ABSTRACT
Colorectal cancer is a major public health concern worldwide, and early detection through screening significantly reduces mortality. Primary care physicians (PCPs) play a crucial role in recommending and facilitating colorectal cancer screening. This systematic review and meta-analysis aimed to assess the knowledge, attitudes, and practices of PCPs regarding colorectal cancer screening and referral patterns in Saudi Arabia. A systematic search was conducted in PubMed, Scopus, Web of Science, and Google Scholar following PRISMA guidelines. Studies assessing PCP knowledge, attitudes, or practices toward colorectal cancer screening in Saudi Arabia were included. Ten studies comprising 1648 physicians met the inclusion criteria. The pooled analysis showed that 98% of physicians recognized the effectiveness of colorectal cancer screening. Colonoscopy was perceived as effective by 93% of physicians, fecal occult blood testing by 86%, flexible sigmoidoscopy by 70%, and CT colonography by 56%. Despite generally positive attitudes toward screening, variability in knowledge and referral practices was observed across studies. Barriers such as lack of awareness of screening guidelines, limited resources, and absence of reminder systems were frequently reported. Overall, while PCPs demonstrate good awareness and positive attitudes toward colorectal cancer screening, gaps remain in practical implementation and referral practices. Strengthening physician training and implementing structured national screening programs may improve adherence to screening guidelines.
Keywords: Attitude, colon cancer, knowledge, practice, primary care physicians, screening
Introduction
Colon cancer is a type of cancer that affects the colon, ordinarily starting as pre-cancerous polyps.[1] Colon cancer is part of colorectal cancer, which is a broader term for cancer that affects both the colon and the rectum.[2] The global prevalence of colon cancer is 10% of all cancer cases, and it is responsible for 9.4% of cancer mortality.[2] The prevalence of colorectal cancer has been increasing significantly over the last few decades, both globally and in Saudi Arabia.[3] In the Saudi context, while a defined prevalence is not well established, incidence data show that colorectal cancer is a major health concern, accounting for 14.6% of all newly diagnosed cancer cases in the country.[3] The increase in the prevalence of colorectal cancer is attributable to the adoption of a sedentary lifestyle by many people, the consumption of processed foods, sugar, and high-fat foods, and the less consumption of healthy foods, among other factors.[4] Colorectal cancer is currently considered one of the most common cancers in developed countries, as they experience fewer infection-related cancers and more of lifestyle-related cancers.[5]
Elwali et al.[6] report that in Saudi Arabia, colorectal cancer is the second most common cancer among men and the third most common among women. As of 2015, colon cancer was responsible for 12% of the total cancer incidence in Saudi Arabia.[5] According to Al-Thafar et al.,[7] colon cancer has one of the lowest survival rates, but the mortality rate decreases significantly when it is diagnosed in its early stages. Therefore, regular screening has proven to be a critical factor in the prevention and early detection of colon cancer, leading to timely treatment, lower treatment costs, and improved patient outcomes.[7] According to a study conducted in the United States, it was established that colon cancer screening can lead to about 50% decline in mortality rate attributable to the disease.[8] Regular screening is particularly recommended for people aged 50 and above because they are at a higher risk of the disease than younger populations.[9]
Effective prevention and management of colorectal cancer requires physicians to have adequate knowledge and awareness of the disease. As key implementers of prevention strategies, primary healthcare physicians play a crucial role, and several studies strongly recommend their active involvement in screening programs.[5,9]
This study is valuable for both practitioners and patients because it identifies specific gaps in primary care physicians’ (PCP) knowledge and screening practices, helping guide targeted training and policy improvements. By strengthening physicians’ competence and confidence in recommending screening, patients benefit through earlier detection, timely referrals, and improved understanding of preventive care. Enhancing PCP practices ultimately contributes to better clinical outcomes and reduced colorectal cancer burden in Saudi Arabia.
Given their key role in colorectal cancer prevention and management, it is essential to assess PCPs’ knowledge and practices. This systematic review and meta-analysis evaluate their knowledge, attitudes, and practices toward colon cancer screening and referrals in Saudi Arabia, providing insight into their preparedness to effectively implement screening programs.
