Prostate cancer, its implications and awareness in the South Asian population: a retrospective cross-sectional cohort analysis

Introduction: The second most frequent form of cancer in males and the main reason for cancer-related deaths worldwide is prostate cancer (PC). Despite being less common than in Western nations, PC incidence and death rates have been rising throughout South Asia. This study intends to evaluate how well-informed and knowledgeable the South Asian public is about PC, its symptoms, and screening procedures among men and women. Methods: From August to September of 2022, a cross-sectional survey was carried out throughout South Asia. Participants in the research had to be at least 24 years old, and it used a practical sampling approach. A self-created questionnaire with both closed- and open-ended questions was used to gather the data. SPSS was used to conduct statistical analysis, including χ 2 tests for relationships. Results: A total of 378 individuals, comprising 57.6% men and 41.8% women, were involved in the study. Only 45.0% of participants were aware of prostate specific antigen testing for early PC diagnosis, however, 81.7% of people recognized what the prostate gland was. Approximately 87% of individuals had never received a screening for PC. Compared to males, women showed a stronger understanding of PC and its screening techniques. Notably, 94.7% believed the likelihood of effective therapy was increased by early identification. Conclusion: While women demonstrated better levels of knowledge, the study’s findings show that the general population in South Asia suffers from a serious shortage of reliable knowledge concerning PC. To promote early identification, lower morbidity, and enhance treatment success, awareness-raising and educational initiatives are essential, with a focus on both sexes. This study establishes the foundation for future research and emphasizes the necessity for targeted educational programmes in the area.


Introduction
Among the cancers that affect men, the second most common cancer and sixth commonest cause of cancer-related deaths worldwide is prostate cancer (PC) [1][2][3] .PC primarily affects males over the age of 50, with younger men facing a more severe type when diagnosed [4] .PC affects 9.4 men out of every 100 000 in Asia, making it the most frequent male cancer in the region [5] .
Chinese men had the lowest risk of PC, followed by men of mixed race and then Asian men, as compared to Black and White men, according to the National Cancer Intelligence Network and Cancer Research UK [6] .As an essential part of the male reproductive system, it is a walnut-sized (25 g) gland, which wraps the

HIGHLIGHTS
• Prostate cancer, a significant health concern, lacks awareness in South Asian population.In Asia, it is the most common cancer that only affects men.• The key objective was to analyze the knowledge gap on the risks, screening protocols, and people's unwillingness to seek medical treatment.• There is inadequate understanding of screening methods and preventive strategies, which needs to be addressed in South-Asian countries.• The study's distinctive conclusion was that women displayed higher awareness of PC that may help persuade their male family members to get examined early.• Government officials and medical professionals must both significantly contribute to educating the public in order to reduce the prevalence of PC. • Urgent need for public awareness campaigns and physician involvement to improve early detection.
urethra below the bladder and between the pubic bone and the rectum.It grows larger with age and can get rather huge in geriatric men [1] .Natural growth of the prostate gland with age is common.However, significant enlargement may suggest BPH, a disorder unrelated to PC.The American Urological Association generally advises surgery for prostates greater than 30 cc in volume, especially if lower urinary symptoms are present [7] .The genesis of PC appears to be influenced by factors such as age, genetics, environmental toxins, chemical dangers, and radiations, but the precise mechanism is unknown till today; however, PC can spread to the bones through the lymphatic system [8] .Despite having significantly lower PC prevalence than Western countries, PC incidence and mortality rates have recently increased in Asian countries.There is a recognized lack of information regarding the PC impact in South Asia as a result of the region's cultural, economic, and racial diversity [9] .Further to this, national cancer registration systems and fully developed prostate specific antigen (PSA) screening programs are still lacking in many Asian countries [10] .It is predicted that due to ageing and population growth, it has been estimated that by 2040, there would be 740 000 deaths and 2.3 million new cases worldwide from PC [2] .
PSA is frequently used for early PC screening.According to a review published in the Annals of Internal Medicine, screening reduced the risk of PC mortality by 25-31 and 27-32%, respectively, in the ERSPC (European Randomised Study of Screening for Prostate Cancer) trial and the PLCO (Prostate, Lung, Colorectal, and Ovarian Cancer) trial [11] .
Patients in the Asia-Pacific (APAC) region have a poor understanding of PC, its symptoms, and stages.In a study conducted in Pakistan it was documented that out of 383 (100%) men, 217 (56.7%) were not aware of PC, and only 64 (16.7%) were aware of the relevant diagnostic tests [12] .In Saudi Arabia, 64% participants of the calculated sample size were aware of PC and they had inadequate knowledge about the screening methods [13] .Similar results about the lack of knowledge of PC were reported in India [14] .
PC mortality patterns are clearly seen in WHO statistics.Since the 1970s, PC mortality rates have gradually increased in Hong Kong and Singapore, while they have significantly increased since the late 1990s in the Philippines, Korea, and Thailand.Mortality rates have stayed the same in Bahrain and Kuwait while being noticeably low in Sri Lanka.In addition, death rates in Australia, New Zealand, and Japan have decreased during the 1990s; this development may be attributable to improvements in therapy and early detection methods like PSA testing [10] .
The current study was undertaken to establish the general public's level of knowledge and comprehension of PC, its symptoms, and causes among both sexes in South Asia.

