participants (58%) thought genetics predisposes to HNC, whereas 28.6% did not have this belief ( Figure 4D).
A large percentage of participants (40%) believed that screening for HNC is the joint responsibility of dentists, dental hygienists, and general physicians ( Figure 5A); however, 82% had never been screened for HNC, while the remainder were screened by dentists (53%) or physicians (40%) but not by dental hygienists (Figure 5B).

Discussion
The results of this study revealed a considerable lack of knowledge and awareness of HNC and associated risk factors among the general population in Jeddah. This is consistent with studies conducted in other countries such as United Arab Emirates, Britain, USA, and Iran among others (West et al., 2006;Amarasinghe et Luryi et al., 2014;Dwojak et al., 2015). Although social media is an effective and accessible way to deliver information and raise public knowledge and awareness of diseases (Saleh et al., 2012), and was one of the major sources of HNC information in the study population, not all registered accounts provide accurate information. As such, there is a need for social media accounts monitored by licensed experts. In addition, dentists who are one of the primary sources of HNC information-should strive to stay current with HNC diagnosis methodologies and ensure that they screen all patients regardless of their specialization.
Most participants (83.9%) knew that use of tobacco products (including cigarettes, shamma, and hoka), and alcohol are considered risk factors for HNC. This is consistent with previously reported findings in other populations (TE O Connor et al., 2010;Croucher et al., 2011;Al-Rawi et al., 2012;Shakoor et al., 2014), and may be attributed to media campaigns highlighting the association between cancer occurrence and tobacco use.
More than 30% of all HNC lesions occur in the tongue, followed by the floor of the mouth (Bsoul et al., 2005;http://www.cancer.org/, Accessed 7-2015). The majority of our participants did not identify the tongue as a major site of HNC, with 32.1% suggesting that it could occur anywhere in the oral cavity. However, in a study carried out in Iran, only 8.8% of participants reported the tongue and floor of the mouth as the most frequently affected sites (Pakfetrat et al., 2010). This indicates a general lack of awareness about the locations of HNC and underscores a need for increasing public knowledge and awareness and promoting HNC self-examination.
Only 19% of participants in the present study were aware of HPV, and only 18% associated it with HNC. This low percentage is in accordance with the 0.8%-36% reported by other studies (Luryi et al., 2014;Dwojak et al., 2015). In contrast, the proportion of individuals who knew that HIV was a risk factor for HNC vs. those who were unaware of this association was similar. The general lack of knowledge and awareness of HPV and HIV in Saudi Arabia can be explained by cultural reticence about discussing sexually transmitted diseases.
Interestingly, 58.9% of participants identified poor oral hygiene as a risk factor for HNC, in contrast to the results of studies carried out in Sri Lanka (11.4%) and Ireland (12%) (TE O Connor et al., 2010). Most participants (58%) identified genetics as a risk factor as compared to 9.5% of participants in a study conducted in Sri Lanka (Amarasinghe et al., 2010).
A cause for significant concern is the fact that the majority of participants (82.1%) had never been screened for HNC. Similarly, in the Sri Lankan study, < 5% had undergone screening (Amarasinghe et al., 2010). In addition, although most participants thought that this could be performed by dentists, dental hygienists, or general physicians (40.2%), only 14% preferred dentists. This is in agreement with the Iranian study, in which 72.8% of participants did not think the oral mucosa should be examined by dentists but 60% preferred general physicians to perform the screening. This suggests that dentists in Jeddah need to educate their patients about HNC and actively promote and practice HNC screening (Pakfetrat et al., 2010).
In conclusions, There is a need for greater knowledge and awareness among both public and dental professionals regarding HNC and for more routine screening. In addition, health ministries should take definitive action to increase public awareness of HNC in Saudi Arabia, for instance by using social media to reach to the community. Furthermore, engaging health professional-including dentists and dental hygienists-in HNC awareness campaigns throughout the year can have a significant impact on reducing mortality rates associated with this disease.