Methods and Materials
Review of the literature
This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.[10] The PROSPERO ID (CRD42024571741) was obtained before the start of the research. The databases used to access articles included PubMed, Google Scholar, and Saudi Digital Library. The following keywords were used: “Colon Cancer Screening” AND “Primary Care Physicians” AND “Knowledge” AND “Attitude” AND “Practice” AND “Referrals” AND “Saudi Arabia”. Articles were selected based on the population, intervention, comparison, and outcome.
Methodology for selecting studies
All articles met the following criteria: cross-sectional studies; PCPs in Saudi Arabia; studies assessing the knowledge, attitudes, and practices of PCPs in Saudi Arabia regarding colon cancer screening tests and referrals; and no applicable comparison. The primary outcomes were knowledge scores, attitude scores, practice scores, and referral rates. The secondary outcome was barriers to colon cancer screening. Studies that did not report the outcomes of interest, were not cross-sectional, were not in the English language, or focused on non-healthcare professionals were excluded.
Process of screening and data extraction
Two independent reviewers screened titles and abstracts using the Rayan web-based tool designed for systematic reviews.[11] Studies that passed the title and abstract screening underwent a full-text review. Data extraction was performed by two investigators and was divided into three categories. The first category dealt with study characteristics and included the following: title, author’s last name, year of publication, name of the journal, study design, city of origin, and sample size. The second category consisted of participant characteristics and included the age range, mean age in years, along with its standard deviation, sex (female and male), and years of experience. Finally, the third category contained intervention details and outcome measures, encompassing knowledge, attitude, practice, barriers, and referrals.
Assessment of quality and bias risk
We used the Appraisal tool for Cross-Sectional Studies (AXIS) to evaluate the quality and risk of bias of the included studies. The AXIS tool has 20 questions across five domains: introduction, methods, results, discussion, and others. Each question is scored as “Yes” (1 point) or “No” (0 points), with a maximum score of 20, where higher scores indicate a lower bias risk.[12] Two reviewers independently scored the studies, resolving disagreements through discussion or with the assistance of a third reviewer.
Meta-analysis of the included data
The statistical analysis was conducted using RStudio (version 2023.09.1 + 494), employing the meta and metafor packages to perform single-arm meta-analyses across multiple domains of colorectal cancer (CRC) screening knowledge, attitude, and practice. Categorical variables—such as awareness of the starting age for screening, perceived effectiveness of screening methods, clinical practice behavior, referral destinations, and reported barriers—were summarized using frequencies and pooled proportions with 95% confidence intervals. The DerSimonian–Laird random-effects model was applied to account for heterogeneity. Forest plots were generated for each domain to present the proportion of agreement among PCPs visually. The geographic origin of the included studies was visualized using ggplot2 with geospatial data to display the distribution across Saudi cities. Heterogeneity across studies was assessed using the I² statistic, with publication bias evaluated through appropriate statistical methods. Statistical significance was set at P < 0.05.
Results
Study selection and characteristics
The literature search was conducted across multiple databases, yielding the following results: Google Scholar (59), Saudi Digital Library (7), and PubMed (20), totaling 86 records. After removing duplicates, 59 unique records remained and were screened for further analysis. Titles and abstracts were independently reviewed by two assessors based on predefined inclusion and exclusion criteria. Disagreements were resolved through discussion or consultation with a third reviewer. Of these, 41 studies were excluded, leaving 18 articles for full-text assessment. After detailed evaluation, eight studies were excluded—seven for not including the target population and one for not reporting the outcomes of interest. The PRISMA flow diagram illustrates the study selection process [Figure 1]. A total of 10 cross-sectional studies published between 2014 and 2023 were included in the review. The most recent studies were published in 2023 and 2022 (n = 3), while earlier publications dated back to 2014. All studies employed a cross-sectional design [Table 1]. Geographically, the studies were conducted across various regions in Saudi Arabia: Riyadh (n = 2), Al-Ahsa (n = 3), Jeddah (n = 2), Buraydah in Qassim (n = 1), Qassim (n = 1), and Abha (n = 1) [Figure 2].
