F1000Research F1000Research 2046-1402 F1000 Research Limited London, UK 10.12688/f1000research.144432.1 Research Article Articles Awareness of lung cancer risk factors and symptoms in Syria: an online cross-sectional study

[version 1; peer review: 1 approved, 1 not approved]

 Alibrahim Hidar Conceptualization Data Curation Writing – Original Draft Preparation Writing – Review & Editing 1 Bohsas Haidara Writing – Original Draft Preparation Writing – Review & Editing 1 Swed Sarya Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0002-9983-2020 1 Abouainain Yasmeen Writing – Original Draft Preparation Writing – Review & Editing 2 Almoshantaf Mohammad Badr Conceptualization Data Curation Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0002-7369-8978 a 3 Nasif Mohamad Nour Writing – Original Draft Preparation 1 Kazan Lazaward Writing – Original Draft Preparation Writing – Review & Editing 4 Alnadaf Rawan Farid Writing – Original Draft Preparation Writing – Review & Editing 5 Schkeif Nadim Writing – Original Draft Preparation Writing – Review & Editing 5 Al Ali Raghad Writing – Original Draft Preparation 5 Sawaf Bisher Writing – Original Draft Preparation 6 Swed Enas Writing – Original Draft Preparation 7 fathey Sherihan Writing – Original Draft Preparation 8 Rashid Gowhar Writing – Original Draft Preparation Writing – Review & Editing 9 Hafez Wael Supervision Writing – Review & Editing 10 11 Faculty of Medicine, Aleppo University, Aleppo, Syria University of Jordan, Amman, Faculty of Medicine, University of Jordan,, Amman, Jordan Neurosurgery, Ibn Al-walid Hospital, Homs, Homs, Syria Altınbaş university, ISTANBUL, Turkey Faculty of Medicine, Damascus University, Damascus, Damascus Governorate, Syria Hamad Bin Khalifa University, Doha, Doha, Qatar Faculty of Pharmacy, Damascus University, Damascus, Damascus Governorate, Syria Health, Giza university, Giza, Egypt Amity Medical School, Amity University, Haryana, India NMC Royal Hospital, Abu Dhabi, United Arab Emirates Internal Medicine, The National Research Centre, Cairo, Egypt baderalmoushantaf1995@gmail.com

No competing interests were disclosed.

 11 3 2024 2024 13 172 23 2 2024 Copyright: © 2024 Alibrahim H et al. 2024 This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background

Globally, lung cancer is the leading cause of cancer fatalities and the second most frequent cancer. Population knowledge of the features of lung cancer is a crucial strategy for early diagnosis and decreasing the mortality rate of lung cancer patients. In this study, we aim to assess the Syrian population’s knowledge of lung cancer and its risk factors and to measure awareness of symptoms related to lung cancer.

 Methods

This national cross-sectional study was conducted between October 12 to November 21, 2022, in Syria. We included Syrian people above 18 years from all Syrian governorates. The questionnaire consisted of three categories of questions: sociodemographic information, awareness of lung cancer symptoms, and awareness of lung cancer risk factors.

 Results

Overall, 2251 participants were involved in this research; almost half of them (47.3%) were aged between 21-30 years, and 30.9% indicated they are smoking cigarettes. The overall mean score of knowledge regarding closed questions about risk factors of lung cancer was 4.29; however, the mean score of knowledge regarding open questions about symptoms of lung cancer was 1.52. About half of the study sample (51.3%) indicated that unexplained weight loss is a possible symptom of lung cancer. Our findings showed that cigarette smokers have a lower probability of having adequate knowledge toward lung cancer risk factors than a non-smoker (AOR=0.73, COR=0.68, P-value<0.05). We also defined that females have higher statistically significant odds (AOR=1.3, COR=1.38, P-value<0.05) for being knowledgeable about the symptoms of lung cancer compared to the male sample study.

 Conclusion

According to our findings, there is inadequate knowledge toward lung cancer risk factors and moderate knowledge of lung cancer symptoms. Along with educational programs to raise public knowledge of the dangers of smoking and other LC risk factors, effective tobacco control policy execution is crucial.

 Lung Cancer Risk factors Symptoms Syria The author(s) declared that no grants were involved in supporting this work. 1. Background

Lung cancer is the most common cause of cancer-related deaths and the second most prevalent cancer worldwide (WHO, 2020). It is estimated that the incidence of lung cancer is 2.2 million globally. Also, there are 1.7 million death cases every year from lung cancer. 1 , 2 It is classified histologically into two types: Non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). NSCLC is more common, accounting for 85% of lung cancers, and includes three major subgroups: adenocarcinoma, large cell carcinoma, and squamous cell carcinoma. 3 In 2018, the number of new lung cancer cases was evaluated as 79887 in the Middle East and North Africa region, and 2144 were from Syria. Although diagnosis and treatment of lung cancer have been improved, the 5-year survival rate in those regions remains at 8%. Among all countries in the region, Morocco and Tunisia had the highest number of lung cancer-related deaths. 4 The most significant contributing risk factor to lung cancer is cigarette smoking. It is believed that there is a 5 to 10-fold increase in lung cancer risk among smokers. Also, the risk increases by 20% for nonsmokers exposed to passive smoking. 5 Although more than 85% of the cases are caused by avoidable tobacco exposure, lung cancer remains the leading cause of cancer deaths worldwide. 4 , 6 Other risk factors include family history, genetic tendency, occupational exposure (radon, ionizing radiation, diesel, and asbestos), chronic lung diseases and infections, lifestyle factors, and bad diet habits. 6 , 7 Since lung cancer symptoms are non-specific, most patients are diagnosed at advanced stages, particularly stage IV. 8 The most presenting symptoms are persistent cough, hemoptysis, chest pain, and dyspnea. Other metastatic symptoms can also occur, such as weight loss, fatigue, fever, and bone pain. 8 , 9 It is confirmed that many genetic and epigenetic modifications are triggered by cigarette smoking. 10 The knowledge of lung cancer-associated epigenetics helps us assess the risk, understand the process of carcinogenesis, diagnose the subtypes of cancer and predict the aggressiveness of the cancerous cells, response to treatment, prognosis, and metastasis. Therefore, we can make effective screening and treatment plans targeting those epigenetic alterations. 10 – 12 An early lung cancer diagnosis is critical to decreasing mortality and enhancing prognosis. Screening people at high risk using low-dose computed tomography (LDCT) results in a 20% reduction in mortality rate, as proved by The National Lung Screening Trial (NLST). Annual screening of high-risk groups starting from age 50 is recommended in many current guidelines. 13 – 15 It is recognized that late lung cancer diagnosis is due to the lack of understanding of the disease’s common symptoms. Therefore, raising public knowledge and awareness of lung cancer is crucial for early detection and treatment. 16 It is believed that low-income countries and high tobacco consumption have less knowledge of symptoms and contributing factors of lung cancer, resulting in less effective treatment and a low survival rate. 1 , 4 Therefore, our aim in this study is to assess the knowledge of lung cancer and its risk factors and to measure the awareness of lung cancer-related symptoms among the Syrian population.

 2. Methods 2.1 Study design and setting

An online survey cross-sectional study was conducted between October 12 to November 21, 2022 in Syria. The inclusion criteria of study participants were adults (≥18 years old), Syrian nationals from all Syrian governorates. Participants who were non-Syrians, students or workers in healthcare facilities were excluded from the study. This survey was created in the light of a previous research that used modified, approved scales. 17 , 18 Then, the questionnaire was translated into Arabic by healthcare professionals in order to be easily understood and answered for the participants, which the utilized questionnaire was uploaded as extended data (see data availability statement). Specific collaborators from many medical Syrian colleges ( Data Collection Group) were responsible to collect the data by disrupting the online survey, which was generate at google form website, on social media platforms such as WhatsApp, Telegram, and Facebook. Regarding, the sample size calculation, it was estimated using Calculator.net tool (Population Size (The number of the individuals of the Syrian community in 2021 according to the world bank organization 19 (PS) = 18,275,704. The proportion of the population who are aware toward the lung cancer (PP) = 50%, Confidence level (CL) = 95%, and the margin error (ME) = 5%, which the recommended sample size to represent overall findings at level of the Syrian population was 385.

