Knowledge attitude and practice regarding cancer screening among Chinese medical students

Abstract

To investigate the knowledge, attitude, and practice (KAP) of cancer screening among medical students. A web-based cross-sectional study was conducted between June and July 2023 across two medical universities in China. A self-administered questionnaire was distributed to medical students to collect their demographic characteristics and KAP of cancer screening. A total of 520 valid questionnaires were collected, with 304 (58.46%) females and a mean age of 21.07 ± 2.25 years. The mean knowledge, attitude, and practice scores were 9.39 ± 3.82 (possible range: 0–20), 31.4 ± 4.06 (possible range: 8–40), and 25.2 ± 7.04 (possible range: 8–40), respectively. Structural equation modeling (SEM) indicated that knowledge directly influenced attitude (β = 0.140, P = 0.003), attitude directly affected practice (β = 0.145, P = 0.002), and knowledge had a substantial and direct impact on practice impact on practice (β = 0.219, P < 0.001). The study highlights inadequate knowledge, suboptimal attitude, and moderate practice towards cancer screening among medical students. The findings emphasize the need to enrich their knowledge through curriculum enhancements, foster positive attitudes via educational initiatives, and provide practical training opportunities.

Supplementary Information

The online version contains supplementary material available at 10.1038/s41598-025-29124-w.

Introduction

Cancer represents a significant global health challenge, with a staggering 19.3 million new cases and 10.0 million fatalities reported in 2020. This issue is particularly pronounced in China, where nearly 23.7% of new cases and 30.2% of the recorded deaths recorded¹. As a critical component of cancer control, cancer screening assumes a pivotal role in early detection, potentially saving lives by identifying cancers in their early stages or preventing their development altogether². In China, cancer screening boasts a substantial history, spanning almost six decades, during which approximately two million high-risk individuals had undergone screening. This concerted effort resulted in the diagnosis of 55,000 cancer cases, achieving an impressive early detection rate of 80%^1,3. Despite these accomplishments, the quality of cancer screening in China has not yet met the desired standards, underscoring the necessity for ongoing enhancements in cancer screening practices and policies.

The Knowledge, Attitude, and Practice (KAP) survey serves as a diagnostic research tool, shedding light on a group’s understanding, beliefs, and actions regarding a specific topic, especially within the realm of health literacy. This tool is based on the premise that knowledge positively influences attitudes, which, in turn, shape behaviors^4–6. Given that medical students are the future healthcare providers currently undergoing medical education, destined to become doctors, nurses, and healthcare professionals directly involved in patient care and diagnosis^7–9, their KAP have a significant impact on the promotion and implementation of cancer screening. Assessing the level of knowledge among medical students regarding cancer screening is crucial for evaluating the effectiveness of medical education and determining the need to incorporate additional content related to cancer screening into the curriculum. Furthermore, understanding their attitudes and practices can reveal their viewpoints and behaviors concerning cancer screening, which is of paramount importance for future medical practice and patient care. If medical students exhibit a positive attitude and proactive practices in cancer screening, they are likely to play a more active role in advocating for early cancer detection and screening throughout their future careers. Moreover, while existing KAP studies on cancer screening are available, there is a noticeable gap in research that focuses on medical students’ KAP regarding cancer screening^10–12. Therefore, this study aimed to investigate the KAP of medical students towards cancer screening.

Methods

Study design and participants

This cross-sectional study was conducted between June and July 2023 at Zhejiang Chinese Medical University and Zunyi Medical College, and included medical students from both institutions. The inclusion criteria were: (1) undergraduate medical students; (2) aged > 18 years old. The exclusion criteria were: (1) Refuse to participate, (2) withdrawal of informed consent. The years of study was not restricted. Ethical approval for this study was obtained from the Ethics Committee of the First Affiliated Hospital of Zhejiang Chinese Medical University (Approval number: No. 2023-KLS-195-01), and informed consent was secured from all participants.

Questionnaire

The questionnaire was developed in accordance with pertinent studies^12–14 and established Chinese guidelines and expert consensus, including the Lung cancer screening guideline of China (T/CPMA 013-2020)¹⁵, China consensus on the protocol of early gastric cancer screening¹⁶, China guideline for the screening, early detection and early treatment of colorectal cancer¹⁷, Guideline for stratified screening and surveillance of primary liver cancer¹⁸, Female breast cancer screening guideline of China (T/CPMA 014-2020)¹⁹, and Expert Consensus on Issues Related to Cervical Cancer Screening and Abnormal Management in China²⁰. Following the initial design, expert input was sought from two domain specialists to eliminate redundant or duplicative questions and to clarify any ambiguous statements. Prior to the official distribution, a preliminary pilot test was conducted among 39 participants, and the Cronbach’s α coefficient was 0.881, indicating a good internal consistency.