Figure 1.
PRISMA flowchart illustrating the study selection process. PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analysis
Table 1.
Basic demographics of the included studies
| Last name of the first author | Year of publication | Name of Journal Published in | Study design | City of origin | Sample Size | Age range | Mean Age in years, SD | Sex, Male (n) | Sex, Female (n) |
|---|---|---|---|---|---|---|---|---|---|
| Alghamdi[4] | 2022 | Cureus | Cross-sectional | Riyadh | 313 | 25 to 62 | 35.34 | 126 | 87 |
| Alessa[13] | 2023 | Cureus | Cross-sectional | Al-Ahsa | 186 | Not mentioned | 33 | 113 | 73 |
| Demyati[14] | 2014 | International Journal of Family Medicine | Cross-sectional | Riyadh | 130 | Not mentioned | 38 | 62 | 68 |
| Surendra[15] | 2017 | Global Journal of Health Science | Cross-sectional | Al-Ahsa | 160 | Not mentioned | Not mentioned | 124 | 36 |
| Altwijri[16] | 2022 | Journal of Women Medical & Dental College | Cross-sectional | Qassim | 110 | 27 to 58 | Not mentioned | 73 | 37 |
| Mosli[17] | 2017 | Saudi Journal of Gastroenterology | Cross-sectional | Jeddah | 127 | Not mentioned | 34 ± 8.49 | 55 | 72 |
| Aldukhayel[18] | 2021 | International Journal of Medicine in Developing Countries | Cross-sectional | Qassim | 284 | 24 to 63 | Not mentioned | 127 | 157 |
| Alshaikhi[19] | 2021 | World Family Medicine/Middle East Journal of Family Medicine | Cross-sectional | Abha | 104 | <30 to>35 | Not mentioned | 68 | 36 |
| Banamah[20] | 2017 | International Journal of Biological & Medical Research | Cross-sectional | Jeddah | 106 | <50 | Not mentioned | 39 | 67 |
| Al Mutawah[21] | 2018 | International Journal of Scientific Study | Cross-sectional | Al-Ahsa | 128 | 25 to 60 | 34 ± 7.45 | 80 | 48 |
N, Number; SD, Standard Deviation
Figure 2.
Geographic distribution of included studies across Saudi Arabian cities. The size of each bubble represents the number of studies originating from each city
Risk-of-bias assessment
The risk of bias in the ten included studies was independently assessed by two reviewers using the AXIS.[12] The overall AXIS assessment revealed that nine studies, with scores ranging from 17 to 19, were classified as having a low risk of bias, while one study, scoring 16, was classified as having a moderate risk of bias. A summary of the risk-of-bias assessment is shown in Table 2.
Table 2.