 2.2 Measures

A modified version of the Lung Cancer Awareness Measure (LCAM) was utilized as an assessment tool. LCAM is a face-to-face questionnaire that was developed and approved by University College London and Cancer Research UK to measure the awareness of lung cancer. 20 The questionnaire had three parts: The first one contained sociodemographic data of the participants. The second part focused on measuring the awareness of the — symptoms of lung cancer, and the last part analyzed the level of the knowledge toward the lung cancer risk factors. Although the awareness level was assessed in the original LCAM questions by using yes/no/unknown responses scale, in modified Arabic LCAM we used a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree) to reduce the possibilities of random answers. Then, the resultant responses were converted into correct/incorrect responses as was done in the previous researches. 21 – 25

2.2.1 Sociodemographic variables

In this section, the sociodemographic data of the respondents were included. There were 10 questions covering the needed details about: 1) age. 2) Gender. 3) Marital status explained as single, married, divorced, or widowed. 4) Educational level as below secondary or post-secondary. 5) Occupational status as unemployed, student, employed, or retired. 6) Monthly income. 7) Suffering from a chronic disease. 8) Living place. 9) Knowing someone diagnosed with cancer. 10) History of cigarette/water pipe smoking expressed as never smoked, former, or current smoker.

2.2.2 Awareness of lung cancer symptoms

This section was contained 14 questions with answers using 3- Likert scale (Yes, No, I don’t know) evaluating participants’ awareness level of symptoms lung cancer. Included symptoms were 1) unexplained weight loss. 2) Persistent chest infection ≥ 3 weeks. 3) Persistent cough for ≥ 2/3 weeks. 4) Persistent shortness of breath. 5) Persistent tiredness. 6) Persistent chest pain. 7) Persistent shoulder pain. 8) Coughing up blood. 9) Pain while breathing. 10) Loss of appetite. 11) Painful cough. 12) Changes in the shape of fingers and nails. 13) Developing an unexplained loud, high-pitched sound when breathing. 14) Worsening or change in an existing cough.

2.2.3 Awareness of lung cancer risk factors

This part involved 9 questions with answers using 5 - Likert scale (1 = strongly disagree, 2 = disagree, 3 = not sure, 4 = agree, 5 = strongly agree) evaluating participants’ awareness level of risk factors lung cancer. Included risk factors were 1) Exposure to radon gas. 2) Exposure to near smoker. 3) Having a previous treatment of cancer. 4) Having a relative with lung cancer patient. 5) Exposure to chemicals such as asbestos. 6) Having a previous diagnosis of any cancer. 7) Air pollution. 8) Smoking. 9) Having a previous diagnosis with lung disease such as interstitial lung disease.

 2.3 Pilot study

To ensure clarity and readability for respondents, we distributed the online survey among various Syrian individuals and incorporated their feedback to enhance the questionnaire. Although the initial questionnaire was adapted from a study conducted in an Arabic country (Palestine), 21 we rigorously assessed its reliability and validity. Specifically, we computed Cronbach’s alpha for each scale, including knowledge of risk factors and symptoms of lung cancer, confirming consistency with previously published work.

 2.4 Ethical consideration

The study was ethically reviewed and approved by Syrian Ethical Society for Scientific Research in Aleppo University (IRB: SA19/01). In compliance with ethical standards, a comprehensive statement about informed consent was provided to all participants on the first page of the online survey. At the first page of the online survey, all participants were informed about the study goal, research group’s identity, their right to pull out from the research, collected data privacy and protection, and the fact that only totally submitted information would be analyzed. Completing the whole survey takes from 5 to 10 minutes. For clarity, consent from participants was obtained, and this process was approved by the ethical review committee. Participants were presented with the necessary information to make an informed decision, and their consent was obtained written.

 2.5 Statistical analysis

The IBM SPSS V. 28.0 package application was used to analyses the data (IBM Corporation, Armonk, NY, USA). a proprietary research instruments. It is confirmed that a valid copyright license for the use of SPSS v. 28.0 has been obtained. A P-value of 0.05 or less indicated statistical significance. A mean and standard deviation were provided for the quantitative data. In contrast, the categorical data was presented as frequency and percentage after the Shapiro-Wilk test confirmed that the distribution of the data was non-parametric. Kruskal–Wallis one-way analysis of variance and One-way analysis of variance tests were performed to determine the difference in the level of knowledge toward the risk factors and symptoms of the lung cancer between the subgroups. In order to determine the expected values of “Odds ratios” between the dependent variable (knowledge the risk factors and symptoms of the lung cancer) and independent factors (sociodemographic variables), we utilized a binary logistic regression, which we relied on the cut off points from the Palestinian research. 17 , 18

3. Results 3.1 Sociodemographic characteristics and health-related factors of study participants

We define that 2303 participants were invited to participate in this study, and 52 participants refused to complete the received online survey, so the final sample size of the study participants was 2251. Almost half of the respondents (n = 1041, 47.3%) aged between 21-30 years, and about two-thirds were females and were lived in the city (n = 1430, 63.5%), (n = 1475, 65.5%). Regarding the educational level, 72.6% of participants had a university (Bachelor’s\Master) degree, and 35.1% (n = 791) of respondents were married. However, 1234 of the study participants (54.8%) reported moderate monthly income. The majority of participants (92.7%) were with no chronic disease. Finally, 30.9% of study participants indicated they were smokers ( Table 1).

Baseline characteristics of the inquired participants in the study sample.
Variable Frequency Percentage %
Age 18-20 470 21.3%
21-30 1041 47.3%
31-40 332 15.1%
41-50 214 9.7%
51-60 111 5.0%
61-70 31 1.4%
70< 4 0.2%
Gender Male 821 36.5%
Female 1430 63.5%
Residency Village 776 34.5%
City 1475 65.5%
Educational level Primary 46 2.0%
Secondary (1-3) 133 5.9%
Secondary (4-6) 415 18.4%
University (Bachelor’s\Master) 1634 72.6%
Ph.D. 23 1.0%
Marital status Married 791 35.1%
Single 1399 62.2%
Widowed 30 1.3%
Divorced 31 1.4%
Occupation Unemployed 351 15.6%
Student 940 41.8%
Employed 960 42.6%
Monthly income Bad 179 8.0%
Moderate 1234 54.8%
Good 766 34.0%
Excellent 72 3.2%
Chronic disease No 2087 92.7%
Yes 164 7.3%
Have you ever smoked cigarettes? No 1556 69.1%
Yes 695 30.9%
3.2 Summary of participants’ knowledge scores on lung cancer risk factors and symptoms

The mean score and standard deviation of knowledge regarding closed questions of risk factors of lung cancer (mean = 4.29, SD = 2.32); however, the mean score and stander deviation regarding the open questions were 8.63 and 3.07, respectively. Concerning the knowledge of lung cancer symptoms, the closed questions scored mean = 8.63, SD = 3.07, while open questions scored (mean = 1.52, SD = 1.25) ( Table 2).

The observational findings of the utilized sub-scales.
Items Mean Std. Deviation Minimum Maximum
Knowledge of risk factors (Closed) 4.29 2.42 .00 9.00
knowledge of lung cancer symptoms (Closed) 8.63 3.07 .00 14.00
Knowledge of risk factors (open) 1.29 0.83 .00 7.00
knowledge of lung cancer symptoms (open) 1.52 1.25 .00 7.00

3.2.1 Participants’ Awareness of Lung Cancer Symptoms

Concerning the knowledge toward lung cancer symptoms, about half of the study respondents (1155, 51.3%) indicated that unexplained weight loss is a possible symptom. On the other hand, about 80% of participants believed that persistent (3 weeks or longer) chest infection might be a lung cancer symptom. Regarding the persistent shortness of breath (1904, 84.6%) of participants revealed it as one of the lung cancer symptoms. Nearly a quarter of participants didn’t identify loss of appetite as a possible symptom of lung cancer (543, 24.1%). Also, about a third of respondents didn’t recognize that lung cancer symptom include changes in the shape of fingers or nails. Finally, (n=518, 23.0%) didn’t know if worsening or change in an existing cough is one of the lung cancer symptoms ( Table 3).