The finalized questionnaire encompassed the following dimensions: (1) Demographic characteristics, which included gender, age, residence, experience of internship (yes/no; as most students begin internships in later years, this variable partly reflects the period/year of study), professional category (Clinical: majors directly involving patient care; Non-clinical: majors not involving direct patient care). (2) Knowledge dimension, comprising 10 questions with a scoring system allocating 2 points for “well-known,” 1 point for “heard of,” and 0 points for “unclear”, with a possible range of 0–20. (3) Attitude dimension, composed of eight questions rated on a five-point Likert scale from “very positive” (5 points) to “very negative” (1 point), with a possible range of 8–40. (4) Practice dimension, consisting of eight questions similarly assessed on a five-point Likert scale ranging from “always” (5 points) to “never” (1 point), with a possible range of 8–40. Higher scores within each dimension indicated greater knowledge, more positive attitudes, and more proactive practices. Participants who scored above 80% of the total were categorized as having adequate knowledge, positive attitudes, and proactive practices. Those falling within the range of 60–80% of the total were classified as having moderate knowledge, attitudes, and practices. Scores below 60% of the total indicated inadequate knowledge, negative attitudes, and inactive practices. These thresholds were determined according to Bloom’s cutoff, which is widely applied in KAP studies to categorize respondents’ performance levels¹¹.

Questionnaire distribution and quality control

The questionnaire was primarily disseminated through online channels using a WeChat-based survey application. This platform allowed for the creation of unique QR codes and accessible survey links. The research team collaborated with the academic administration and student affairs offices at Zhejiang Chinese Medical University and Zunyi Medical College. With their endorsement, the survey links and QR codes were shared with medical students through official university communication channels, including student online forums, departmental notice boards, and via student representatives during relevant academic sessions.

A convenience sampling method was employed. Participants accessed the electronic questionnaire by scanning the QR code or clicking the shared link. To prevent duplicate submissions and maintain data integrity, the online survey platform was configured with restrictions, allowing each unique IP address to complete the survey only once. Following data collection, a rigorous quality control process was instituted to ensure the integrity and validity of the data. All questionnaire items were mandatory to guarantee completeness. Submitted questionnaires were reviewed for quality. Responses were classified as invalid and excluded if they showed signs of poor data quality, including refusal to participate, incomplete or missing crucial information, unusually brief completion times (e.g., less than 90 s), logical inconsistencies, or discernible patterns of repetitive answers.

Statistical analysis

All data were processed and analyzed utilizing SPSS version 26.0 and AMOS version 24.0 (IBM Corp., Armonk, NY, USA). Continuous variables were described as mean ± standard deviation (SD), while categorical variables are reported as frequency and percentage (n, %). For comparisons between two groups, t-tests were performed on normally distributed data; non-normally distributed data were analyzed using Wilcoxon-Mann-Whitney tests. For the analysis of three or more groups, ANOVA was employed for normally distributed data exhibiting equal variance, while Kruskal-Wallis tests were utilized in cases where these assumptions were not satisfied. Spearman’s rank correlation was applied to assess the relationships among knowledge, attitude, and practice scores, accommodating potential non-normality. Confirmatory factor analysis (CFA) was conducted to assess the measurement model, including the KMO test and multiple model fit indices (CMIN/DF, SRMR, RMSEA, IFI, TLI, and CFI). The structural equation modelling (SEM) was then conducted to analyze the interaction among knowledge, attitude, and practice, and each latent construct (KAP) was represented by its respective questionnaire items. To address concerns about the internal validity of the knowledge assessment and enhance our findings, we conducted a sensitivity analysis. This involved recalculating the overall knowledge score and re-evaluating Spearman’s rank correlations among knowledge, attitude, and practice scores after excluding problematic items due to evidence updates, differences in clinical practice among countries, and terminologies (items 1, 6, 8, and 10). All statistical tests were two-tailed, with a P-value of less than 0.05 considered statistically significant.

Results

Initially, a total of 599 questionnaires were collected for this study. Subsequently, 79 cases were excluded for declined to participate (n = 10), incomplete or conflict response (n = 49), or chose the same answer for all items (n = 20), the remaining valid dataset consisted of 520 cases, with a validity rate of 86.81%. The overall Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was 0.887, indicating that the data were appropriate for factor analysis. The confirmatory factor analysis (CFA) demonstrated strong model fit for the hypothesized structure (CMIN/DF value: 3.182, SRMR value: 0.058, RMSEA value: 0.065, IFI value: 0.916, TLI value: 0.907, and CFI value: 0.916), validating the structural coherence of the measurement model and its alignment with the theoretical framework (Supplementary Tables 1 & Supplementary Fig. 1).

