Awareness, knowledge, and willingness about early detection of bladder cancer in Saudi Arabia: a cross-sectional study

Introduction

Bladder cancer was the ninth most common diagnosed cancer worldwide in 2022, with 614,000 new cases and 220,000 deaths (1). In Saudi Arabia understanding bladder cancer awareness is crucial due to the country’s unique demographic profile, healthcare access patterns, and rising prevalence of noncommunicable illnesses, which might impact cancer risk and early detection efforts. The total incidence of bladder cancer from 2008 to 2017 was 1.4 per 100,000 individuals, as reported by a retrospective cohort analysis from the Saudi Cancer Registry (2). According to the Saudi Cancer Registry, bladder cancer ranks as the eighth most common malignancy in men and the twentieth in women (3). While the prevalence of bladder cancer in Arab countries is comparatively low, bladder cancer-related deaths are among the highest globally. Bladder cancer appears more aggressive in Arab countries, necessitating the use of appropriate methods (4).

Bladder cancer most commonly presents with irritative symptoms and hematuria. Most patients are asymptomatic and have a diagnosis during assessments for microscopic hematuria or, less often, pyuria (5).

Bladder cancer is four times more common in males than in females and often manifests in those aged >65 years (6-8). It is regarded as a predominantly preventable and avoidable malignancy due to its primary risk factors: smoking and chemical exposures (9,10). Individuals exposed to toxic substances are more likely to develop bladder cancer, regardless of sex (11). Those in occupations such as machinists, truck drivers, and metalworkers, particularly those employed in the textiles, paint, and rubber sectors, are at greater risk. Prolonged exposure to chemicals with aromatic amines, including benzidine and beta-naphthylamine, as well as dangerous organic compounds common in the dye industry and related industrial sectors, is a risk factor for bladder cancer (10,12). Additionally, a recent study highlighted that metabolic factors, such as high triglyceride levels, could also play a role in increasing bladder cancer risk (13). The most critical intervention in preventing bladder cancer is the cessation of smoking, followed by decreased exposure to environmental and occupational carcinogens. While routine screening is not currently recommended, it may be useful in high-risk patients, such as heavy smokers (14).

Currently, very few studies have examined the level of bladder cancer awareness in the Saudi population (15,16). Noncommunicable diseases, such as bladder cancer, are increasing worldwide. In Saudi Arabia, public knowledge about early detection and risk factors is frequently inadequate due to cultural, educational, or systemic impediments. Therefore, this study aimed to determine how well-informed the Saudi population is about bladder cancer, its risk factors, and its presenting signs and symptoms, as well as their willingness to undergo early screening, as early presentation and diagnosis are critical for optimal care and quality of life. The findings of this study can help identify misunderstandings, anxieties, stigma, and lack of awareness about bladder cancer. Additionally, it can help in identifying knowledge gaps based on age, gender, and education level. It can also highlight areas where actions are required and assists governments and healthcare practitioners in prioritizing efforts and incorporating brief educational interventions or risk discussions during routine treatment, especially in primary care and urology settings. It will also contribute to filling gaps in the research, as most studies are from Western or industrialized nations. We present this article in accordance with the STROBE reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-323/rc).

Methods

Study design

This questionnaire-based study employed a cross-sectional design. This study employed a convenience sampling approach, primarily through online distribution channels such as social media. The online tool was used because according to Global Media Insight [2024], Saudi Arabia has 37.10 million internet users, accounting for 99% of the total population. In addition, Saudi Arabia presently boasts the world’s largest social media presence (17). Using social media to send out questionnaires may not be a well-known research technique in some communities; however, this technique is widespread in Saudi Arabia.

Prior to the distribution of the questionnaires, a pilot test involving 18 participants was conducted to evaluate clarity and feasibility. The evaluation of internal consistency utilized Cronbach’s alpha, indicating overall acceptable reliability (α=0.81). The required sample size was estimated using the Raosoft sample size calculator, assuming a 95% confidence level, a 5% sampling error, and a 50% prevalence of the outcome of interest. Using a 50% response distribution increases the needed sample size while maintaining appropriate power and variability. Therefore, we aimed to recruit at least 377 individuals. Data were collected using a questionnaire designed to measure the knowledge of Saudi Arabian men and women about bladder cancer, its risk factors, and its symptoms, as well as their willingness to undergo early screening (12). It was divided into two sections. The first section collected respondents’ demographic characteristics, including sex, age, education level, marital status, and occupation, as well as their health information, including smoking status, bladder cancer diagnosis, and family history of bladder cancer. The second section evaluated respondents’ knowledge and understanding of bladder cancer, including its signs, symptoms, and risk factors, as well as their willingness to undergo early screening.