Risk-of-bias assessment of included studies using the AXIS Tool
| AXIS Criteria | Alessa 2023[13] | Alghamdi 2022[4] | Altwijri 2022[16] | Aldukhayel 2021[18] | Alshaikhi 2021[19] | Al Mutawah 2018[21] | Surendra 2017[15] | Mosli 2017[17] | Banamah 2017[20] | Demyati 2014[14] |
|---|---|---|---|---|---|---|---|---|---|---|
| 1. Clear aims/objective | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y |
| 2. Appropriate study design | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y |
| 3. Sample size justified | Y | Y | N | N | N | N | N | N | N | N |
| 4. Target/reference population clearly defined | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y |
| 5. Appropriate sample frame | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y |
| 6. Representative selection process | N | Y | Y | Y | Y | Y | Y | Y | Y | Y |
| 7. Addressed non-responders | N | N | Y | Y | Y | Y | Y | Y | N | Y |
| 8. Appropriate measurement of variables | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y |
| 9. Correct measurement instruments | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y |
| 10. Statistical significance/precision clear | N | Y | N | N | Y | Y | N | Y | Y | Y |
| 11. Methods reproducible | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y |
| 12. Basic data adequately described | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y |
| 13. Concerns about non-response bias | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y |
| 14. Information on non-responders | N | N | Y | Y | Y | Y | Y | Y | N | Y |
| 15. Internal consistency of results | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y |
| 16. Results described in methods | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y |
| 17. Justified discussions/conclusions | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y |
| 18. Limitations discussed | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y |
| 19. Conflicts of interest/funding | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y |
| 20. Ethical approval/consent attained | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y |
| Total AXIS Score (out of 20) | 16 | 18 | 18 | 18 | 19 | 19 | 18 | 19 | 17 | 19 |
AXIS=Appraisal tool for Cross-Sectional Studies; N=No, Y=Yes
Participant characteristics
The total sample across all 10 included studies was 1648 PCPs. Individual study sample sizes ranged from 104 to 313 participants. The most significant sample was from a study conducted in Riyadh (n = 313), while the smallest was from a study based in Abha (n = 104). Across the 10 included studies (total N = 1648), participant age ranged from 24 to 63 years, where reported. The mean age was approximately 34.5 years. Gender was reported in all studies: 867 (52.6%) were male and 781 (47.4%) were female. Years of experience were reported in eight of the 10 studies. Across these, the majority of PCPs had ≤10 years of experience, with most clustered in the 3–10 year range. Pooled estimates indicate approximately 51% had ≤10 years of experience, 27% had >10 years, and 22% had ≤2 years. One study reported a mean experience of 8.54 ± 8.08 years.
Knowledge and awareness of colorectal cancer screening guidelines
A total of five studies reporting the proportion of PCPs aware of CRC screening were included in the meta-analysis, encompassing 1090 participants. The pooled awareness proportion was 65% (95% CI: 0.53 to 0.76) using a random-effects model [Figure 4]. The individual study proportions ranged from 43% to 78%. Considerable heterogeneity was observed among studies (I² = 93.6%, P < 0.0001) [Figure 3]. Six studies reported the proportion of PCPs who correctly identified 50 years as the appropriate age to initiate CRC screening, with a combined sample of 1068 participants. The pooled proportion was 0.66 (95% CI: 0.48 to 0.81) using a random-effects model, indicating moderate overall knowledge of the correct starting age for average-risk patients. Considerable heterogeneity was observed across studies (I² = 96.6%, P < 0.0001), reflecting variability in awareness across regions and study periods [Figure 5]. A pooled summary of key knowledge and practice indicators among PCPs in Saudi Arabia revealed varying levels of adherence to CRC screening guidelines [Figure 4]. The highest pooled awareness was observed for initiating screening at age 50, with a proportion of 0.66 (95% CI: 0.48 to 0.81). Awareness of the appropriate age to stop screening (75 years) was moderate (0.51, 95% CI: 0.39 to 0.63). Awareness of fecal occult blood testing (FOBT) (either Guaiac or FIT) was 0.52 (95% CI: 0.40 to 0.64), while the proportion recommending annual FOBT was 0.44 (95% CI: 0.32 to 0.57). Recommendations for colonoscopy every 10 years and sigmoidoscopy every 5 years were 0.43 (95% CI: 0.30 to 0.56) and 0.50 (95% CI: 0.37 to 0.62), respectively.
Figure 4.
Forest plot showing the proportion of PCPs who correctly identified age 50 as the starting point for CRC screening in average-risk patients. CRC = colorectal cancer, PCP = primary care physician
Figure 3.
Forest plot of the proportion of PCPs aware of CRC screening across five studies. CRC = colorectal cancer, PCP = primary care physician
Figure 5.