Among the participants, 334 (64.23%) resided in rural areas, while 394 (75.8%) reported no engagement in an internship. Regarding professional classification, 408 (78.46%) were identified as being in non-clinical specialties, which include disciplines such as basic medical sciences, public health, and pharmacology. The remaining participants were categorized within clinical specialties, which entail direct patient care, including fields such as surgery, internal medicine, and imaging. Additionally, 357 (68.65%) had no family or friends with cancer, 417 (80.19%) had not undergone cancer screening themselves, or for their family or friends, and 356 (68.46%) had not engaged in hospital volunteering (Table 1).

Table 1.

Demographic characteristics and KAP scores.

Variables	N (%)	Knowledge, mean ± SD	P	Attitude, mean ± SD	P	Practice, mean ± SD	P
N	520
Total score		9.39 ± 3.82		31.4 ± 4.06		25.2 ± 7.04
Gender			0.081				0.115
Male	216(41.54)	9.76 ± 3.83		30.74 ± 3.99		25.80 ± 7.02
Female	304(58.46)	9.12 ± 3.79		32.03 ± 4.03		24.87 ± 7.05
Age, years	21.07 ± 2.25
Residence			0.240		0.001		0.697
Rural	334(64.23)	9.14 ± 3.51		31.02 ± 4.06		25.08 ± 7.05
Urban	148(28.46)	9.88 ± 4.31		32.42 ± 3.88		25.67 ± 6.90
Suburban	38(7.31)	9.65 ± 4.27		32.05 ± 4.09		25.18 ± 7.70
Experience of internshipa			< 0.001		0.092		0.943
No	394(75.8)	8.87 ± 3.65		31.66 ± 4.11		25.23 ± 7.17
Yes	126(24.2)	11.01 ± 3.90		30.97 ± 3.86		25.33 ± 6.66
Professional typeb			0.001		0.011		0.041
Clinical	112(21.54)	10.62 ± 4.02		32.34 ± 3.85		26.35 ± 6.76
Non-clinical	408(78.46)	9.05 ± 3.70		31.26 ± 4.09		24.96 ± 7.10
Self-assessment of knowledge level about cancer	4.97 ± 1.84
Family members or friends with cancerc			0.431		0.003		0.046
Yes	163(31.35)	9.66 ± 4.22		32.28 ± 3.90		26.27 ± 7.46
No	357(68.65)	9.26 ± 3.62		31.13 ± 4.08		24.79 ± 6.81
History of cancer screeningd			0.001		0.316		0.002
Yes	103(19.81)	10.66 ± 4.28		31.80 ± 4.22		27.20 ± 7.21
No	417(80.19)	9.07 ± 3.63		31.41 ± 4.02		24.78 ± 6.93
Hospital volunteer experience			< 0.001		0.522		0.005
Yes	164(31.54)	10.98 ± 4.18		31.64 ± 4.12		26.55 ± 6.83
No	356(68.46)	8.66 ± 3.40		31.42 ± 4.03		24.66 ± 7.07

^aThe period of study was reflected by internship experience (No = pre-clinical stage; Yes = clinical stage).

^b“Professional type” indicated whether the major involved direct patient care (Clinical) or not (Non-clinical).

^cCollected by the question: Do any of your family members or friends have had cancer?

^dCollected by the question: Have you, your family members, or friends ever undergone cancer screening?

The scores for knowledge, attitude, and practice were 9.39 ± 3.82 (possible range: 0–20), 31.4 ± 4.06 (possible range: 8–40), and 25.2 ± 7.04 (possible range: 8–40), respectively. The knowledge score exhibited variations among students with different internship status (P < 0.001), medical specialization (P = 0.003), professional category (P = 0.001), whether they, their family members, or friends had ever undergone cancer screening (P = 0.001), and whether they had ever volunteered at a hospital (P < 0.001). Concerning the attitude score, differences were observed among students with different residences (P = 0.001), professional category (P = 0.011), and whether any of their family members or friends had experienced cancer (P = 0.003). Differences in practice scores were identified among students with different professional categories (P = 0.041), whether any of their family members or friends had experienced cancer (P = 0.046), whether they, their family members, or friends had ever undergone cancer screening (P = 0.002), and whether they had ever volunteered at a hospital (P = 0.005) (Table 1).