The description of the inquired items within the knowledge of lung cancer symptoms scale.
Statement Frequency Percentage %
1. Unexplained weight loss No 501 22.3%
Don’t Know 595 26.4%
Yes 1155 51.3%
2. Persistent (3 weeks or longer) chest infection No 221 9.8%
Don’t Know 232 10.3%
Yes 1798 79.9%
3. A cough that does not go away for two or three weeks No 227 10.1%
Don’t Know 227 10.1%
Yes 1797 79.8%
4. Persistent shortness of breath No 170 7.6%
Don’t Know 177 7.9%
Yes 1904 84.6%
5. Persistent tiredness or lack of energy No 377 16.7%
Don’t Know 620 27.5%
Yes 1254 55.7%
6. Persistent chest pain No 210 9.3%
Don’t Know 240 10.7%
Yes 1801 80.0%
7. Persistent shoulder pain No 724 32.2%
Don’t Know 933 41.4%
Yes 594 26.4%
8. Coughing up blood No 324 14.4%
Don’t Know 318 14.1%
Yes 1609 71.5%
9. An ache or pain when breathing No 262 11.6%
Don’t Know 398 17.7%
Yes 1591 70.7%
10. Loss of appetite No 543 24.1%
Don’t Know 726 32.3%
Yes 982 43.6%
11. Painful cough No 211 9.4%
Don’t Know 325 14.4%
Yes 1715 76.2%
12. Changes in the shape of your fingers or nails No 769 34.2%
Don’t Know 1026 45.6%
Yes 456 20.3%
13. Developing an unexplained loud, high-pitched sound when breathing No 348 15.5%
Don’t Know 641 28.5%
Yes 1262 56.1%
14. Worsening or change in an existing cough No 218 9.7%
Don’t Know 518 23.0%
Yes 1515 67.3%
3.3 Participants’ perceptions of lung cancer risk factors: Responses to specific statements

Regarding the knowledge of lung cancer risk factors, 45.7% of study participants were unsure whether exposure to radon gas is one of the risk factors. As well, concerning cigarette smoke exposure, about half of the participants (n = 1065, 47.3%) agreed it is a lung cancer risk factor. Almost a quarter of respondents (546, 24.3%) didn’t agree that lung cancer risk factors included the presence of a close relative with lung cancer. In addition, 8.3% of participants strongly disagreed that exposure to chemicals, for example asbestos is one of the lung cancer risk factors, and just half of the study respondents indicated that smoking is a risk factor for developing lung cancer ( Table 4).

The description of the inquired items within the knowledge of lung cancer risk factors scale.
Statement Frequency Percentage %
Exposure to radon gas Strongly Disagree 165 7.3%
Disagree 144 6.4%
Not Sure 1028 45.7%
Agree 712 31.6%
Strongly agree 202 9.0%
Cigarette smoke exposure Strongly Disagree 181 8.0%
Disagree 348 15.5%
Not Sure 377 16.7%
Agree 1065 47.3%
Strongly Agree 280 12.4%
Past cancer treatment Strongly Disagree 163 7.2%
Disagree 504 22.4%
Not Sure 942 41.8%
Agree 549 24.4%
Strongly Agree 93 4.1%
Close relative with lung cancer Strongly Disagree 374 16.6%
Disagree 546 24.3%
Not Sure 573 25.5%
Agree 649 28.8%
Strongly Agree 109 4.8%
Exposure to chemicals for example asbestos Strongly Disagree 186 8.3%
Disagree 151 6.7%
Not Sure 653 29.0%
Agree 1006 44.7%
Strongly Agree 255 11.3%
Past history of cancer, for example head and neck Strongly Disagree 218 9.7%
Disagree 444 19.7%
Not Sure 869 38.6%
Agree 639 28.4%
Strongly Agree 81 3.6%
Air pollution Strongly Disagree 199 8.8%
Disagree 282 12.5%
Not Sure 470 20.9%
Agree 1082 48.1%
Strongly Agree 218 9.7%
Being a smoker Strongly Disagree 216 9.6%
Disagree 119 5.3%
Not Sure 189 8.4%
Agree 1134 50.4%
Strongly Agree 593 26.3%
History of lung disease, for example Chronic obstructive pulmonary disease Strongly Disagree 204 9.1%
Disagree 283 12.6%
Not Sure 770 34.2%
Agree 809 35.9%
Strongly Agree 185 8.2%
3.4 Knowledge of lung cancer symptoms and risk factors by demographic characteristics

As shown in Table 5, we noticed the mean score of knowledge (8.78, 4.38) toward symptoms and risk factors of lung cancer were higher in females than males. Regarding the education status, participants with University (Bachelor’s\Master) and with a Ph.D. degree were more knowledgeable (mean = 8.77, 4.65) about lung cancer symptoms and risk factors, respectively. However, single participants had more knowledge (mean = 4.44) of risk factors of lung cancer than other marital status subgroups. Students had more averages of knowledge about symptoms and risk factors of lung cancer compared to other occupation status subgroups. Respondents who were smokers were less knowledgeable about identifying lung cancer symptoms and risk factors (mean = 8.36, 3.99). The participants said that persons aged 70 years old had a higher understanding regarding the symptoms and risk factors of lung cancer ( Table 5).

Knowledge of lung cancer symptoms and risk factors score for each sub-groups in the inquired sample.
Statement Age
Age groups Mean Std. Deviation P-value
Knowledge of symptoms of lung cancer 20> 8.4702 2.97218 0.420760
21-30 8.7185 2.92544
31-40 8.4849 3.30198
41-50 8.6168 3.30356
51-60 9.0000 3.46935
61-70 8.7097 3.33860
70< 6.7500 3.50000
Total 8.6310 3.06818
Knowledge of risk factors of lung cancer 20> 4.2213 2.28977 0.089128
21-30 4.4419 2.38399
31-40 4.2500 2.44100
41-50 4.2103 2.48520
51-60 3.8288 2.93838
61-70 4.2581 2.35185
70< 2.5000 1.73205
Total 4.3064 2.41534
Gender
Knowledge of symptoms of lung cancer Male 8.3630 3.21919 0.001594
Female 8.7881 2.98384
Total 8.6331 3.07787
Knowledge of risk factors of lung cancer Male 4.1352 2.36437 0.020010
Female 4.3818 2.45056
Total 4.2919 2.42187
Residency
Knowledge of symptoms of lung cancer Village 8.6933 3.09485 0.500681
City 8.6014 3.06948
Total 8.6331 3.07787
Knowledge of risk factors of lung cancer Village 4.2255 2.43298 0.345868
City 4.3268 2.41609
Total 4.2919 2.42187
Education’s status
Knowledge of symptoms of lung cancer Primary 7.2826 3.82775 0.000005
Secondary (1-3) 7.6015 3.83749
Secondary (4-6) 8.5928 3.27270
University (Bachelor’s\Master) 8.7785 2.89580
Ph.D. 7.6957 3.71036
Total 8.6331 3.07787
Knowledge of risk factors of lung cancer Primary 2.7391 2.39847 0.000
Secondary (1-3) 3.2932 2.68210
Secondary (4-6) 4.0337 2.53551
University (Bachelor’s\Master) 4.4774 2.33397
Ph.D. 4.6522 2.14495
Total 4.2919 2.42187
Monthly income
Knowledge of symptoms of lung cancer Bad 8.3966 3.53541 0.104242
Moderate 8.5600 2.98062
Good 8.8394 3.08003
Excellent 8.2778 3.39935
Total 8.6331 3.07787
Knowledge of risk factors of lung cancer Bad 4.0726 2.67537 0.554220
Moderate 4.2804 2.34304
Good 4.3525 2.46036
Excellent 4.3889 2.68305
Total 4.2919 2.42187
Marital status
Knowledge of symptoms of lung cancer Married 8.6321 3.30668 0.882820
Single 8.6219 2.93625
Widowed 8.7333 3.61923
Divorced 9.0645 2.81585
Total 8.6331 3.07787
Knowledge of risk factors of lung cancer Married 4.0632 2.57073 0.001376
Single 4.4417 2.31636
Widowed 3.5333 2.59620
Divorced 4.0968 2.50805
Total 4.2919 2.42187
Occupation
Knowledge of symptoms of lung cancer Unemployed 8.7379 3.33975 0.014080
Student 8.8160 2.88862
Employed 8.4156 3.14660
Total 8.6331 3.07787
Knowledge of risk factors of lung cancer Unemployed 4.0627 2.55042 0.001754
Student 4.5021 2.33120
Employed 4.1698 2.44722
Total 4.2919 2.42187
Chronic disease
Knowledge of symptoms of lung cancer No 8.6593 3.02584 0.148658
Yes 8.2988 3.67078
Total 8.6331 3.07787
Knowledge of risk factors of lung cancer No 4.3076 2.40191 0.271187
Yes 4.0915 2.66266
Total 4.2919 2.42187
Have you ever smoked cigarettes?
Knowledge of symptoms of lung cancer No 8.7532 2.99273 0.005555
Yes 8.3640 3.24657
Total 8.6331 3.07787
Knowledge of risk factors of lung cancer No 4.4248 2.40474 0.000095
Yes 3.9942 2.43532
Total 4.2919 2.42187
Taking an appointment from a doctor
Knowledge of symptoms of lung cancer I don’t have symptoms 8.5204 3.60924 0.000163
I don’t know 7.2874 4.17609
I will wait for a week or more 8.8362 2.92962
Immediately (within 3 days) 8.7329 2.87410
Total 8.6635 3.05239
Knowledge of risk factors of lung cancer I don’t have symptoms 4.1338 2.49565 0.000007
I don’t know 3.1034 2.66779
I will wait for a week or more 4.2560 2.43392
Immediately (within 3 days) 4.4200 2.35949
Total 4.3111 2.41217
Who is most at risk of developing lung cancer in the next year?
The Knowledge of symptoms of lung cancer Not related to age 8.4490 3.09703 0.000047
30 years old person 8.3506 3.41346
50 years old person 9.1184 2.91826
70 years old person 9.1692 2.96163
Total 8.6331 3.07787
The Knowledge of risk factors of lung cancer Not related to age 4.1937 2.35402 0.000007
30 years old person 3.6623 2.52675
50 years old person 4.4324 2.53097
70 years old person 5.0050 2.52685
Total 4.2919 2.42187
3.5 Association between knowledge of lung cancer risk factors and demographic characteristics