Methodology
This is a cross-sectional study conducted in the region of South-Asia from August to September 2022.OpenEpi software was used to calculate the sample size.The calculated sample size was n = 385, that was calculated at 50% proportion of total population and nonprobability convenient sampling technique was used to recruit the participants.The set inclusion criteria were males and females of age 24 and above and the exclusion criteria was nonconsenting participants.The present work has been reported in line with the strengthening the reporting of cohort, cross-sectional, and case-control studies in surgery (STROCSS) criteria [15] .Ethical approval for this cross-sectional cohort analysis was diligently obtained in accordance with established ethical principles and guidelines.

Data collection procedure
A self-developed questionnaire was administered after taking consent from the study participants.The questionnaire enclosed a close ended question regarding demographics and knowledge of PC and a few open-ended questions to seek the response and evaluate the degree of awareness among general population.The data collecting approach was carried out by delivering questionnaires to participants over the internet.

Data analysis procedure
Data was analyzed using SPSS version 20.Frequency and percentages were calculated to identify the correct responses.χ 2 test was used to find the association between groups; male and female.P-value less than 0.05 will be considered as significant at 95% CI.

Results
The total participants who wished to participate in the study and given consent were n = 378.Seven participants were excluded from the original sample size because their forms were incomplete.The mean age of study participants was 27.45 12.6.There were 218 (57.6%) male participants and 158 (41.8%) female participants.The education status of participants included matriculation till postgrade studies, 54% of study participants were graduates.(Fig. 1).
When participants were questioned on their knowledge about the prostate gland and PC, they gave positive response to all of the questions.When queried about screening techniques, a considerable portion of respondents demonstrated limited awareness.Specifically, 55.0% of respondents were not aware of PSA testing, and 48.4% were unaware of the DRE as early diagnosis methods for PC.This suggests that a notable portion of participants lacked knowledge about these screening techniques for detecting PC.Table 1 shows the responses of participants regarding knowledge of PC.
When questioned about the most prevalent age group at risk for PC, the study's participants indicated diverse responses: 39.9% marked 51-60 years, while 22.8% marked 41-50 years (Fig. 2).When asked where they first learned about PC screening tests, 37.6% said they had no knowledge about screening, nevertheless, 34% named doctors as their source of information.When asked if they had ever undergone prostate screening, 87% replied 'no'.Additionally, 5% of respondents indicated that both PSA and DRE were utilized as screening methods for the detection of prostate disease (Fig. 3).
Chi-square analysis was performed to determine the differences in knowledge between sexes regarding PC.When questioned about what a prostate is and have you heard about prostate disease, there was no discernible difference in awareness about PC.It was discovered that women were more knowledgeable than men about the screening procedure used for prostate disease diagnosis (P-value = 0.05).Table 2 shows the comparison of knowledge between sex.

Qualitative assessment of study participants regarding PC
We used open-ended questions to gage participant awareness of symptoms, risk factors, treatment options, justifications against prostate screening, and perceptions of uncomfortable urine and dribbling.We discovered that the majority of participants were aware of the symptoms of PC.Their responses included burning sensation while passing urine, painful ejaculation, blood in urine or semen, trouble commencing urination, and flank pain.However, few responses included symptoms like nausea, fever, vomiting, shaking, and chills, which are not symptoms of PC and therefore highlight the lack of awareness.Based on education, we found that those who had only completed matriculation lacked sufficient knowledge of PC symptoms, which highlights the lack of knowledge among literate people.
When questioned about risk factors, the majority of participants identified diet as a significant risk factor for developing PC; a small number also mentioned age over 50, family history, and obesity.Even after taking into account the investigated population's level of education, their answers suggested a lack of knowledge of risk factors.
Regarding treatment strategies the targeted population appeared knowledgeable.They included radiotherapy, chemotherapy, and surgery as possible modalities of treatment for PC patients.Homeopathic drugs and therapy with traditional remedies (Hikmat) were mentioned by a few participants.
When the participants were asked about prostate screening test, their responses included: not recommended by physician, not aware of screening test, unaware of screening test availability or no symptoms.For this question, their comments emphasized the necessity to end the taboo of doctor's referral for a disease screening and the general public's need for basic screening procedures for chronic illnesses.
On being questioned, what potential health risks might you take into account if you have uncomfortable urination and dribbling.The majority of patients indicated kidney stones and urinary tract infections in their responses.Rarely did any responses conclude PC.Following this, we asked what you would do if you experienced painful urination.In response, some said they would try some home remedies, increase water intake, and, for appropriate diagnosis and treatment, only a handful said they would visit a doctor.