The distribution of knowledge dimensions revealed that the three questions with the highest number of participants selecting the “Heard of” option were as follows: “Taking into consideration the epidemiological characteristics of cancer in our country and considering the national context, eight common types of cancer have been included in the national cancer screening program. These cancers are lung cancer, stomach cancer, colorectal cancer, esophageal cancer, liver cancer, breast cancer, cervical cancer, and nasopharyngeal cancer.” (K2), chosen by 77.31% of participants. “When cancer is diagnosed early in the natural course of the disease, the prognosis is significantly improved. The ultimate goal of early cancer screening in asymptomatic individuals is to reduce the incidence of late-stage disease and implement treatment when it’s most effective, thereby preventing cancer-related deaths.” (K1), selected by 76.54% of participants. “Cancer screening in China still primarily focuses on high-risk populations. Individuals with suspected cancer or precancerous conditions identified through screening require further confirmation and standardized treatment.” (K3), preferred by 72.31% of participants. On In contrast, the three questions with the highest number of participants choosing the “Unclear” option were as follows: “Liver cancer ranks fifth in the incidence of malignant tumors in China. It is recommended to conduct abdominal ultrasound combined with AFP (Alpha-Fetoprotein) testing for high-risk individuals. Enhanced MRI is applicable for liver cancer screening in extremely high-risk populations to enhance the ability to distinguish liver cirrhosis nodules, low-grade dysplastic nodules, and high-grade dysplastic nodules, as well as to improve the detection of early-stage liver cancer. " (K7), which was selected by 30.19% of participants. “Colorectal cancer ranks as the third most common malignancy in China. The National Cancer Center recommends screening for low to moderate-risk individuals aged 50–75 and high-risk individuals aged 40–75. Screening involves a combination of colonoscopy (every 5–10 years) and annual fecal immunochemical testing.” (K6), chosen by 30% of participants. “Lung cancer has the highest incidence rate in China, and the National Cancer Center recommends low-dose spiral CT screening for high-risk individuals.” (K4), which was selected by 25.19% of participants (Table 2). To comprehensively delineate the areas exhibiting the most pronounced knowledge deficiencies, the items characterized by the lowest ‘Well-known’ rates pertained to screening guidelines for colorectal cancer (K6, 7.5%), liver cancer (K7, 7.88%), lung cancer (K4, 12.12%), stomach cancer (K5, 10.19%), and cervical cancer (K9, 13.27%), as detailed in Supplementary Table 2.

Table 2.

Knowledge, attitude, and practice.

Statement			Well-known		Heard of	Unclear
1. Early diagnosis of cancer significantly improves the prognosis as it allows for more effective treatment, reducing the incidence of advanced disease and preventing cancer-related deaths in asymptomatic individuals.a			99(19.04)		398(76.54)	23(4.42)
2. Considering the epidemiological characteristics in our country and the national context, the national cancer screening program includes eight common cancer types: lung cancer, stomach cancer, colorectal cancer, esophageal cancer, liver cancer, breast cancer, cervical cancer, and nasopharyngeal cancer.			52(10)		402(77.31)	66(12.69)
3. Cancer screening in China primarily targets high-risk populations. Individuals with suspected cancer or precancerous conditions identified through screening require further confirmation and standardized treatment.			98(18.85)		376(72.31)	46(8.85)
4. Lung cancer has the highest incidence rate in China, and the National Cancer Center recommends low-dose spiral CT screening for high-risk individuals. High-risk individuals are those aged 50–74 who meet at least one of the following criteria: (1) a smoking history of at least 30 pack-years, including those who quit smoking less than 15 years ago; (2) passive smoking for more than 20 years while living or working with someone from the (1) category; (3) chronic obstructive pulmonary disease; (4) occupational exposure history of at least one year, including exposure to asbestos, radon, beryllium, chromium, cadmium, silica, coal smoke, and coal ash; (5) having a first-degree relative diagnosed with lung cancer.			63(12.12)		326(62.69)	131(25.19)
5. Stomach cancer ranks as the second most common malignancy in China. Currently, it is recommended to conduct a three-item initial screening for high-risk individuals, which includes serum pepsinogen I/II, gastrin-17 levels, and Helicobacter pylori antibodies, followed by further screening using gastroscopy. High-risk individuals are those aged 40 and above who meet at least one of the following criteria: (1) residing in high-incidence areas for stomach cancer; (2) Helicobacter pylori infection; (3) a history of chronic atrophic gastritis, gastric ulcers, gastric polyps, post-gastrectomy, hypertrophic gastritis, or pernicious anemia; (4) having a first-degree relative diagnosed with stomach cancer; (5) other risk factors for stomach cancer, such as a high-salt diet, pickled foods, smoking, heavy alcohol consumption, etc.			53(10.19)		338(65)	129(24.81)
6. Colorectal cancer is the third most common malignancy in China. The National Cancer Center recommends screening for individuals aged 50–75 with low to moderate risk and those aged 40–75 at high risk. Screening includes a combination of colonoscopy (every 5–10 years) and annual fecal immunochemical testing. General-risk individuals do not have the following risk factors: (1) a family history of colorectal cancer, including non-hereditary and hereditary cases; (2) a personal history of colorectal cancer; (3) a history of colorectal adenomas; (4) suffering from inflammatory bowel disease for 8–10 years without remission; (5) positive results on fecal immunochemical tests.			39(7.5)		325(62.5)	156(30)
7. Liver cancer is the fifth most common malignancy in China. It is recommended to conduct abdominal ultrasound combined with Alpha-Fetoprotein (AFP) testing for high-risk individuals. Enhanced MRI is applicable for liver cancer screening in extremely high-risk populations to enhance the ability to distinguish liver cirrhosis nodules, low-grade dysplastic nodules, and high-grade dysplastic nodules, as well as to improve the detection of early-stage liver cancer. High-risk individuals are defined as those with liver cirrhosis, chronic hepatitis B or C virus infections who haven’t received antiviral treatment or achieved a sustained virological response.			41(7.88)		322(61.92)	157(30.19)
8. Breast cancer is the seventh most common malignancy in China. Screening for breast cancer is recommended using breast ultrasound or mammography. Routine screening is advised for individuals at general risk from ages 45 to 70, while high-risk individuals should commence screening from age 40. High-risk individuals meet any of the following criteria: (1) a family history of breast or ovarian cancer, including first-degree relatives with a history of breast or ovarian cancer, two or more second-degree relatives diagnosed with breast cancer before the age of 50, or the presence of known BRCA1/2 pathogenic gene mutations. (2) Meeting any of the following criteria: early menarche (≤ 12 years old), late menopause (≥ 55 years old), a history of breast biopsy or benign breast disease surgery, pathologically confirmed atypical hyperplasia of the breast (lobular or ductal), or hormone replacement therapy with “estrogen and progestin” for more than 6 months, breast mammography after age 45 indicating dense breast tissue (heterogeneously dense or extremely dense). (3) Meeting any of the following two criteria: no history of breastfeeding or breastfeeding for less than 4 months, nulliparity or first full-term pregnancy at age 30 or older, hormone replacement therapy using “estrogen” for more than 6 months, or two or more miscarriages (including natural and induced abortions).			58(11.15)		364(70)	98(18.85)
9. Cervical cancer is the tenth most common malignancy in China. For females aged 30 and above, the recommended primary screening method for cervical cancer is high-risk human papillomavirus (HPV) testing. If the initial HPV16/18 test is positive, a vaginal colposcopy examination is performed. If the test result shows non-high-risk HPV or untyped HPV, cytological examination is conducted, and further examination with a colposcope is determined based on the cytological pathology.			69(13.27)		351(67.5)	100(19.23)
10. Cancer screening plays a vital role in the early detection of cancer, increasing the chances of successful treatment and survival. However, it may also give rise to issues such as misdiagnosis and overtreatment. False-positive results can lead to unnecessary treatment, while false-negative results may result in delayed diagnosis.			87(16.73)		365(70.19)	68(13.08)