Composite forest plot showing the pooled proportions (with 95% confidence intervals) of PCPs’ knowledge and practices regarding key CRC screening recommendations CRC = colorectal cancer, PCP = primary care physician
Attitudes toward the effectiveness of colorectal cancer screening modalities
Figure 6 presents a pooled analysis of PCPs’ attitudes regarding the perceived effectiveness of CRC screening and its modalities. The overall pooled proportion indicating CRC screening is effective was 98% (95% CI: 0.97–0.99). Colonoscopy was recognized as effective by 93% (95% CI: 0.91–0.94), followed by FOBT at 86% (95% CI: 0.84–0.88), flexible sigmoidoscopy at 70% (95% CI: 0.67–0.73), and CT colonography at 56% (95% CI: 0.53–0.59). Only 39% (95% CI: 0.37–0.42) considered the double-contrast barium enema to be effective. Considerable heterogeneity was observed (I² =99.6%, τ² =1.3242, P < 0.0001).
Figure 6.
Forest plot showing pooled proportions of PCPs who perceive various CRC screening modalities as effective. CRC = colorectal cancer, PCP = primary care physician
Implementation of colorectal cancer screening practices
A meta-analysis of eight practice-related outcomes demonstrated considerable variability in CRC screening implementation among PCPs [Figure 7]. The highest pooled practice proportion was for performing CRC screening in asymptomatic average-risk patients, with 74% [95% CI: 70%–77%], followed by preference for structured screening programs at 64% [95% CI: 60%–67%]. However, key gaps were evident: only 48% [95% CI: 44%–52%] reported routinely discussing FOBT with patients, and just 26% [95% CI: 21%–33%] had reminder systems in place for follow-up. The overall pooled estimate of appropriate CRC screening practices was 38% [95% CI: 24%–55%], with substantial heterogeneity observed (I² = 99.1%, τ² = 0.9984, P < 0.0001).
Figure 7.
Forest plot of pooled proportions reflecting CRC screening practices among PCPs. CRC = colorectal cancer, PCP = primary care physician
Barriers to effective implementation of colorectal cancer screening
A pooled analysis of the most frequently reported barriers to CRC screening among PCPs revealed that patient non-adherence was the most prevalent barrier, reported by 55% (95% CI: 52–58) of participants. Other commonly cited barriers included the absence of reminder systems (50%, 95% CI: 47–53), the lack of institutional screening policy (47%, 95% CI: 44–50), and limited awareness of screening guidelines (46%, 95% CI: 43–49). Additionally, shortages of trained providers (44%, 95% CI: 41–48) and time constraints (42%, 95% CI: 39–46) were also significant limiting factors. The heterogeneity was high (I² = 87.5%, P < 0.0001), indicating considerable variation in reported barriers across studies [Figure 8].
Figure 8.
Forest plot of pooled proportions reporting barriers to CRC screening among PCPs. CRC = colorectal cancer, PCP = primary care physician
Screening referrals and influencing factors
Across the studies reporting referral patterns, the majority of PCPs referred patients to gastroenterologists for colonoscopy (pooled proportion = 0.71; 95% CI: 0.66–0.75). Referrals to surgeons were less common (0.22; 95% CI: 0.18–0.26), while referrals to internal medicine (0.05; 95% CI: 0.03–0.08) and oncology (0.00; 95% CI: 0.00–0.02) were rare. Heterogeneity was high (I² = 99.2%, P < 0.0001), indicating variability in referral practices [Figure 9].
Figure 9.
Forest plot of pooled proportions of physician referral destinations for CRC screening. CRC = colorectal cancer
Discussion
Colon cancer is the most common type of cancer reported worldwide, with a high incidence in all age groups.[22] It has an insidious onset, progresses rapidly, and is often diagnosed in the middle or late stages.[23] The National Cancer Center of the Saudi Health Council states that colon cancer is the first common cancer among men and the second most common among women in Saudi Arabia.[24] This systematic review aimed to assess the knowledge, attitudes, and practices of PCPs regarding colon cancer screening tests and referrals in Saudi Arabia. By synthesizing data from multiple regions, this review provides a clearer national overview of existing gaps and variations in physician readiness.