Inclusion/exclusion criteria

All Saudi men and women aged >18 years were eligible to participate in this study, regardless of their marital status (single, married, divorced, or widowed). No age cutoff was established to increase the number of Saudi men and women who were eligible to participate. To ensure we recruited the intended population, we inquired whether the participants were Saudi nationals before obtaining their consent. Those who were not Saudi nationals were excluded.

Data collection

The data were collected using an online survey hosted on Google Forms. The survey was distributed via messages to appropriate accounts on social media platforms, including Telegram, Facebook, WhatsApp, and Instagram, that were relevant to the Saudi population. Respondents who indicated willingness to engage in this research were provided a link to relevant information about the study’s purpose, the informed consent document, and the questionnaire.

Ethical considerations

This study received approval from the Ethics Committee at Taif University B (Date 02/03/2025/No. HAPO-02-T105) before data collection commenced. In order to minimize potential harm, it is essential to consider the ethical implications at every stage of the research process. Therefore, the respondents were asked non-intrusive questions about bladder cancer. They were well-informed about the study’s objectives, and their participation was entirely voluntary. Informed consent was obtained from all individual participants included in the study. They were also assured that they were not obligated to participate in this study, and it was confirmed that no personal, cultural, or social pressure was associated with their involvement. Access to the data collected during this study was restricted to the research team, and all participant data was treated and maintained with utmost confidentiality. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Statistical analysis

The data were entered into an Excel spreadsheet and statistically analyzed using Statistical Package for the Social Sciences (version 24; IBM Corp., Armonk, NY, USA). The internal consistency of the scale including dichotomous (yes/no) items was evaluated using Cronbach’s alpha. Categorical variables are presented as the frequency (percentage). Chi-squared test was employed to investigate the association between categorical variables. A significance level of P<0.05 was used.

Results

Respondents’ sociodemographic characteristics

Among respondents, 410 met the inclusion criteria, and 25 were excluded. Table 1 comprehensively summarizes the respondents’ sociodemographic characteristics. More respondents were female (78.0%) than male (22.0%). Regarding the age distribution, 138 were aged 18–25 years (33.7%), 62 were aged 26–35 years (15.1%), 94 were aged 36–49 years (22.9%), 90 were aged 50–60 years (22.0%), and 26 were aged >60 years (6.3%). Most respondents were married (46.8%), followed by single (42.4%), separated (8.3%), and widowed (2.4%). Regarding education level, 58.0% held a bachelor’s degree, 22.0% held a secondary school diploma, 8.8% held a master’s degree, 6.3% were uneducated, and 4.9% held a doctoral degree. Regarding health status, 88.3% were nonsmokers, while 11.7% were smokers; only 2 (0.5%) had been diagnosed with bladder cancer; and only 4.4% had a family history of bladder cancer.

Respondents’ level of awareness and knowledge of bladder cancer

Overall, 43.9% respondents had not heard of bladder cancer before this study. Comparisons of the level of knowledge across various personal and sociodemographic characteristics (Tables 2,3) indicated a low level of awareness among men 46.7%, those who are separated 58.8%, those aged 26–35 years 54.8%, those without formal education 69.2%, those who are unemployed 65.0%, those who smoked 50.0%, those who have not been diagnosed with bladder cancer 43.6%, and those without a family history of bladder cancer 45.9%.

Notably, most respondents 88.8% were aware that age increases the risk of bladder cancer. However, most 82.4% were unaware that smoking increases the risk of bladder cancer. In addition, only 21.5% were aware that using carcinogenic dyes increases the risk of bladder cancer. Most of these respondents were elderly, had never smoked, lacked a diagnosis, and had no family history of bladder cancer (Tables 2,3).