Attitude	Strongly agree	Agree		Neutral	Disagree	Strongly disagree
1. Cancer screening plays a crucial and meaningful role in early cancer detection, increasing the chances of successful treatment and survival. (P)	282(54.23)	225(43.27)		9(1.73)	3(0.58)	1(0.19)
2. Cancer screening is an essential part of a doctor’s responsibilities and a manifestation of their duty to patients. (P)	253(48.65)	238(45.77)		27(5.19)	2(0.38)	0
3. Cancer screening can lead to unnecessary anxiety and fear, affecting the quality of life for patients. (N)	83(15.96)	168(32.31)		134(25.77)	111(21.35)	24(4.62)
4. As a medical student, I should actively participate in cancer screening efforts, offering professional assistance and guidance to patients. (P)	250(48.08)	244(46.92)		25(4.81)	1(0.19)	0
5. Gaining a thorough understanding and mastering the relevant knowledge and skills of cancer screening can provide robust support for our future clinical practice. (P)	256(49.23)	245(47.12)		16(3.08)	2(0.38)	1(0.19)
6. Screening is sufficient for high-risk populations, so for low-risk individuals, it may not be very meaningful and could be a waste of time and resources. (N)	61(11.73)	108(20.77)		46(8.85)	190(36.54)	115(22.12)
7. Cancer screening demands significant time and financial resources, which may pose challenges for resource-poor regions. Increased support at the national level is needed. (P)	227(43.65)	269(51.73)		20(3.85)	2(0.38)	2(0.38)
8. Cancer screening requires a significant investment of time and money, which can lead to wastage of healthcare resources. (N)	47(9.04)	99(19.04)		99(19.04)	213(40.96)	62(11.92)

Practice	Always	Often		Sometimes	Occasionally	Never
1. Regularly update and acquire knowledge related to cancer screening, understanding its indications, methods, and key techniques. (P)	43(8.27)	90(17.31)		235(45.19)	131(25.19)	21(4.04)
2. Actively engage in cancer screening efforts. (P)	49(9.42)	70(13.46)		180(34.62)	170(32.69)	51(9.81)
2.1 Assist patients in understanding the importance and necessity of screening, encouraging them to undergo screening tests.	60(11.54)	116(22.31)		172(33.08)	126(24.23)	46(8.85)
2.2 Assist in screening procedures, provide counseling and guidance services.	48(9.23)	95(18.27)		167(32.12)	154(29.62)	56(10.77)
2.3 Promote and advocate for the significance and necessity of cancer screening.	63(12.12)	134(25.77)		172(33.08)	115(22.12)	36(6.92)
3. Actively learn and master various cancer screening techniques and methods during internships and training. (P)	56(10.77)	107(20.58)		170(32.69)	139(26.73)	48(9.23)
4. Avoid indiscriminately promoting a particular cancer screening method, and approach the existing limitations and issues in a scientific manner. (P)	90(17.31)	122(23.46)		198(38.08)	86(16.54)	24(4.62)
5. Pay attention to safeguarding the privacy and rights of patients. (P)	254(48.85)	137(26.35)		84(16.15)	34(6.54)	11(2.12)