This study found that 65% of Saudi PCPs were aware of CRC screening, with significant differences based on location, time, and training. About 66% correctly identified 50 years as the recommended starting age, while only 51% recognized 75 years as the stopping age. Awareness of screening methods was low: 44% recommended annual FOBT and 43% suggested colonoscopy every 10 years, indicating notable gaps in applying evidence-based guidelines. Similarly, Alghamdi et al. found that physicians strongly support early screening for average-risk patients.[4] In addition, the study by Albinsaad et al.[25] found that 69.2% of the participants were aware of breast cancer risk factors and symptoms, with strong correlations between nationality, personal diagnosis, age, marital status, occupation, education, and individual diagnosis. This implies that, despite widespread awareness of cancer screening, significant gaps remain in practical knowledge, particularly regarding adherence to guidelines. Addressing the sociodemographic factors associated with lower awareness through tailored interventions may improve the deficiencies highlighted in this study.
This study further found that 98% of primary care doctors believe CRC screening is beneficial, with 93% indicating that colonoscopy is the most effective approach.
The pooled data showed that 86% of respondents supported FOBT as an effective CRC screening method, reflecting strong preference for non-invasive options in regions with limited colonoscopy access. About 70% favored flexible sigmoidoscopy, while 56% endorsed CT colonography. In contrast, the double-contrast barium enema was considered less effective. Despite general support for CRC screening, variability in attitudes highlights differences based on physicians’ education, experience, and practice region. Similarly, Demyati et al.[14] reported a gap between physicians’ beliefs and actual screening practices, noting that board-certified physicians were more knowledgeable and active in screening. In a study by Surendra et al.,[15] it was revealed that 60% of physicians understood the risk factors, clinical characteristics, and the optimal screening age. Despite this, most doctors were found to be interested in learning more about CRC and its screening techniques. This emphasizes the importance of focused educational efforts. This study also found that, while 74% of doctors perform screening for asymptomatic average-risk patients, overall practice patterns do not meet the guidelines.
Furthermore, this study revealed high heterogeneity (I2 = 99.1%) regarding screening methods. Sixty-four percent of respondents stated that they prefer structured screening procedures, and only 48% of clinicians were found to frequently address FOBT. Only 26% of healthcare providers use follow-up reminder systems for CRC screening, and 38% of suitable techniques are deemed optimal, demonstrating unequal and suboptimal implementation across different contexts and physician groups.[14,17]
This study also identifies patient-related and systemic obstacles preventing PCPs from effectively implementing CRC screening, with non-adherence among the patients being the most common barrier, followed by fear, ignorance, and practical difficulties contributing to this issue. Moreover, the study identified system-level problems, including a lack of reminder systems and inadequate screening policies, in many institutions. The study found that 46% of respondents had limited awareness of screening guidelines, 42% faced time constraints during patient visits, and 44% experienced shortages of skilled clinicians, highlighting the challenges posed by limited resources and conflicting clinical demands, which resulted in high heterogeneity among the included studies.[15,19] Nonetheless, this study found that PCPs strongly prefer specialists, specifically gastroenterologists, for colorectal cancer screening. Furthermore, 71% of clinicians recommend patients to gastroenterologists for colonoscopies, emphasizing the importance of these procedures in screening and diagnosis. Surgeons are less common because of their limited participation. The study found that referrals to oncologists and internal medicine experts were infrequent (5%) and 0%, respectively, in regular CRC screening for asymptomatic patients, with significant variation among settings.[20,21] This high reliance on specialists may reflect PCPs’ limited confidence in managing CRC screening independently, highlighting the need for enhanced primary-care-based training and clearer referral pathways in national screening programs.
This study had some limitations. Among them are significant variations in methodology, populations, and contexts, as shown by high study heterogeneity. This restricts the generalizability of the study’s findings. Furthermore, the majority of the included studies were cross-sectional and relied on self-reported data, which could create biases in recall and response. Despite its limitations, this study provides a comprehensive review of PCPs’ knowledge, attitudes, and practices regarding CRC screening in Saudi Arabia. The primary benefits are its systematic methodology and robust meta-analytic techniques, which provide a pooled estimate and identify patterns across multiple studies. The critical practice gaps and challenges identified by the analysis also offer insightful information that can be used by healthcare policymakers and trainers to improve day-to-day practices among healthcare professionals. On this basis, future studies should examine how well primary care doctors can learn, follow guidelines, and conduct screenings in various clinical situations using focused educational interventions and training programs.