In overall, good knowledge toward the risk factors of lung cancer was shown in females (34.8%, P-value < 0.05) more than in males (17.8%), and for the educational level, more knowledgeable persons were found in participants with university (Bachelor’s\Master) degree group (40.4%, P-value < 0.01) compared to other educational sub-groups. Participants who were smokers and had an inadequate level of awareness regarding risk factors formed just 14.2%, and the participants who reported lung cancer not related to age and had good knowledge of risk factors of lung cancer were (34.8%) ( Table 6).

Knowledge of Risk factors based on baseline characteristics of the study sample.
Statement Knowledge of Risk factors of lung cancer P-value
Poor knowledge Good knowledge
Frequency Percentage % Frequency Percentage %
Age 20> 229 10.4% 241 10.9% 0.125848
21-30 470 21.3% 571 25.9%
31-40 164 7.4% 168 7.6%
41-50 105 4.8% 109 4.9%
51-60 58 2.6% 53 2.4%
61-70 12 0.5% 19 0.9%
70< 4 0.2% 0 0.0%
Gender Male 421 18.7% 400 17.8% 0.006468
Female 646 28.7% 784 34.8%
Residency Village 387 17.2% 389 17.3% 0.279274
City 680 30.2% 795 35.3%
Educational level Primary 34 1.5% 12 0.5% 0.000
Secondary (1-3) 88 3.9% 45 2.0%
Secondary (4-6) 211 9.4% 204 9.1%
University (Bachelor’s\Master) 725 32.2% 909 40.4%
Ph.D. 9 0.4% 14 0.6%
Marital status Married 399 17.7% 392 17.4% 0.007510
Single 635 28.2% 764 33.9%
Widowed 16 0.7% 14 0.6%
Divorced 17 0.8% 14 0.6%
Occupation Unemployed 179 8.0% 172 7.6% 0.003189
Student 413 18.3% 527 23.4%
Employed 475 21.1% 485 21.5%
Monthly income Bad 99 4.4% 80 3.6% 0.447395
Moderate 580 25.8% 654 29.1%
Good 357 15.9% 409 18.2%
Excellent 31 1.4% 41 1.8%
Chronic disease No 987 43.8% 1100 48.9% 0.296619
Yes 80 3.6% 84 3.7%
Have you ever smoked cigarettes? No 692 30.7% 864 38.4% 0.000065
Yes 375 16.7% 320 14.2%
Taking an appointment from a doctor I don’t have symptoms 129 5.9% 140 6.4% 0.000251
I don’t know 52 2.4% 35 1.6%
I will wait for a week or more 140 6.4% 153 7.0%
Immediately (within 3 days) 714 32.5% 836 38.0%
Who is most at risk of developing lung cancer in the next year? Not related to age 775 34.4% 784 34.8% 0.000002
30 years old person 44 2.0% 33 1.5%
50 years old person 175 7.8% 239 10.6%
70 years old person 73 3.2% 128 5.7%
Knowledge of lung cancer symptoms Poor Knowledge 582 25.9% 399 17.7% 0.000
Good Knowledge 485 21.5% 785 34.9%
3.6 Association between knowledge of lung cancer symptoms and demographic characteristics

There was a statistically significant difference between specific subgroups regarding the knowledge of symptoms of lung cancer, of which 37.7% and 25.8% of females have shown good and inadequate knowledge of risk factors of lung cancer, respectively. In addition, we define that there was a statistical difference between the educational subgroups regarding the level of knowledge of lung cancer risk factors, which the participants in the university educational category and those who had adequate knowledge (42.3%) were more than those who hadn’t (30.3%). In addition, less recognition toward lung cancer symptoms has been found among 29.1% of smokers, and 39.7% of respondents reported they taking an immediate appointment with a doctor with adequate knowledge toward lung cancer symptoms ( Table 7).

Knowledge of symptoms based on sociodemographic variables of the study sample.
Variable Knowledge of lung cancer symptoms P-value
Poor knowledge Good knowledge
Count Layer N % Count Layer N %
Age 20> 202 9.2% 268 12.2% 0.320125
21-30 446 20.2% 595 27.0%
31-40 152 6.9% 180 8.2%
41-50 97 4.4% 117 5.3%
51-60 44 2.0% 67 3.0%
61-70 14 0.6% 17 0.8%
70< 3 0.1% 1 0.0%
Gender Male 400 17.8% 421 18.7% 0.001027
Female 581 25.8% 849 37.7%
Residency Village 331 14.7% 445 19.8% 0.369899
City 650 28.9% 825 36.7%
Educational level Primary 30 1.3% 16 0.7% 0.000388
Secondary (1-3) 72 3.2% 61 2.7%
Secondary (4-6) 185 8.2% 230 10.2%
University (Bachelor’s\Master) 681 30.3% 953 42.3%
Ph.D. 13 0.6% 10 0.4%
Marital status Married 346 15.4% 445 19.8% 0.721687
Single 610 27.1% 789 35.1%
Widowed 11 0.5% 19 0.8%
Divorced 14 0.6% 17 0.8%
Occupation Unemployed 141 6.3% 210 9.3% 0.005210
Student 384 17.1% 556 24.7%
Employed 456 20.3% 504 22.4%
Monthly income Bad 82 3.6% 97 4.3% 0.117684
Moderate 559 24.8% 675 30.0%
Good 305 13.5% 461 20.5%
Excellent 35 1.6% 37 1.6%
Chronic disease No 900 40.0% 1187 52.7% 0.380556
Yes 81 3.6% 83 3.7%
Have you ever smoked cigarettes? No 655 29.1% 901 40.0% 0.010937
Yes 326 14.5% 369 16.4%
Taking an appointment from a doctor I don't have symptoms 102 4.6% 167 7.6% 0.022422
I don't know 49 2.2% 38 1.7%
I will wait for a week or more 123 5.6% 170 7.7%
Immediately (within 3 days) 678 30.8% 872 39.7%
Who is most at risk of developing lung cancer in the next year? Not related to age 715 31.8% 844 37.5% 0.000199
30 years old person 38 1.7% 39 1.7%
50 years old person 157 7.0% 257 11.4%
70 years old person 71 3.2% 130 5.8%
Knowledge of Risk factors Poor Knowledge 582 25.9% 485 21.5% 0.000
Good Knowledge 399 17.7% 785 34.9%
3.7 Predictors of adequate knowledge toward lung cancer risk factors

Seven out of twelve predictor factors were significantly linked with a good knowledge of lung cancer risk factors (P-value < 0.05). The university participants (Bachelor’s\Master) educational category were more likelihood to recognize the lung cancer risk factors than other participants with primary degree (OR = 2.620, P-value < 0.05), and the respondents who were smokers were less likely to identify the adequate degree of the knowledge toward risk factors of lung cancer than who weren’t a smoker (OR = 0.773, P-value < 0.05). In addition, we showed that persons aged 70 years under the most risk of developing lung cancer in the next year had higher odds of understanding the risk factors 1.579 times than those who reported that lung cancer was not related to age ( Table 8).