^a“Early diagnosis” in this context pertains to cases identified through organized screening programs.

Regarding attitudes towards cancer screening, a significant proportion (94.42%) acknowledged that cancer screening is a part of a doctor’s role (A2). Notably, 48.26% concurred that screening may lead to unnecessary anxiety and fear, potentially impacting patients’ quality of life (A3). Optimistically, 95% believed that as medical students, they should actively participate in cancer screening to offer professional assistance and guidance to patients (A4). Furthermore, 58.66% believed that screening should target not only high-risk groups but also be valuable for low-risk groups (A6). In addition, 52.88% disagreed that cancer screening would result in a wastage of medical resources (A8) (Table 2).

The practice of medical students revealed that nearly half (45.19%) stated that they occasionally update and learn about cancer screening-related knowledge (P1). It’s noteworthy that 67.31% participated in the cancer screening process with low frequency (sometimes or occasionally) (P2). However, only 33.85%, 27.5%, and 37.89%, respectively, always or often encouraged patients to undergo screening tests (P2.1), assisted in the execution of screening, provided counseling and guidance (P2.2), and actively promoted and advocated the importance and necessity of cancer screening (P2.3). On a relatively positive note, 75.2% reported that they take extra care to safeguard patients’ privacy and rights (P5) (Table 2).

Correlation analysis demonstrated significant positive correlations between knowledge and practice (r = 0.230, P < 0.001), as well as between attitude and practice (r = 0.136, P = 0.002) (Table 3). The SEM analysis demonstrated a satisfactory fit for the proposed model, as evidenced by a SRMR value of 0.078, an RMSEA of 0.088, a TLI of 0.830, and a CFI of 0.845 (Supplementary Table 3). The SEM exhibited that knowledge directly affected attitude (β = 0.140, P = 0.003), and attitude directly affected practice (β = 0.145, P = 0.002), and knowledge was also found to exert a direct impact on practice (β = 0.219, P < 0.001) (Fig. 1; Table 4).

Table 3.

Spearman correlation analysis.

	Knowledge	Attitude	Practice
Knowledge	1
Attitude	− 0.020 (P = 0.650)	1
Practice	0.230 (P < 0.001)	0.136 (P = 0.002)	1

Fig. 1.

The structural equation modeling (SEM). K: knowledge; A: attitude; P: practice.

Table 4.

Structural equation model (SEM) results.

Model path			Estimate	P
Attitude	←	Knowledge	0.140	0.003
Practice	←	Attitude	0.145	0.002
Practice	←	Knowledge	0.219	< 0.001

In the sensitivity analysis, we recalculated the overall mean knowledge score for the study population after excluding the problematic knowledge questions (items 1, 6, 8, and 10), yielding a score of 5.51 ± 2.45. Spearman’s rank correlation analysis conducted on this adjusted dataset revealed a statistically significant positive correlation between knowledge and practice (r = 0.188, P < 0.001) as well as between attitude and practice (r = 0.136, P = 0.002). However, no statistically significant correlation was identified between knowledge and attitude (r = -0.021, P = 0.634) (Supplementary Table 4). These findings reinforce the robustness of the primary results concerning the relationships among knowledge, attitude, and practice, even after addressing potential issues associated with specific questionnaire items.

Discussion

Medical students demonstrated insufficient knowledge, suboptimal attitudes, and moderate practices concerning cancer screening. These findings illuminate significant deficiencies in medical education that may hinder effective early cancer detection in clinical environments. They highlight the pressing necessity for curriculum enhancements aimed at better preparing future healthcare professionals with the requisite skills to promote proactive screening and enhance patient outcomes.

Our analysis identifies knowledge gaps (Supplementary Table 2) that outline a roadmap for enhancing the curriculum. Deficiencies were observed in understanding screening protocols for colorectal, liver, and stomach cancers, including risk stratification, biomarker tests (such as FIT, AFP, and pepsinogen), and imaging techniques. This indicates that current medical education may not adequately convey the practical application of complex screening algorithms. Additionally, the ambiguity surrounding high-risk criteria for lung cancer (e.g., pack-year calculation) and the triage process for positive HPV tests in cervical screening highlights a disconnect in translating guidelines into actionable clinical knowledge. Targeted educational interventions are imperative to address these deficiencies. These interventions should include case-based learning, interactive risk calculation tools, and simulated patient counseling sessions. Such strategies can bridge the gap between guideline knowledge and the practical skills needed for advising patients in clinical practice. This focused approach ensures that educational resources are allocated to the most critical areas, potentially improving overall competency.

