Women’s Awareness of Colon Cancer Screening in Real-world Clinical Setting in Nagasaki, Japan: a descriptive cross-sectional study

Women’s Awareness of Colon Cancer Screening in Real-world Clinical Setting in Nagasaki, Japan: a descriptive cross-sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Women’s Awareness of Colon Cancer Screening in Real-world Clinical Setting in Nagasaki, Japan: a descriptive cross-sectional study Maiko Tabuchi, Yuko Akazawa, Ayako Mine, Hiroko Inomata, Siota Junya, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6426323/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background: Colorectal cancer (CRC) is a global health concern and the first cause of cancer-related mortalities among women in Japan. Despite the effectiveness of fecal immunochemical tests (FITs), screening rates for colorectal cancer in Nagasaki, Japan remain suboptimal. Investigating the determinants of CRC screening rates and awareness among women in Nagasaki may improve screening. Methods: This study included female patients with CRC knowledge and screening questionnaires at facilities conducting colonoscopy in Nagasaki Prefecture, Japan. Participants were categorized into three age groups: young (20s-30s), middle-aged (40s-60s), and older (over 70 years), and two areas (Urban and Rural). Descriptive statistics were used for analysis. Results: Of 107 facilities surveyed, 72 responded. The analysis was conducted on 1210 cases after excluding 52 incomplete responses. Overall, 83% of those qualified for screening were over the age of 40 years. Moreover, 92% of respondents were from urban areas and 5% from rural areas. Although the awareness on FITs was 83%, only 48% underwent FITs within 2 years. Knowledge on CRC (regarding the existence of asymptomatic CRC and importance of early detection) was approximately 40%. Regarding the second screening, 36% of patients opted for another FITs. Gender preference for colonoscopy was observed at 24%, and common concerns about colonoscopy were “pain,” “laxatives,” and “embarrassment.” Conclusions: In Nagasaki Prefecture, knowledge on CRC and second colonoscopy screening remains low. It is crucial to disseminate accurate information about CRC, its screening, and address patients' concerns regarding colonoscopy screening. Trial registration : The study protocol was approved by the Ethics Committee of Nagasaki University Graduate School of Biomedical Sciences (approval number: 2412602, approval date: 8, February 2024). Colorectal cancer Screening Awareness Women Japan Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Colorectal cancer (CRC) is the third most common cause of cancer-related death in women, after lung and breast cancers( 1 – 3 ). CRC has become the most common cause of cancer-related death in women in recent years in Japan( 4 ). Colon cancer mortality in Europe and North America has been decreasing significantly( 2 ), while Japan has turned the tables to other countries since 2010. Fecal immunochemical tests (FITs) have emerged as valuable tools for CRC screening( 5 , 6 ) with substantial evidence supporting their effectiveness. FITs detect the majority of CRCs, with pooled sensitivities ranging from 73% for stage I cancers to 82% for stage III cancers( 7 ). They offer better sensitivity and comparable specificity compared to guaiac-based fecal occult blood tests with cross-sectional studies suggesting higher detection rates for advanced neoplasia( 6 ). Since 1992, 2-days fecal immunochemical tests (FITs) have been employed as an initial health screening program for individuals over the age of 40 years( 8 ). In Japan, individuals requiring further evaluation are referred for colonoscopy as a secondary screening measure. Screening rates and subsequent follow-up examinations for CRC are of significant importance (Kamo et al. 2022)( 9 ). Nevertheless, the CRC screening rate for both men and women remains low nationally at 41.5% (Nagasaki: 35.8%, 6th worst), and the rate for women is lower than that for men (Nagasaki: 32.6% women, 39.6% men, 2022)( 4 ). In 2020, the region of Nagasaki topped the nation's list of mortality rates from CRC among women( 4 ). Recommendations and awareness for CRC screening are challenging not only in Nagasaki prefecture but also nationwide( 10 ). This lack of awareness is also observed in the U.S., where only 20% knew about colonoscopy screening and 13% knew about FITs( 11 ). To date, no survey has been conducted to assess Japanese