Consistent with the limited awareness, only 13.2% respondents knew about the signs and symptoms of bladder cancer. Of these respondents, 66.7% had a family history of bladder cancer. Fortunately, 92.7% were aware that bladder cancer is treatable. However, 94.1% were unaware that bladder cancer is preventable (Tables 2,3).

Respondents’ willingness to undergo bladder cancer early detection

Of the 410 respondents, 21.0% stated they would refuse early detection of bladder cancer, if offered, mostly those aged >60 years and retired. However, most respondents 90.2% were willing to learn more about early detection of bladder cancer. Interestingly, those who had not been diagnosed or had no family history of bladder cancer were unwilling to undergo early screening or learn more about screening (Table 4).

Association between awareness level and demographic characteristics

The lack of awareness level was significantly associated with and the lack of education (P=0.001). Similarly, the unemployment status was associated with the lack of awareness about bladder cancer (P<0.001). The presence of family history of bladder cancer was significantly correlated with the awareness level of bladder cancer (P<0.001) (Table 5).

Discussion

Advances and research in cancer have transformed cancer perception substantially in recent decades. However, preventative measures such as cancer education for the public and health professionals have received little attention. These initiatives have, regrettably, revealed a lack of awareness and comprehension of cancer worldwide. Therefore, studies must analyze baseline data, such as public awareness and attitudes about cancer, to ensure the effectiveness of such initiatives (18,19). A dearth of data exists about bladder cancer awareness in the Saudi population. Therefore, this study aimed to assess the Saudi population’s knowledge about bladder cancer, its risk factors, and its signs and symptoms, as well as willingness to undergo early screening, as timely presentation and diagnosis are essential for optimal care and quality of life.

Our study revealed that bladder cancer awareness is insufficient in the Saudi population, as 43.9% of the respondents had not heard of bladder cancer before completing the questionnaire for this study. This finding is unsurprising, as bladder cancer awareness is low in other countries, including Jordan (20), Lebanon (21), Ghana (12), and France (22). The survey also indicated that respondents who were uneducated or unemployed were unknowledgeable about bladder cancer, consistent with a previous study that demonstrated that education level correlates positively with knowledge (23). This correlation could be explained by a few interconnected factors that may contribute to a lower cancer awareness among individuals who are unemployed and uneducated. One is restricted access to information (24); in the absence of formal education, individuals may lack knowledge about topics concerning health, particularly those requiring fundamental literacy for comprehension. Comprehending medical concepts such as cancer, its symptoms, or preventive measures may also be difficult without formal education (25). Accessing healthcare services, such as early cancer screenings and educational resources, can be challenging when unemployed or with a limited income (26). The limited cancer awareness among the general population is concerning since it hinders individuals’ ability to make informed health decisions, potentially resulting in delayed presentation and reduced survival rates.

Our study also showed that most respondents were aware that age increases the risk of bladder cancer. However, there was a lack of awareness about bladder cancer’s association with smoking and carcinogenic dyes. In Saudi Arabia, there is still a lack of awareness of bladder cancer and its primary risk factors, particularly smoking and occupational exposures, which is consistent with our findings and recent regional studies. For instance, a 2019 survey conducted in western Saudi Arabia revealed that despite the fact that over 78% of respondents were aware of bladder cancer, only 24.8% exhibited a high level of overall knowledge (15). Furthermore, smoking was identified as a risk factor for bladder cancer by only 36.9% of urology patients in Riyadh (16). A study conducted in Pakistan revealed that the general population has a similarly low level of awareness of bladder cancer risk factors (27). The lack of nationwide education programs for bladder cancer in Saudi Arabia, restricted public health messages, and a lower perceived prevalence as compared to other malignancies are the main reasons for the low awareness level about bladder cancer. These gaps underscore the imperative necessity of culturally appropriate interventions. Public campaigns that capitalize on primary care clinics, mosques, and digital platforms could concentrate on high-risk populations, such as industrial laborers and male smokers. Evidence-informed program design and evaluation can be facilitated through collaboration with national organizations, including the Gulf Evidence-Based Health Practice Center and the Saudi Center for Disease Prevention and Control (Weqaya). By establishing educational initiatives in local epidemiology and healthcare infrastructure, they can transcend generic awareness and achieve quantifiable enhancements in early detection and prevention.