While there are currently no established competency standards delineating the expected level of cancer screening knowledge for medical students, our findings can be contextualized by comparing them to analogous studies conducted in other countries, which have similarly identified knowledge gaps among medical students in this domain^21,22. It is crucial to acknowledge that the knowledge level reported in this study was self-evaluated, which may influence the interpretation of the absolute scores. Comparable international studies have demonstrated insufficient knowledge among medical students regarding cancer screening, thereby reinforcing the consistency of our findings with global trends^23–25. Our assessment indicates that a considerable proportion of students possess an insufficient understanding of critical components related to cancer screening. This encompasses national guidelines for liver cancer screening, recommended methods for colorectal cancer screening, and the criteria for low-dose CT screening for lung cancer^15,26,27. Furthermore, the study identifies various factors that affect medical students’ knowledge, attitudes, and practices, including their internship status, medical specialization, professional category, personal experiences with cancer screening, hospital volunteering, place of residence, and familial or social connections to cancer. These findings underscore the necessity for targeted interventions, such as specialized educational programs, to address these knowledge deficiencies and promote a more proactive and informed approach to cancer screening among future healthcare professionals^28,29.

It is essential to acknowledge that discrepancies between the questionnaire statements and contemporary literature may arise from advancements in clinical practice or variations in recommendations across diverse healthcare contexts, particularly between Chinese national guidelines and international standards. For instance, Questionnaire Item 6 concerning colorectal cancer screening advocates for the utilization of both colonoscopy and fecal immunochemical testing (FIT) for individuals aged 50–75 with low to moderate risk, and for those aged 40–75 at high risk. This recommendation is consistent with the 2020 Chinese guidelines, which endorse quantitative FIT as the primary screening modality, followed by colonoscopy for individuals with positive results, and suggest a colonoscopy every 5–10 years for high-risk populations¹⁷. However, this combined approach is not universally adopted internationally; for example, the U.S. Preventive Services Task Force (USPSTF) recommends colonoscopy every 10 years or annual FIT as standalone options for average-risk adults aged 45–75, without routine combination for all, to avoid over-screening and resource strain¹⁴.

Similarly, Questionnaire Item 8 regarding breast cancer screening for high-risk individuals identifies criteria such as early menarche, late menopause, a history of benign breast disease, and breastfeeding duration, recommending the initiation of ultrasound or mammography at age 40. While this aligns with elements of the Chinese expert consensus that emphasizes risk-stratified screening¹⁹, international guidelines, including those from the American Cancer Society (ACS), prioritize annual mammography beginning at age 45 for average-risk individuals and at age 40 for high-risk individuals—primarily defined by family history or genetic mutations such as BRCA1/2—with limited endorsement for ultrasound as an adjunct due to insufficient evidence regarding its independent efficacy in reducing mortality¹⁴. These discrepancies highlight how evolving and region-specific guidelines can impact knowledge assessment, as our items were informed by earlier national standards^17,19, which may not fully align with current international best practices. Nevertheless, our study underscores persistent gaps in guideline awareness among Chinese medical students, offering insights for curricular enhancements that could address these discrepancies and improve adherence in clinical settings, ultimately leading to improved early detection rates and reduced cancer morbidity^13,14.

Furthermore, students generally demonstrate a positive attitude toward cancer screening, acknowledging its significance for early detection and its role within clinical practice. However, a considerable proportion of respondents expressed apprehensions regarding the anxiety and fear that screening may provoke, indicating a need for balanced patient education and support. To optimize clinical practice, interventions should prioritize bridging knowledge gaps and addressing these concerns through comprehensive educational programs that integrate the latest evidence-based guidelines and effective patient communication strategies^30,31.

A key finding of the study is that, while medical students acknowledge the importance of cancer screening, a substantial proportion demonstrates only moderate engagement in practical application. This observation underscores a disparity between their comprehension of the significance of screening and their actual participation in screening initiatives, thereby indicating a need for enhancement. This gap can be attributed to inadequate practical experience and exposure to screening procedures within their educational framework. To mitigate this issue, medical curricula should integrate hands-on training and internships specifically focused on cancer screening, thereby equipping students with practical skills and fostering confidence in their ability to promote and engage in these initiatives^32,33. Moreover, strategies should be employed to underscore the responsibility of medical professionals, including students, to actively participate in cancer screening as an integral component of their clinical duties^34,35. This approach is consistent with the perspective that, as future healthcare providers, medical students play a critical role in advancing early detection and mitigating cancer-related morbidity and mortality^9,36.