perspectives on CRC, especially in women. We hypothesized that there is a significant deficit in awareness and knowledge concerning CRC and its screening methods among women in Nagasaki, which contributes to the observed low screening rates. This study aimed to investigate the awareness and knowledge of CRC and colorectal examinations among women in Nagasaki and to identify factors that could enhance screening rates. Material and Methods Objective and Recruitment The target population was female patients who visited 107 facilities in Nagasaki Prefecture where colonoscopy was available. The survey was conducted from February 8 to 28, 2024. Patients who agreed to participate were asked to complete the questionnaire and place it in an individual envelope prior to collection. The inclusion criteria were defined as those who could understand Japanese through the questionnaire. Because the content of the responses could include allegations against the medical facility, the preface clearly stated 1) that the questionnaire should be submitted in a sealed envelope so that the content would not be disclosed to the facility personnel and 2) that the questionnaire could be submitted blank if the respondents did not wish to write anything in the questionnaire. Age was defined as 20’s-30’s as not eligible for screening and ≥ 40 years as eligible for screening. Individuals in their 20s and 30s were categorized as young adults, those in their 40s to 60s as middle-aged adults, and those aged 70 years and above as older adults. Japan is an island nation and Nagasaki Prefecture is located in the western part of Kyushu Island, which consists of many islands of various sizes. Therefore, we divided the regional characteristics into urban areas, which are contiguous with Kyushu Island, and rural areas, which are separated from the island. Regarding the regional analysis section (all figures and tables, except for Table 1 and Figure 5), 30 participants with unknown residency were excluded. Questionnaire contents The survey first inquired about participants’ age, followed by questions regarding their experience, knowledge, and impressions of CRC, CRC screening, and colonoscopy. The questions were presented in a choice-type, free-response, and multiple-choice format. Questions focused on this study, with unrelated inquiries and excluded outcomes, are presented below. The questionnaire is attached as supplemental data; however, it is a translation of the questionnaire ( Supplemental data ). Questionnaire about knowledge of colorectal cancer screening (binary choice) 1. Do you think that these symptoms are common with colorectal cancer? (I think so, as incorrect; I do not think so, as correct; I have no idea, as incorrect) 2.Do you know that the 5-year survival rate of colorectal cancer is greater than 95% if the disease is detected at an early stage? (Yes, No) 3. Do you know that FITs are the first step in screening for colorectal cancer? (Yes, No) 4. What will you do if the first screening test is positive? (Take another FITs, as incorrect; colonoscopy, as correct; do nothing due to no symptoms. as incorrect; have no idea, as incorrect.) Questionnaire about prior history of colorectal cancer screening and colonoscopy (binary choice) Prior FITs (options: every year, ≤ 2 years, ≥ 2 years before, never, regular colonoscopy. Every year and regular colonoscopy options were represented as option under ≤ 2 years.) 2. Prior colonoscopy (yes or no) Questionnaire on the reasons/impressions of individuals who have never undergone a colonoscopy (multiple and free choice) Reasons for never undergoing a colonoscopy (health check normal, no symptoms, having regular defecation, constipation is usual, slight bleeding is likely hemorrhoids, hesitant to disclose health condition, busy or financial concerns). Perceptions of colonoscopy (seems painful, embarrassing, resistant to laxative use, preference for female physicians, low awareness of colonoscopy, do not know where to get the colonoscopy, do not know where sedation is available, no information available online) Perception regarding colonoscopy experience (free-response format） If you have undergone a colonoscopy, what is your advice for the examination? Analysis Descriptive statistics were used to summarize the patients’ characteristics and questionnaire responses based on their age and/or residential area. Additionally, we summarized the responses of the patients who underwent colonoscopy and those