Conclusion
This study reveals inadequate awareness, practice, and system-level support for CRC screening among Saudi PCPs. Although most acknowledge the importance of screening, gaps remain in applying protocols and identifying the correct starting age. Major limitations include irregular use of FOBT, lack of reminder systems, and poor awareness of screening intervals. These findings highlight the gap between knowledge and real-world practice, emphasizing the need for stronger institutional support through reminder systems, national policies, and structured programs. Future studies should assess how targeted education and training can improve physicians’ adherence to CRC screening guidelines.
Supplementary material
It contains a PRISMA guideline checklist, which helps lay out the structure of the systematic review.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
References
- 1.Pinheiro M, Moreira DN, Ghidini M. Colon and rectal cancer: An emergent public health problem. World J Gastroenterol. 2024;30:644–51. doi: 10.3748/wjg.v30.i7.644. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Balata GF, Azzam HN. Synopsis of colorectal cancer: Prevalence, symptoms, screening, staging, risk factors, and treatment. Egypt J Intern Med. 2025;37:4. [Google Scholar]
- 3.Alessa AM, Khan AS. Epidemiology of colorectal cancer in Saudi Arabia: A review. Cureus. 2024;16:e64564. doi: 10.7759/cureus.64564. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Alghamdi AA, Almutairi AH, Aldosari FS, Al-Owayed AM, AlOtaibi HK, Alghamdi TA, et al. Knowledge, attitude, and practice of colorectal cancer screening among primary healthcare physicians in Riyadh Second Health Cluster. Cureus. 2022;14:e32069. doi: 10.7759/cureus.32069. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Arishi AA, Al-Hulaibi MA, Hakami AA, Khormi KJ, Daraj KM, Hakami EA, et al. Knowledge, attitude, and practices of physicians toward screening of colorectal cancer in Saudi Arabia. SAGE Open. 2025;15 [Google Scholar]
- 6.Elwali NE, Jarrah O, Alzahrani S, Alharbi M, Alhejaily A, Alsharm A, et al. Colorectal cancer in Saudi Arabia: The way forward. Asian Pac J Cancer Prev. 2023;24:13–9. doi: 10.31557/APJCP.2023.24.1.13. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Al-Thafar AK, Al-Naim AF, Albges DS, Boqursain SK, Aldhafar AS, Ghreiz SM, et al. Knowledge attitude and practice of colorectal cancer among school teachers in Al-Ahsa Saudi Arabia. Asian Pac J Cancer Prev. 2017;18:2771–4. doi: 10.22034/APJCP.2017.18.10.2771. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Zauber AG. The impact of screening on colorectal cancer mortality and incidence: Has it really made a difference? Dig Dis Sci. 2015;60:681–91. doi: 10.1007/s10620-015-3600-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Mahmoud M, Parambil J, Danjuma M, Abubeker I, Najim M, Ghazouani H, et al. Knowledge, attitude and practice of physicians regarding screening of colorectal cancer in Qatar: A Cross-sectional survey. Adv Med Educ Pract. 2020;11:843–50. doi: 10.2147/AMEP.S268315. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med. 2009;6:e1000097. doi: 10.1371/journal.pmed.1000097. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan—a web and mobile app for systematic reviews. Syst Rev. 2016;5:210. doi: 10.1186/s13643-016-0384-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Downes MJ, Brennan ML, Williams HC, Dean RS. Development of a critical appraisal tool to assess the quality of cross-sectional studies (AXIS) BMJ Open. 2016;6:e011458. doi: 10.1136/bmjopen-2016-011458. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Alessa M, Alhelal FM, Al Ahmed AA, AlKhars AA, Alomran RK, Albaqshi MM, et al. Role of primary healthcare physicians in early detection of colorectal cancer in Al-Ahsa, Saudi Arabia. Cureus. 2023;15:e48732. doi: 10.7759/cureus.48732. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Demyati E. Knowledge, attitude, practice, and perceived barriers of colorectal cancer screening among family physicians in National Guard Health Affairs, Riyadh. Int J Family Med 2014. 2014:1–7. doi: 10.1155/2014/457354. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Surendra B, Hashir MM, Harbi FSA, Nuwaysir MJA, Khaldi KMA, Alqahtani AM. Knowledge and awareness about colorectal cancer and its screening guidelines among doctors in Al Ahsa, Eastern Province, Kingdom of Saudi Arabia. Glob J Health Sci. 2016;9:145. [Google Scholar]
- 16.Altwijri A, Rabbani U. Knowledge, attitude, and practice towards colorectal cancer screening among primary health care physicians in Buraydah, Qassim, Saudi Arabia. J Women Med Dent Coll. 2023;1 [Google Scholar]
- 17.Mosli M, Alnahdi Y, Alghamdi A, Baabdullah M, Hadadi A, Khateery K, et al. Knowledge, attitude, and practices of primary health care physicians toward colorectal cancer screening. Saudi J Gastroenterol. 2017;23:330–6. doi: 10.4103/sjg.SJG_1_17. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Aldukhayel AM, Alsudairi HA, Alhomidani RA, Almutairi NS, Alturki FM, Almehmadi RG, et al. Knowledge and attitude of primary healthcare physicians toward colorectal cancer screening in Qassim region, Saudi Arabia. International Journal of Medicine in Developing Countries. 2021;5:1784–90. doi:10.24911/IJMDC.51-1631463181. [Google Scholar]
- 19.Alshaikhi SA, Assiri AS, Alshaikh AA, Alshaikhi SA, Assiri HA, Alshaiki OA, et al. Knowledge, attitude and practice of primary care physicians regarding colon cancer in Abha City, Saudi Arabia. Middle East J Fam Med. 2021;19:68–80. [Google Scholar]
- 20.Banamah OB, Al-Mutairi OM, Alshuaibi AM, Alamri RSA, AlRahmani DA, Alhojaily MM. Knowledge, attitudes and practices of primary care physicians in colorectal cancer screening, Jeddah, Saudi Arabia 2012. Int J Biol Med Res. 2017;8:5799–804. [Google Scholar]
- 21.Al Mutawah MR, Al Jassim M, Al Saleh E. Knowledge, attitude, and practice toward colorectal cancer screening among primary health-care physicians in Alhasa Area, 2018. Int J Sci Study. 2018;6:29–40. [Google Scholar]
- 22.Alsakkaf GEA, Boşnak AS, Birand N. Assessment of pharmacy students’ knowledge about breast cancer and colon cancer in Northern Cyprus universities. J Oncol Pharm Pract. 2023;30:710–20. doi: 10.1177/10781552231184588. [DOI] [PubMed] [Google Scholar]
- 23.Li C, Cao S, Sun X, Lu C, Guo M. Prognostic modeling of overall survival and analysis of K-M survival curves in patients with primary colon cancer: A SEER-based study. Medicine. 2023;102:e33902. doi: 10.1097/MD.0000000000033902. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Cancer Incidence Report Saudi Arabia 2022. Saudi Health Council, National Cancer Center. 2022. [[Last accessed on 2025 Oct 01]]. Available from: https://shc.gov.sa/Arabic/NewNCC/Activities/AnnualReports/Cancer%20Incidence%20Report%202022.pdf .
- 25.Albinsaad L, Alessa M, Alraihan JI, Albesher MA, Alessa HA, Almubarak A. Women's knowledge and attitudes regarding the risk factors and warning signs of breast cancer in the Eastern Province, Saudi Arabia: A cross-sectional study. Cureus. 2023;15:e49463. doi: 10.7759/cureus.49463. [DOI] [PMC free article] [PubMed] [Google Scholar]