This study reveals the complex relationships within the KAP framework, providing valuable insights into how these elements interact among medical students regarding cancer screening. The positive correlations observed between knowledge and practice, as well as between attitude and practice, highlight the importance of equipping medical students with comprehensive knowledge and fostering a positive attitude, as both factors significantly influence their participation in cancer screening initiatives. Interestingly, the lack of a significant correlation between knowledge and attitude suggests that these components are separate. This indicates that having knowledge does not automatically result in a positive attitude. Several factors could contribute to this unexpected finding, such as reliance on self-assessed knowledge instead of objective evaluations, differences in educational exposure among various subgroups, or unmeasured variables, like indirect experiences with cancer through family or community interactions, which may shape attitudes independently of knowledge levels^4,8. Results from SEM further clarify these relationships, showing that knowledge directly influences both attitude and practice, while attitude acts as a mediator between knowledge and practice. This highlights the critical role of attitude as a link between knowledge and practice^37,38. It is important to note that the non-significant Spearman correlation between knowledge and attitude represents a zero-order association that does not account for other variables, whereas the SEM path coefficient reflects the direct effect of knowledge on attitude, considering its simultaneous relationships with practice. This distinction explains why SEM identified a statistically significant path from knowledge to attitude, despite the lack of significance in the simple correlation. From a clinical perspective, these findings suggest that targeted interventions aimed at enhancing knowledge could indirectly improve attitudes and practices, leading to more effective patient counseling on screening, higher adherence rates, and ultimately better cancer outcomes in underserved populations³⁹. Overall, these results underscore the need for comprehensive educational interventions that not only increase medical students’ knowledge but also foster a positive attitude toward cancer screening, thereby promoting proactive and informed clinical practice^32,40. Moreover, these outcomes emphasize that medical education should go beyond mere factual knowledge acquisition to include the development of a positive and proactive mindset. This highlights the necessity for well-rounded curricula that simultaneously address both knowledge and attitude components to drive improvements in clinical practice and patient outcomes⁴¹.

This study presents several limitations. Firstly, social desirability bias may have influenced participant responses, potentially creating a discrepancy between their true beliefs and behaviors and the reported data. Furthermore, the geographic and institutional focus on only two Chinese medical colleges constrains the generalizability of the findings to other medical schools in China or to international contexts. The voluntary nature of participation and convenience sampling may also introduce self-selection bias, and the lack of response rate prevents us from further assessing the extent of the bias. Meanwhile, the cross-sectional design limits the ability to examine longitudinal changes. Moreover, the knowledge assessment was grounded in national standards and expert consensus at the time of the study’s design. However, updates to guidelines, variations in clinical practice, and choice of terms may affect the accuracy of certain items, particularly Questions 1, 6, 8, and 10, which may not fully align with the international guidelines^13,14, this further limited the generalizability of our findings.

Conclusions

In conclusion, medical students exhibited inadequate knowledge, suboptimal attitudes, and moderate practices regarding cancer screening. Based on the findings, there is a clear opportunity to advocate for a comprehensive strategy aimed at bolstering clinical practice among medical students in the field of cancer screening. This involves fortifying the educational curriculum to establish a strong knowledge base, cultivating a positive attitude through targeted educational initiatives emphasizing the importance of early detection, and seamlessly integrating practical training and workshops into the curriculum to hone vital clinical skills. Through the implementation of these measures, medical students can be better prepared to deliver holistic and effective care, leading to enhanced early cancer detection and improved patient outcomes.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviation

KAP

Knowledge, attitude, and practice

Author contributions

C.W. Conceptualization, Methodology, Writing—Original Draft J.J. Software, Validation, Supervision, Project administration C.W. Formal analysis, Investigation J.W. Resources, Data Curation, Visualization Y.L. Funding acquisition, Writing—Review & Editing.

Funding

This research was supported by the Huadong Medicine Joint Funds of the Zhejiang Provincial Natural Science Foundation of China (Grant No. LHDMZ22H050001); the Construction of Key Projects by Zhejiang Provincial Ministry (Project No.WKJ-ZJ-2302); The Key Project of Scientific Research Foundation of Chinese Medicine (2022ZZ002); the “Pioneer” and “Leading Goose” R&D Program of Zhejiang (2023C03075); The Key project of Basic Scientific Research Operating Funds of Hangzhou Medical College (KYZD202002);the General Project of the Medical and Health of Zhejiang Province (Grant Number 2021KY833).

Data availability

All data generated or analysed during this study are included in this published article.

Declarations

Competing interests

The authors declare no competing interests.

Ethical approval and consent to participate

All procedures were performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. This study was approved by the Ethics Committee of Zhejiang Traditional Chinese Medicine University Affiliated Hospital (2023-KLS-195-01), and informed consent was secured from all participants from both universities. The study was carried out in accordance with the applicable guidelines and regulations.