who did not. All statistical analyses were performed using JMP Pro, version 17.2.0 (SAS Institute, Inc.). Results Of the 107 facilities, 72 responded to the survey. The survey response was 1262 of 2140 (response rate was 59.1%). The analysis was performed on 1210 cases, excluding three blank sheets and 49 partial responses. Respondents’ characteristics are listed in Table 1 . The age groups included 202 (17%) young, 743 (61%) middle-aged, and 265 (22%) older adults. The collection regions were Urban areas 1120 (92%), Rural areas 60 (5%), and Unknown 30 (2%) ( Table 1 ). From the FITs history of all age groups, 48% had undergone the test within 2 years and 52% had never undergone FITs or undergone the test more than 2 years ago ( Table 1 ). The percentages of middle-aged and older adults who had never undergone FITs were 28% and 26%, respectively ( Table 1 ). When asked if they had ever undergone colonoscopy, overall 37% answered yes, with a relatively high testing rate of 59% for older adults and 36% for middle-aged adults ( Table 1 ). Table 1. Patients’ characteristics Total n= 1,210 Young adults 20-39 years n=202 Middle-aged adults 40-69 years n=743 Older adults ≥ 70 years n=265 n (%) n (%) Residence Urban 1,120 (92) 187 (92) 678 (91) 255 (96) Rural 60 (5) 6 (3) 44 (6) 10 (4) Unknown 30 (2) 9 (4) 21 (3) 0 (0) History of FITs a ≤ 2 years 579 (48) 38 (19) 416 (56) 125 (47) > 2 years 198 (16) 11 (5) 117 (16) 70 (26) none 433 (36) 153 (76) 210 (28) 70 (26) History of Colonoscopy b ≥ 1 time 443 (37) 19 (9) 267 (36) 157 (59) none 767 (63) 183 (91) 476 (64) 108 (41) a FITs, fecal immunochemical tests; b Colonoscopy, a person who underwent colonoscopy at least once. Next, we analyzed the percentage of correct knowledge of CRC and colorectal for each generation ( Figure 1 ). When asked whether most CRCs have symptoms and who knew that CRC could lack symptoms (answer,” I do not think so”), the rate was approximately 40% for all ages, and this rate decreased with each successive generation. Only 40% of respondents were aware that early detection of CRC provides a high survival rate, with younger generations having the lowest knowledge retention rate (young adults, 29%; middle-aged, 41%; older adults, 45%) ( Figure 1 , Supplemental Table 1 ). In Japan, only FITs are recognized as a CRC screening method, and 83% of all respondents were aware of it in the order of middle-aged adults (87%), older adults (82%), and young adults (72%), with young adults showing slightly lower knowledge ( Figure 2, Supplemental Table 1 ). In addition, knowledge about secondary screening was declining, particularly in middle-aged rural areas ( Figure 2, Supplemental Table 1 ). To assess their understanding of secondary screening, the participants were asked about their actions following a positive primary screening result. In urban areas, 70% indicated that they would perform a colonoscopy, whereas in rural areas, only 53% indicated that they would conduct a colonoscopy, and 36% indicated that they would perform another FITs ( Figure 2 ). Notably, more than 40% of middle-aged adults in rural areas prefer alternative FITs for secondary screening ( Online Resource 1 ). Therefore, we surveyed the respondents’ impressions of colonoscopy. A total of 747 respondents (excluding 30 with unknown region answers) who had never undergone colonoscopic screening were asked to provide reasons for undoing colonoscopy and their perceptions of colonoscopy through a multiple-choice questionnaire ( Figure 3, Supplemental Table 2 ). The most prevalent reason was the absence of abnormalities in health checks (44%), whereas middle age was the most common factor (48%) ( Figure 3 , Supplemental Table 2 ). The absence of symptoms was observed in 39% of patients. Young adults and middle-aged individuals, representing the working population, were more likely than the elderly to cite busy or financial constraints as reasons. Young adults more frequently reported constipation as a usual occurrence (young: 11%, middle-older: 5-6%) and believed that minor bleeding was attributable to hemorrhoids (young: 11%, middle-older: 5-6%) ( Figure 3, Supplemental Table 2 ). The most common perceptions regarding colonoscopy were pain (34%), embarrassment (34%), and laxative resistance (33%) ( Figure 4 ). Twenty-four percent of respondents expressed a preference for female physicians ( Figure 4, Supplemental Table 2 ). Furthermore, individuals aged 20s–60s were twice as likely to prefer