Discussion
This cross-sectional study's primary objective in terms of the demography of South-Asia was to evaluate the paucity of information on the prevalence of PC's malignancy.The central theme in this cross-sectional study was to identify the gap of knowledge regarding the risks of PC, its symptoms and its screening tests among both sexes.The findings of this study revealed trends and an insight of 378 participants regarding the knowledge of PC of  The current study highlighted that among the recruited males, 73.4% had awareness regarding PC which is higher than Kenyan men (61.9%) [16] and South African men (45.6%) [17] .However, in contrast to this finding, a study conducted in Nigerian population in Oyo state, 80% males were aware of the ailment [18] .In spite of the availability of extensive knowledge tools (TV, social media), 88 (23.3%) participants were unaware of PC, indicating that about one-quarter of the population is at risk and cannot reach the hospital in time for early diagnosis and management of the condition.
Among the recruited participants, 130 (82.3%) female participants were familiar with PC, compared to 73.4% male participants.This suggests that women in our cohort understand PC, which in turn emphasizes the necessity for more research to uncover potential rationale.It is crucial for women to educate themselves and their male partners or male family members in order to facilitate in early detection of PC.Hence, in order to better understand and adherence to screening guidelines, it is necessary to examine women's knowledge regarding PC [19] .Tanveer et al. [1] measured the awareness of older men about PC, but did not evaluate females' knowledge.Even though PC affects male, there is need for public awareness initiatives targeting both the sexes in order to aid in PC prevention.
There are several media strategies to increase awareness about avoidable medical issues in the present day.When surveying our population, 37.6% said they were unfamiliar of screening methods, which contributes to the delayed diagnosis of the disease.This raises serious concern as screening is a major preventive  modality for PC, this highlights the importance of need of awareness campaigns in most countries of South Asia.However, 34.7% claimed that doctors were their source of information, which emphasizes the role of healthcare practitioners in disseminating information to the public.Whereas 21.4% learnt about PC from the internet, signifying the critical role that internet can play in raising awareness.This suggests that social media can be an informative medium for the younger generation and can play a potential role in near future to spread awareness regarding the prevalent diseases of our population.Around 5.8% gathered information from relatives and friends demonstrating low levels of awareness amongst the general population.It is regrettable that just 0.5% of the individuals learnt about PC via television, reflecting the government's lack of effort in providing health care awareness to their population.
The current data demonstrates that doctors play a crucial role in raising public knowledge of PC and influencing public opinion and attitudes.Additionally, Ridgway and Aning [20] illustrated the importance of general physicians in the identification and referral of patients with probable PC for additional testing.
One of the most notable findings of this study was that about 87% of participants were never screened, compared to only 5% who had both PSA and DRE tests, 4.5% only PSA tests, and 3.4% only DRE tests.On the contrary, when questioned about screening techniques, respondents in this study were aware of PSA testing in 45.0% of cases and DRE in 51.6% of cases for an early diagnosis of PC.Despite having extensive knowledge about screening methods, the majority of people were never screened.This demonstrates the patients' disregard and noncompliance on their part for refusing to get tested in spite of awareness.As PSA is the most important PC screening tool therefore, more men falling in the screening criteria according to WHO guidelines should be examined to determine PC for early diagnosis and management and for this purpose spread of knowledge among population and its acceptability can play a dominant role [21] .
According to this survey of both sexes, 94.7% of respondents think early detection of PC increases the likelihood of a successful treatment, and 90.5% think all elderly men should get PC screening.This demonstrates that a significant portion of people concur that PC screening is important.Similarly, in another research, 66.6% thought yearly screening for PC should be promoted whereas 74.2% had knowledge regarding the PSA and digital rectal exam as diagnostic tools for the condition [19] .
PC, according to almost 40% of the participants, mostly affects males in the age bracket of 51-60 years, with roughly 22% believing it affects men in the age group 41-50 years and around 20% believing it affects men in the age group 61-70 years.The vast majority of people associate PC with men between the ages of 51 and 60.As PC affects older individuals, our findings are consistent with previous literature.Males over the age of 65 are diagnosed approximately six times out of 10, while men under the age of 40 are seldom diagnosed, therefore the average age of men upon diagnosis is around 66 [22] .Although it affects men at the age of 60 years and more, screening is done at an earlier age of around 40 years.Men with risk factors such as a family history of cancer, African-American ethnicity, or an age of roughly 40 years old should consult their doctors regarding PC screening [23] .
After doing a quantitative analysis in accordance with the study's methodology, a qualitative analysis was carried out by posing questions to the intended audience.The perception regarding the risk factors associated with PC emphasizes the lack of accurate information on the disease's genesis among the investigated participants.This further suggests the need of taking appropriate measures to enhance the knowledge of our community in order to diagnose the disease early and improve prognosis.The overall responses regarding the preventative initiatives such as screening methods were inadequate.This significantly adds to the government's lack of efforts and, more crucially, the failure of healthcare professionals like physicians to educate our population.It is advisable that doctors should start routine PC screening of their patients in order to reduce the burden of morbidity and mortality associated with the disease.Furthermore, other factors contributing to the failure of visits to the doctor can also include financial constraints, limited access to healthcare as well as misconceptions and a general fear of a cancer diagnosis due to limited knowledge regarding the treatment and curability of PC. underscores the significance of widespread awareness initiatives and streamlined healthcare access for those in need.This may further be supported by the evidence of lack of knowledge about the risk factors, which plays a vital role in seeking advice and attention from the doctor.Previous literature has strongly linked the role of doctors and healthcare workers in providing patients with screening information [12] .Nevertheless, the staunch cultural belief in home remedies in order to control the symptoms of PC has also played a detrimental impact in disease prevalence as reflected through this study.