Binary logistic regression of the predictors variables to having adequate level of knowledge toward lung cancer risk factors.
Predictor Item for having adequate knowledge toward lung cancer risk factors P-value Adjusted odds ratio Upper Lower P-value Non-adjusted odds ratio Upper Lower
Age 20> Ref
21-30 .088 1.261 .966 1.645 .197 1.154 .928 1.436
31-40 .178 1.313 .884 1.952 .851 .973 .735 1.289
41-50 .102 1.456 .928 2.286 .934 .986 .714 1.363
51-60 .615 1.152 .664 1.997 .504 .868 .574 1.314
61-70 .081 2.158 .909 5.119 .283 1.504 .714 3.169
70< .999 .000 .000 . .999 .000 .000 .
Gender Male Ref
Female .137 1.165 .952 1.425 .005 1.277 1.076 1.517
Residency Village Ref
City .354 1.094 .904 1.325 .089 1.163 .977 1.384
Educational level Primary Ref
Secondary (1-3) .590 1.253 .552 2.847 .332 1.449 .685 3.066
Secondary (4-6) .037 2.257 1.050 4.854 .004 2.739 1.380 5.438
University (Bachlor’s\Master) .013 2.620 1.230 5.581 .000 3.552 1.826 6.910
Phd .022 3.967 1.220 12.901 .006 4.407 1.519 12.786
Marital status Married Ref
Single .174 1.210 .919 1.592 .023 1.225 1.028 1.458
Widowed .878 1.067 .464 2.456 .756 .891 .429 1.849
Divorced .614 1.228 .553 2.729 .631 .838 .408 1.724
Occupation Unemployed Ref
Student .625 1.089 .775 1.529 .024 1.328 1.039 1.698
Employed .956 .992 .742 1.326 .626 1.063 .832 1.357
Monthly income Bad Ref
Moderate .421 1.152 .816 1.627 .038 1.395 1.018 1.912
Good .859 1.033 .718 1.488 .036 1.418 1.022 1.966
Excellent .405 1.293 .707 2.365 .080 1.637 .943 2.842
Chronic disease No Ref
Yes .202 1.286 .873 1.895 .713 .942 .685 1.295
Have you ever smoked cigarettes? No Ref
Yes .014 .773 .628 .950 .000 .683 .571 .818
Taking an appointment from a doctor I don’t have symptoms Ref
I don’t know .344 .779 .465 1.306 .056 .620 .380 1.013
I will wait for a week or more .734 1.062 .749 1.508 .967 1.007 .723 1.403
Immediately (within 3 days) .388 1.128 .858 1.483 .566 1.079 .833 1.398
Who is most at risk of developing lung cancer in the next year? Not related to age Ref
30 years old person .456 .827 .501 1.363 .204 .741 .467 1.177
50 years old person .056 1.257 .994 1.589 .007 1.350 1.085 1.680
70 years old person .006 1.579 1.141 2.185 .000 1.733 1.279 2.349
Knowledge of lung cancer symptoms Poor Knowledge Ref
Good Knowledge .000 2.258 1.887 2.703 .000 2.361 1.991 2.800
3.8 Predictors of adequate knowledge toward lung cancer symptoms

Five out of twelve predictor variables were significantly associated with having an acceptable level of knowledge of the symptoms of lung cancer (P-value < 0.05), which females more likelihood to be knowledgeable about the lung cancer symptoms than males (OR = 1.301, P-value < 0.05), and the participants with a university (Bachelor’s\Master) educational stage were more likely to recognize the lung cancer symptoms than other participants with primary degree (OR = 2.030, P-value). The participants who indicated that persons aged 50 years under the most risk of developing lung cancer in the next year had higher odds of understanding the symptoms of lung cancer 1.328 times than those who reported that the lung cancer was not related to age. However, respondents who didn’t know about taking an appointment with a doctor were less likely to identify an acceptable level of knowledge about lung cancer symptoms than those who reported they didn’t have symptoms (OR = .528, P-value < 0.05) ( Table 9).

Binary logistic regression of the predictors variables to having adequate level of knowledge toward lung cancer Symptoms.
Predictor Item for having adequate knowledge toward lung cancer symptoms P-value Adjusted odds ratio Upper Lower P-value Non-adjusted odds ratio Upper Lower
Age 20> Ref
21-30 .988 .998 .763 1.305 .961 1.006 .807 1.253
31-40 .851 .962 .646 1.433 .431 .893 .673 1.184
41-50 .907 1.027 .654 1.614 .566 .909 .657 1.259
51-60 .172 1.469 .845 2.554 .522 1.148 .753 1.750
61-70 .943 1.031 .444 2.396 .812 .915 .441 1.900
70< .872 .815 .067 9.853 .233 .251 .026 2.433
Gender Male Ref
Female .010 1.301 1.064 1.591 .000 1.388 1.168 1.650
Residency Village Ref
City .149 .868 .716 1.052 .520 .944 .792 1.125
Educational level Primary Ref
Secondary (1-3) .400 1.390 .646 2.988 .192 1.589 .792 3.186
Secondary (4-6) .102 1.816 .889 3.710 .009 2.331 1.233 4.407
University (Bachlor’s\Master) .049 2.030 1.003 4.111 .002 2.624 1.419 4.852
Phd .915 1.065 .339 3.344 .483 1.442 .518 4.014
Marital status Married .454 .892
Single .243 .849 .644 1.118 .950 1.006 .844 1.199
Widowed .304 1.572 .663 3.725 .444 1.343 .631 2.859
Divorced .766 .887 .403 1.952 .876 .944 .459 1.942
Occupation Unemployed Ref
Student .967 1.007 .715 1.420 .825 .972 .757 1.248
Employed .080 .770 .575 1.032 .018 .742 .579 .951
Monthly income Bad Ref
Moderate .576 .906 .642 1.279 .898 1.021 .745 1.398
Good .691 1.077 .748 1.551 .143 1.278 .921 1.773
Excellent .186 .668 .367 1.215 .687 .894 .517 1.545
Chronic disease No Ref
Yes .123 .741 .506 1.085 .120 .777 .565 1.068
Have you ever smoked cigarettes? No Ref
Yes .942 .992 .806 1.221 .034 .823 .687 .985
Taking an appointment from a doctor I don’t have symptoms .061 .025
I don’t know .015 .528 .316 .881 .003 .474 .290 .773
I will wait for a week or more .260 .814 .570 1.164 .326 .844 .602 1.184
Immediately (within 3 days) .037 .742 .561 .982 .075 .786 .602 1.025
Who is most at risk of developing lung cancer in the next year? Not related to age Ref
30 years old person .670 .898 .546 1.475 .549 .869 .550 1.374
50 years old person .019 1.328 1.048 1.683 .004 1.387 1.111 1.732
70 years old person .021 1.468 1.058 2.036 .005 1.551 1.142 2.106
Knowledge of Risk Factors Poor Knowledge Ref
Good Knowledge .000 2.261 1.889 2.706 .000 2.361 1.991 2.800
4. Discussion

Lung cancer (LC) is the main cause of cancer-related fatalities and the second most diagnosed malignancy worldwide. 26 , 27 Due to a lack of education about the disease and its symptoms, lung cancer is frequently identified late in low and middle-income countries (LMICs). If more people knew about lung cancer, it would be diagnosed and treated faster. Evidence shows that providing palliative care early on might increase a patient’s quality of life and possibly extend their lifespan. 16 This research aims to assess how well-informed the Syrian public is about lung cancer and its avoidable risk factors, as well as how well-known the disease’s symptoms are. As per the results, participants’ knowledge levels were categorized as satisfactory and insufficient using two revised Bloom’s cutoff thresholds: 70% and 80% of the overall score. This classification was determined by the number of correct answers, with 24 and 27 correct responses out of a total of 34 questions, respectively. While the knowledge was higher among females, non-smokers, and people with a university degree or a doctorate, the knowledge was still rather low overall.