Similarly, our study showed that most respondents had poor knowledge about the signs and symptoms of bladder cancer. Those who were aware of these signs had a family history of bladder cancer. These results agreed with previous studies that indicated that patients with bladder cancer were unaware of these risk factors (20,28,29). Fortunately, 92.7% of respondents recognized that bladder cancer is curable. In contrast, 94.1% were unaware that bladder cancer is preventable. These results underscore the need for coordinated initiatives to enhance public access to information and resources on bladder cancer, emphasizing its causes, signs and symptoms, prevention, and treatment options.

In addition, 21.0% of the respondents stated they would decline bladder cancer early screening when offered. However, 90.2% were willing to learn more about early detection of bladder cancer. Insufficient evidence exists to endorse regular bladder cancer early screening. Targeted screening of high-risk patients, as determined by smoking history or occupational exposure, may decrease bladder cancer mortality and should be prioritized in prospective randomized trials. Regarding bladder cancer prevention, smoking cessation is the most important, followed by decreased exposure to carcinogens (14). The need for screening was supported by two preliminary trials using microhematuria screening, indicating that bladder cancer screening achieves over 80% downstaging, with high-grade tumors identified before invasion of the bladder wall. Long-term follow-up results indicate a significant decrease in bladder cancer mortality (30). Consequently, it is imperative to establish education campaigns and public awareness initiatives for bladder cancer early screening and prevention.

Given our results, it is evident that immediate measures are needed, and the portrayal of bladder cancer in anti-smoking campaigns should be broadened. Awareness programs are seen as very beneficial, as corroborated by several studies (31,32). Increased efforts to provide specific Arabic bladder cancer information and to promote appropriate medical advice-seeking habits in Arabic-speaking populations are essential. It has also been found that individuals diagnosed with bladder cancer frequently experience a reduced quality of life, potentially more severe than that observed in patients with other prevalent pelvic malignancies (33). Therefore, increasing knowledge about the risk factors, signs, and symptoms of bladder cancer, as well as implementing early screening and prevention measures, could significantly improve survival rates and quality of life for those affected by bladder cancer.

Our findings provide insights into bladder cancer awareness and willingness to undergo bladder cancer early screening in the Saudi population, as this study did not target a specific region of the country, and its sample size was suitably large. While this study was conducted in a single nation setting, we acknowledge that the geographical focus may restrict the findings’ generalizability to larger international populations. However, the findings provide vital insight into public awareness and attitudes concerning bladder cancer in a Middle Eastern environment, which is underrepresented in the literature. These findings may help to create culturally relevant health education programs and risk-based screening procedures not just in Saudi Arabia, but also in other countries with similar demographic, cultural, and healthcare system features. The technique and observed trends can inform comparative study across locations, leading to a better global knowledge of cancer awareness and early detection initiatives.

This study also had a few limitations. Firstly, it distributed the survey via social media platforms, which may have led to an underrepresentation of those aged >50 years and with lower social media usage. Secondly, the self-reported nature of the survey may have introduced recall bias in the data. Although convenience sampling approach was readily accessible and cost-effective, limited generalizability and lack of representativeness were disadvantages. Therefore, prudence is necessary when extrapolating the results to other demographic cohorts. Future research should employ mixed-method recruiting tactics to enhance representativeness. The probability sampling could enhance external validity, but logistical and resource constraints justified the use of a non-probabilistic sampling approach. We also advocate for further studies assessing the overall national knowledge about bladder cancer and its effect on quality of life.

Conclusions

The findings of this study indicated the low level of knowledge and awareness of bladder cancer among the Saudi population. As a result, raising awareness of the risk factors, signs, and symptoms of bladder cancer, as well as introducing screening and preventative strategies, has the potential to greatly improve survival rates and quality of life.

Acknowledgments

The authors extend their appreciation to Taif University, Saudi Arabia, for supporting this work through project number (TU-DSPP-2025-28).

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-323/rc

Data Sharing Statement: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-323/dss

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-323/prf

Funding: This research was funded by Taif University, Saudi Arabia, project (No. TU-DSPP-2025-28).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-323/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Approval was granted by the Ethics Committee at Taif University B (Date 02/03/2025/No. HAPO-02-T105). Informed consent was obtained from all individual participants included in the study.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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