Limitations and strengths of the study
Numerous significant limitations of the study should be taken into account.First, there was a larger representation of women than men in the participant gender distribution, which was unbalanced.Due to this unequal distribution, the results may not have been as generalizable and may have been subject to bias.Furthermore, the majority of participants were graduates, suggesting a possible bias in favor of people with more education.The small sample size of the study may further reduce the reliability of the findings and make it more difficult to identify subtle trends or relationships.
The study, however, has certain noteworthy advantages that add to its relevance.Notably, it is the first research of its kind to assess men's and women's knowledge about PC in the setting of South Asia.This study provides a thorough knowledge of the general public's awareness and attitudes of PC by including both sexes.This thorough methodology gives the results depth and makes it possible to analyze the data holistically.The study's results also made clear the information gaps that still exist about PC and its detection techniques.These results highlight the urgent need for focused awareness initiatives and educational programmes that fill these knowledge gaps and encourage early identification.
Despite these limitations, the study offers important knowledge that will guide subsequent research.Future studies might have a greater generalizability and impact if they used a larger, more varied sample and had gender representation that was more evenly distributed.The findings highlight the need for focused educational efforts to overcome knowledge gaps and preconceptions about PC and associated screening techniques.These approaches have the potential to significantly improve early diagnosis and, as a result, therapeutic outcomes.

Conclusion
When evaluating the general public's knowledge about PC, it was found that there was a severe lack of reliable information.This study's distinct conclusion was that women had high knowledge levels that could assist their male family members in getting screened early.Most participants specially those between the ages of 51 and 60 are considered to be at high risk for PC.More than 80% of people have never had screening, although more than 90% consider that early screening can aid in earlier diagnosis.The study also underlines the importance of health care professionals in assisting individuals in making informed decisions and disseminating accurate information.Future research should focus on assessing the long-term efficacy of awareness interventions while accounting for the diverse demographics of the South Asian region.By addressing these significant discoveries and recommendations, professionals may be able to reduce the prevalence of PC among this population.

Figure 1 .
Figure 1.Education status of study participants.

Figure 3 .
Figure 3. Knowledge about screening method and previously used screening method.

Figure 2 .
Figure 2. Knowledge of age group at risk of prostate cancer.

Table 1
Knowledge of general public about prostate cancer.
which 57.6% were males and 81.7% of the sample population knew what prostate gland is.

Table 2
Comparison of knowledge between sex.