The most widely acknowledged respiratory symptom of lung cancer was identified as ’persistent shortness of breath,’ while the most recognized non-respiratory symptom was ‘unexplained weight loss.’ On the other hand, the least recognized respiratory symptom for lung cancer was ‘developing an unexplained loud, high-pitched sound when breathing,’ and the least acknowledged non-respiratory symptom was ‘changes in the shape of fingers/nails.’

It was found that having a strong knowledge of the symptoms of LC was connected with a shorter amount of time before seeking medical treatment, which can help with the early diagnosis of LC. 28 – 31 As a result, determining the degree to which the general public is aware of the symptoms of LC is essential if one is to locate the knowledge gap that has to be filled by educational interventions. According to the findings of this research, there is potential for advancement in the level of public awareness of the symptoms of LC in Syria. It was discovered that Australia, Nigeria, and the United Kingdom all had less than desirable levels of understanding of LC symptoms. 20 , 32 , 33 This may emphasize the vital need for standardized educational programs to enhance public awareness of LC symptoms by world health authorities. This is particularly important, considering LC substantially contributes to the global burden of cancer-related morbidity and mortality. 27 The high rate of smoking prevalence in Syria, particularly among men, may contribute to increased awareness of the symptoms of LC. 34 The general population is probably well aware that smoking is a risk factor for lung cancer; hence, there could be more curiosity among the general public to read more about lung cancer than other malignancies. This study showed that women had a better understanding of LC symptoms than men did, which is an interesting finding. Women, particularly those who do not smoke, have a greater risk of developing lung cancer than men. 35 Syrian women may be aware of this fact, which may motivate them to increase their health literacy regarding LC. Additional research is required to evaluate people’s awareness of the risk factors associated with LC, as well as to investigate the disparities in awareness that exist between smokers and non-smokers, as well as between men and women. This study found that LC’s least recognized respiratory symptom was ‘developing an unexplained loud, high-pitched sound when breathing.’ The findings of another study carried out in the United Kingdom found that the least recognized respiratory symptom of LC was a ‘cough that does not go away for two or three weeks. 32 It’s possible that people attributed their continuous coughing to something other than LC. This could have been due to participants mistaking the symptoms of LC for those of a less serious lung illness (like COPD) or to their own habits (like smoking). 36 , 37 Conversely, ‘persistent shortness of In contrast to studies conducted in Australia, Nigeria, and Canada, where ‘coughing up blood’ was identified as one of the most recognized respiratory symptoms of lung cancer, the present findings highlight ‘persistent shortness of breath’ as a prominent respiratory symptom. Similarly, aligning with a study from the United Kingdom, 32 the two least recognized non-respiratory symptoms in this study were ‘persistent shoulder pain’ and ‘changes in the shape of fingers or nails’ associated with lung cancer. In the future, educational activities should stress the fact that LC symptoms are not always respiratory. 37 Consistent with previous research in Nigeria and the United Kingdom, 32 , 33 we found that higher levels of education were related to a higher likelihood of demonstrating good awareness of LC. Participants with a greater level of education may be more likely to interact with others who share their expertise in health-related fields. Also consistent with previous research is the finding that having personal experience with cancer increases one’s awareness of LC symptoms. 38 , 39 Female participants were more likely to show a high awareness of LC symptoms, a finding consistent with an Australian study. 20 Assuming that the moderately high levels of awareness found in this study represent the population as a whole, it may be possible to achieve greater social justice by implementing standard educational interventions in Syria to increase public awareness of the symptoms of LC. Previous research has shown that educating the public about cancer symptoms increases consultations with medical professionals and leads to better early identification of LC. 29 , 30 While cancer mortality in high-income nations is stable or decreasing, it is steadily rising in low- and middle-income countries like Syria and is expected to account for 75% of global cancer fatalities by 2030. 39 Anti-smoking programs, better early detection, and more effective treatment are all factors in this drop. 40 Since effective treatment modalities are often in short supply in low- and middle-income nations, early identification of cancer is crucial for better cancer management in these regions. 16 Unfortunately, there is a lack of data on LC awareness or efforts to raise that awareness in poor and middle-income countries. 16 Syrian health policymakers should prioritize identifying LC risk factors, developing educational programs, and implementing effective tobacco control laws to raise risk awareness, alter consumer behavior, and promote early diagnosis and presentation. Smokers aware of the higher risk of developing LC may quit early should they encounter any of the disease’s symptoms. Campaigns like this may also help dispel the misconception that smokers with respiratory difficulties have nothing else to worry about but their habits. 20 , 41

In order to efficiently disseminate information through widely accessed channels targeting various demographic groups such as younger males or older age cohorts, it is imperative to conduct additional research on the information sources preferred by the general public. Understanding the sources from which different segments of the population obtain information can guide tailored communication strategies, ensuring that messages are effectively conveyed to specific audiences is required in Syria and the wider region. This research needs to focus on both Syria and the wider region. In addition, obstacles to health-seeking behavior need to be investigated to find solutions to these problems and enable early presentation at healthcare facilities. 28 , 30 In addition, increasing investments in cancer prevention and control in low- and middle-income nations like Syria, where the disease is prevalent, but resources are limited, is essential but is sometimes neglected to owe to the expenses involved. 40 Yet, programs that focus on LC awareness and prevention, such as anti-smoking campaigns and tobacco control regulations, are potentially low-cost and high-effect interventions that might have a favorable influence on the modification of risk factors and the early presentation of the disease.

4.1 Strengths and limitations

This study has several strengths, the most notable of which are its high response rate and its recruitment of participants from various locations throughout Palestine. Using a cross-sectional questionnaire that was administered during an in-person interview helped reduce the likelihood that respondents relied on information obtained from other sources when responding to survey questions. There are a few limitations to this study. The use of convenience sampling does not assure that a representative sample will be generated and restricts the extent to which the findings may be generalized. On the other hand, this might have been somewhat compensated for by the high response rate and the fact that they were recruited from various geographical locations. For instance, females constituted 63.5% of the participants in this study, despite the fact that they account for around 50% of the population in Syria. 42 Another potential restriction is that most of the people who participated in the research were young (less than 30 years old), and as a result, they were at a lesser risk of getting LC than older people. The fact that younger people make up the majority of Syria’s population. 43 may explain why many younger people are participating in the demonstrations. Nevertheless, increasing awareness among young people may be an efficient technique for building a culture of early detection of LC symptoms and rapid medical care for any probable LC symptoms. This would be a civilization where early recognition of LC symptoms is a cultural norm.

 5. Conclusion

The knowledge of Syrian medical professionals on LC symptoms and risk factors was limited. Factors related to heightened awareness were female gender, postsecondary education, and nonsmoking status. The most recognized respiratory LC symptom was ‘persistent shortness of breath’, whereas the most recognized non-respiratory LC symptom was ‘unexplained weight loss. This research emphasizes the need for education and awareness efforts, especially in low and middle-income countries like Syria, where the prevalence of LC is significant yet often misdiagnosed due to a lack of knowledge about the disease.

 Data availability Underlying data

Zenodo: Awareness of Lung Cancer Risk Factors and Symptoms in Syria: An Online Cross-Sectional Study, https://doi.org/10.5281/zenodo.10148451. 44

This project contains the following underlying data:

lung cancer.xlsx

 Extended data

Zenodo: Awareness of Lung Cancer Risk Factors and Symptoms in Syria: An Online Cross-Sectional Study, https://doi.org/10.5281/zenodo.10148451. 44

This project contains the following extended data:

S1 Table.docx

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

 References Elshami M Abukmail H Aqel W : Awareness of Palestinians about lung cancer symptoms: a national cross-sectional study. BMC Pulm. Med. 2022;22(1):135. 35395762 10.1186/s12890-022-01923-1 PMC8991725 WHO: Cancer. Reference Source Reference Source Duffy MJ O’Byrne K : Tissue and Blood Biomarkers in Lung Cancer: A Review. Adv. Clin. Chem. 2018;86:1–21. 10.1016/bs.acc.2018.05.001 Jazieh AR Algwaiz G Errihani H : Lung Cancer in the Middle East and North Africa Region. J. Thorac. Oncol. 2019;14(11):1884–1891. 31668315 10.1016/j.jtho.2019.02.016 Schwartz AG Cote ML : Epidemiology of Lung Cancer. Adv. Exp. Med. Biol. 2016;893:21–41. 10.1007/978-3-319-24223-1_2 Bade BC Dela Cruz CS : Lung Cancer 2020: Epidemiology, Etiology, and Prevention. Clin. Chest Med. 2020;41(1):1–24. 10.1016/j.ccm.2019.10.001 Malhotra J Malvezzi M Negri E : Risk factors for lung cancer worldwide. Eur. Respir. J. 2016;48(3):889–902. 10.1183/13993003.00359-2016 Ruano-Raviña A Provencio M Calvo de Juan V : Lung cancer symptoms at diagnosis: results of a nationwide registry study. ESMO Open. 2020;5(6):e001021. 33214227 10.1136/esmoopen-2020-001021 PMC7678343 Lung Cancer: May 5, 2022. Reference Source Langevin SM Kratzke RA Kelsey KT : Epigenetics of lung cancer. Transl. Res. 2015;165(1):74–90. 24686037 10.1016/j.trsl.2014.03.001 PMC4162853 Duruisseaux M Esteller M : Lung cancer epigenetics: From knowledge to applications. Semin. Cancer Biol. 2018;51:116–128. 28919484 10.1016/j.semcancer.2017.09.005 Ansari J Shackelford RE El-Osta H : Epigenetics in non-small cell lung cancer: from basics to therapeutics. Transl. Lung Cancer Res. 2016;5(2):155–171. 27186511 10.21037/tlcr.2016.02.02 PMC4858572 Toumazis I Bastani M Han SS : Risk-Based lung cancer screening: A systematic review. Lung Cancer. 2020;147:154–186. 32721652 10.1016/j.lungcan.2020.07.007 Nooreldeen R Bach H : Current and Future Development in Lung Cancer Diagnosis. Int. J. Mol. Sci. 2021;22(16). 34445366 10.3390/ijms22168661 PMC8395394 Jones GS Baldwin DR : Recent advances in the management of lung cancer. Clin. Med. (Lond.). 2018;18(Suppl 2):s41–s46. 10.7861/clinmedicine.18-2-s41 Nwagbara UI Ginindza TG Hlongwana KW : Lung cancer awareness and palliative care interventions implemented in low-and middle-income countries: a scoping review. BMC Public Health. 2020;20(1):1466. 32993570 10.1186/s12889-020-09561-0 PMC7526234 Elshami M Abukmail H Aqel W : Awareness of Palestinians about lung cancer symptoms: a national cross-sectional study. BMC Pulm. Med. 2022;22(1):135. 35395762 10.1186/s12890-022-01923-1 PMC8991725 Mansour AA Elshami M Al-Ser M : P2.11-01 Awareness of Lung Cancer Risk Factors in Palestine: Current Situation and Future Directions. J. Thorac. Oncol. 2022;17(9, Supplement):S148. 10.1016/j.jtho.2022.07.246 Population, total - Syrian Arab Republic. Reference Source Crane M Scott N O’Hara BJ : Knowledge of the signs and symptoms and risk factors of lung cancer in Australia: mixed methods study. BMC Public Health. 2016;16:508. 27296668 10.1186/s12889-016-3051-8 PMC4906715 Elshami M Al-Slaibi I Abukmail H : Knowledge of Palestinian women about cervical cancer warning signs: a national cross- sectional study. BMC Public Health. 2021;21(1):1779. 34598690 10.1186/s12889-021-11792-8 PMC8487127 Elshami M Thalji M Abukmail H : Knowledge of cervical cancer risk factors among Palestinian women: a national cross-sectional study. BMC Womens Health. 2021;21(1):385. 34727914 10.1186/s12905-021-01510-2 PMC8561913 Elshami M Yaseen A Alser M : Knowledge of ovarian cancer symptoms among women in Palestine: a national cross-sectional study. BMC Public Health. 2021;21(1):1992. 34732142 10.1186/s12889-021-12044-5 PMC8567700 Elshami M Elshami A Alshorbassi N : Knowledge level of cancer symptoms and risk factors in the Gaza Strip: a cross-sectional study. BMC Public Health. 2020;20(1):414. 32228661 10.1186/s12889-020-08553-4 PMC7106782 Elshami M Bottcher B Alkhatib M : Perceived barriers to seeking cancer care in the Gaza Strip: a cross-sectional study. BMC Health Serv. Res. 2021;21(1):28. 33407426 10.1186/s12913-020-06044-1 PMC7788935 International Agency for Research on Cancer: Lung Cancer Fact Sheet. 2020. Accessed 1 November 2022. Reference Source Sung H Ferlay J Siegel RL : Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J. Clin. 2021;71(3):209–249. 33538338 10.3322/caac.21660 Moffat J Bentley A Ironmonger L : The impact of national cancer awareness campaigns for bowel and lung cancer symptoms on sociodemographic inequalities in immediate key symptom awareness and GP attendances. Br. J. Cancer. 2015;112 Suppl 1(Suppl 1):S14–S21. 25734383 10.1038/bjc.2015.31 Ironmonger L Ohuma E Ormiston-Smith N : An evaluation of the impact of large-scale interventions to raise public awareness of a lung cancer symptom. Br. J. Cancer. 2015;112(1):207–216. 25461805 10.1038/bjc.2014.596 PMC4453621 Power E Wardle J : Change in public awareness of symptoms and perceived barriers to seeing a doctor following Be Clear on Cancer campaigns in England. Br. J. Cancer. 2015;112(1):S22–S26. 25734386 10.1038/bjc.2015.32 PMC4385972 Saab MM Noonan B Kilty C : Awareness and help-seeking for early signs and symptoms of lung cancer: A qualitative study with high-risk individuals. Eur. J. Oncol. Nurs. 2021;50:101880. 33333451 10.1016/j.ejon.2020.101880 Simon AE Juszczyk D Smyth N : Knowledge of lung cancer symptoms and risk factors in the U.K.: development of a measure and results from a population-based survey. Thorax. 2012;67(5):426–432. 22426791 10.1136/thoraxjnl-2011-200898 Desalu OO Fawibe AE Sanya EO : Lung cancer awareness and anticipated delay before seeking medical help in the middle-belt population of Nigeria. Int. J. Tuberc. Lung Dis. 2016;20(4):560–566. 26970168 10.5588/ijtld.15.0497 Ward KD Eissenberg T Rastam S : The tobacco epidemic in Syria. Tob. Control. 2006;15 Suppl 1(Suppl 1):i24–i29. 16723671 10.1136/tc.2005.014860 Rivera MP Stover DE : Gender and lung cancer. Clin. Chest Med. 2004;25(2):391–400. 10.1016/j.ccm.2004.01.006 Cunningham Y Wyke S Blyth KG : Lung cancer symptom appraisal among people with chronic obstructive pulmonary disease: A qualitative interview study. Psychooncology. 2019;28(4):718–725. 30693608 10.1002/pon.5005 PMC6492269 Walter FM Rubin G Bankhead C : Symptoms and other factors associated with time to diagnosis and stage of lung cancer: a prospective cohort study. Br. J. Cancer. 2015;112 Suppl 1(Suppl 1):S6–S13. 25734397 10.1038/bjc.2015.30 Lubuzo B Ginindza T Hlongwana K : The barriers to initiating lung cancer care in low-and middle-income countries. Pan Afr. Med. J. 2020;35:38. 10.11604/pamj.2020.35.38.17333 Friedemann Smith C Whitaker KL Winstanley K : Smokers are less likely than non-smokers to seek help for a lung cancer ‘alarm’ symptom. Thorax. 2016;71(7):659–661. 26911574 10.1136/thoraxjnl-2015-208063 PMC4941149 Shah SC Kayamba V Peek RM Jr : Cancer Control in Low- and Middle-Income Countries: Is It Time to Consider Screening? J. Glob. Oncol. 2019;5:1–8. 30908147 10.1200/JGO.18.00200 Haastrup PF Jarbøl DE Balasubramaniam K : Predictive values of lung cancer alarm symptoms in the general population: a nationwide cohort study. NPJ Prim. Care Respir. Med. 2020;30(1):15. 32265450 10.1038/s41533-020-0173-3 PMC7138801 Syria Population: Syria Population clock (live). Reference Source World Population Dashboard Syrian Arab Republic: Syrian Arab Republic - Overview. Reference Source Almoshantaf MB : Awareness of Lung Cancer Risk Factors and Symptoms in Syria: An Online Cross-Sectional Study.[Data set]. Zenodo. 2023. 10.5281/zenodo.10148451 10.5256/f1000research.158224.r274919 Reviewer response for version 1 Smith Robert 1 Referee Early Cancer Detection Science, American Cancer Society,, Atlanta, Georgia, USA

Competing interests: No competing interests were disclosed.

 14 5 2024 Copyright: © 2024 Smith R 2024 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve

The authors have conducted a survey to measure knowledge and awareness of symptoms of lung cancer. 

Comments: In the abstract, a reader will not understand knowledge scores, so suggest the authors describe the knowledge levels instead of using scores.

Please also adhere to IASLC language guidelines to describe people who currently or ever smoked. Specifically, avoid using the term "smoker," since it results in stigma. 

I'm surprised at the high level of education in most of the survey respondents. Probably this warrants a comment.

In the discussion, the authors state that lung cancer is typically diagnosed late due to lack of education about the disease and symptoms. Probably it should be said that lack of knowledge is a factor in later stage at diagnosis, since most lung cancer symptoms do not appear until the disease is quite advanced. Too often, also, health care professionals dismiss symptoms as likely due to something less worrisome (not lung cancer) especially in people who don't smoke, or never smoked. The next statement claims greater knowledge would result in earlier diagnosis and faster initiation of treatment. Probably, but some citations would be useful to support this statement. Reference 8 provides some insights, but we have to infer that the presence of symptoms led to the detection--hence, the awareness. 

In the 3rd paragraph, I'm not sure the 4 references (28-31) truly demonstrate that greater awareness of symptoms leads to those symptoms prompting the patient to seek medical care. I think you can infer that this likely would be the case, but I don't see a direct correlation. If I have missed something, suggest that the authors describe these findings more clearly. I do accept these observations, as well as just good sense, should lead to the goal of raising awareness with the hope that it will lead to earlier diagnosis. 

One thing that warrants discussion is the importance of having health care professionals prepared to consider the possibility of lung cancer when patients present with symptoms. Delays in diagnosis are influenced by health care workers wishing to be reassuring that a common symptom (a cough) probably has a less worrisome cause than lung cancer.

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Yes

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?

Yes

Reviewer Expertise:

Epidemiology of cancer, Cancer Screening

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

 10.5256/f1000research.158224.r256618 Reviewer response for version 1 Saab Mohamad 1 Referee https://orcid.org/0000-0002-7277-6268 University College Cork, Cork, Ireland

Competing interests: No competing interests were disclosed.

 25 4 2024 Copyright: © 2024 Saab M 2024 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation reject

Thank you for inviting me to review this manuscript which I have read with interest. Please see below my comments to improve this manuscript:

GENERAL COMMENTS

“lung cancer patients” replace with “patients with lung cancer” throughout the manuscript.

Either run this paper by a native English speaker or use editing services since there are a number of errors in spelling, syntax, sentence structure etc. which distract from content.

Some statements and conclusions made are not relevant to this study and read like they were written for a different study altogether.

 ABSTRACT

30.9% indicated they were smoking cigarettes (as opposed to are).

“The overall mean score of knowledge regarding closed questions about risk factors of lung cancer was 4.29” you must indicate out of a possible maximum score of XXX, the overall mean score for knowledge…

“Our findings showed that cigarette smokers have a lower probability of having adequate knowledge toward lung cancer risk factors than a non-smoker (AOR=0.73, COR=0.68, P-value<0.05)” rephrase: “We also found that cigarette smokers had a lower probability of having adequate knowledge toward lung cancer risk factors in comparison to non-smokers (AOR=0.73, COR=0.68, P-value<0.05)”

“We also defined that females have higher statistically significant odds (AOR=1.3, COR=1.38, P-value<0.05) for being knowledgeable about the symptoms of lung cancer compared to the male sample study.” Do you mean we also found? The manuscript requires proofreading.

“Knowledge toward” or “knowledge of”? choose one and use consistently throughout the paper.

 INTRODUCTION

Written as one long paragraph. This disrupts flow. Make sure to use new paragraphs to present new ideas. I can easily see 5 to 6 different paragraphs here.

“Therefore, raising public knowledge and awareness of lung cancer is crucial for early detection and treatment.16 It is believed that low-income countries and high tobacco consumption have less knowledge of symptoms and contributing factors of lung cancer, resulting in less effective treatment and a low survival rate.1,4” add to this that population-based research aimed to promote lung cancer awareness, help-seeking and early detection is conducted predominantly in Western countries. Please cite this paper to back this up: (Saab MM, et al., 2021)[ Ref 1]

 METHODS

“Then, the questionnaire was translated into Arabic by healthcare professionals in order to be easily understood and answered for the participants, which the utilized questionnaire was uploaded as extended data (see data availability statement)” this sentence is structurally incorrect and does not make sense. Do you mean: “Then, the questionnaire was translated to Arabic by healthcare professionals to ensure that it is easily understood by participants. The questionnaire can be found in extended data.”

“Which was generate at google form website” do you mean “which was generated using Google Forms?” Unfortunately, there are issues with English language throughout. I encourage you to either run this paper by a native English speaker or use editing services. These errors distract from the content. I will stop making these corrections at this point.

“Specific collaborators from many medical Syrian colleges (Data Collection Group) were responsible to collect the data by disrupting the online survey, which was generate at google form website, on social media platforms such as WhatsApp, Telegram, and Facebook.” Do you mean distributing? Also, how was the questionnaire distributed on these platforms? Facebook groups? Sponsored ads? Who was targeted? As for WhatsApp, as this is a mobile phone messaging application, were participants’ phone numbers obtained?

Pilot study: How many people filled the questionnaire during the pilot study? Were these responses included in the final analysis? Were any changes made to the instrument following the pilot study?

 RESULTS

“We define that 2303 participants were invited to participate in this study, and 52 participants refused to complete the received online survey, so the final sample size of the study participants was 2251.” Not clear what is meant by “we define” also, how did you determine how many participants were invited to participate and how many refused if you sent the questionnaire online via social media? Usually, the reach of the survey and refusal cannot be determined in social media-based surveys. Again, a lot of spelling/English errors here.

“3.2 Summary of participants’ knowledge scores on lung cancer risk factors and symptoms.” The section under this heading does not make sense.

 DISCUSSION

Overall, well written. Again, the discussion must be broken down to several paragraphs to ensure better flow. An argument can be made that early help-seeking is not only the responsibility of the person at risk for LC. Healthcare professionals must also be equipped with the means to “pull” these people into the appropriate services. See these two papers:  (Saab MM, et al., 2022)[ Ref 2] , (Saab MM, et al., 2022)[ Ref 3]

 STRENGTHS AND LIMITATIONS

Do you mean Syria? (as opposed to Palestine).

You mention here that the survey was administered in person, yet in the methods above you say it was an online questionnaire. These discrepancies are concerning.

The use of social media could have led to the younger age group participating in this study.

“in the demonstrations” what demonstrations? The last sentence in this section reads like a recommendation and not a strength/limitation.

 CONCLUSION

I refer to your exclusion criteria under section 2.1 earlier: “Participants who were non-Syrians, students or workers in healthcare facilities were excluded from the study” yet in your conclusion you state “The knowledge of Syrian medical professionals on LC symptoms and risk factors was limited” this reads like a conclusion for a different paper altogether. This is a major concern.

Is the work clearly and accurately presented and does it cite the current literature?

No

If applicable, is the statistical analysis and its interpretation appropriate?

Yes

Are all the source data underlying the results available to ensure full reproducibility?

Partly

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

No

Are sufficient details of methods and analysis provided to allow replication by others?

Partly

Reviewer Expertise:

lung cancer, cancer awareness, systematic reviews, cross-sectional research, testicular cancer.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

References : Promoting lung cancer awareness, help-seeking and early detection: a systematic review of interventions. Health Promot Int .2021;36(6) : 10.1093/heapro/daab016 1656-1671 33647930 10.1093/heapro/daab016 : Referring patients with suspected lung cancer: a qualitative study with primary healthcare professionals in Ireland. Health Promot Int .2022;37(3) : 10.1093/heapro/daac088 35810412 10.1093/heapro/daac088 : Primary healthcare professionals' perspectives on patient help-seeking for lung cancer warning signs and symptoms: a qualitative study. BMC Prim Care .2022;23(1) : 10.1186/s12875-022-01730-x 119 35585504 10.1186/s12875-022-01730-x