female endoscopists than their older counterparts ( Figure 4, Supplemental Table 2 ). In contrast, 462 patients who had undergone colonoscopy were asked to write freely about their impressions of the colonoscopy, of whom 66% were positive or had no claim ( Figure 5 ). Resistance to laxatives was the most common issue (18%); 10% said it was painful, 6% wanted sedation, and 5% said it was embarrassing ( Figure 5 ). Discussion Situated on the western edge of Japan, Nagasaki Prefecture has a poor screening participation rate and a high mortality rate for CRC. Insufficient awareness and knowledge regarding colon cancer screening among women are significant public health concerns. Our study on women's awareness of CRC revealed that approximately 60% were unaware that the disease's early stages often presented with no symptoms (Fig. 1 ). Although the advanced stages of CRC have various symptoms( 12 , 13 ), early-stage CRC may not present symptoms. For instance, a study found that positive predictive values for individual symptoms (such as bleeding, abdominal pain, weight loss, and anemia) were relatively low, ranging from 0.7–4.5% of the patient( 13 ). This highlights the challenge in diagnosing CRC based on symptoms alone. This lack of knowledge could potentially lead to a reluctance to undergo screening, as individuals might assume that the absence of symptoms indicates no need for testing. In this study, young adults awareness was lower for CRC than middle-aged and older adults, as reported in a similar study( 14 ) (Fig. 1 ). However, the global rise in CRC cases among younger individuals has become a significant concern( 15 – 18 ), prompting the United States to lower the recommended screening age from 50 to 45 years( 19 ). Other studies have indicated that educational interventions can play a crucial role in mitigating the risk of this disease( 20 ). Consequently, dissemination of information and raising awareness among young people have emerged as critical priorities for addressing this health concern. In Western countries, 30%-50% of CRC cases are frequently identified at an advanced stage( 21 ). Research supporting the efficacy of FITs screening indicates that 5-year survival rates for CRC vary significantly depending on the stage at diagnosis and whether the cancer was detected through screening( 22 ). Regarding Stage I, screen-detected cases had a 92.4% survival rate (95% CI, 91.6–93.1), compared to 86.7% (95% CI, 86.0-87.4) for non-screen-detected cases. Stage II survival rates were 87.9% (95% CI, 86.6–89.1) for screen-detected cases and 79.2% (95% CI, 78.5–80.0) for non-screen-detected cases( 22 ). Screening plays a crucial role in detecting CRC earlier than when it is discovered through other means, which significantly improves the chances of survival( 22 – 24 ). In this research, FITs in Nagasaki Prefecture were recognized as approximately 80%, yet they exhibit a significantly low rate (≤ 50%) of adoption (Fig. 1 , Table 1 ).Moreover, the regional disparities in misunderstandings about secondary screening become apparent(Fig. 2 ). It is vital to educate the public about the benefits of FITs. However, merely informing them is insufficient; it is important to implement additional strategies, such as distributing FITs with a specified return deadline, as practiced in the United Kingdom( 25 ). Although FITs exhibit high overall sensitivity, they may fail to detect approximately one-third of stage I CRC( 7 ). This limitation is particularly pronounced for T1 tumors, with a sensitivity as low as 52% compared to 79%-93% for more advanced T stages( 7 ). There remains potential for enhancement, particularly in early-stage cancer detection. Colonoscopy screening has emerged as a valuable method for detecting early CRC, with studies indicating that colonoscopy performed once every 10 years has a CRC detection rate equivalent to FITs conducted annually or biennially( 2 ). Moreover, there has been increasing focus on proximal CRC in women( 26 – 28 ), as cancers in the proximal colon may present fewer symptoms( 29 ) challenging to identify with FITs due to anatomical factors( 30 ). Colonoscopy screening should be considered for detecting these lesions( 31 ), although its safety as a medical examination remains a subject of debate( 23 ). In our study, 66% of patients who had undergone colonoscopy had no claims, which may provide reassurance to patients undergoing colonoscopy (Fig. 5 ). Although colonoscopy screening is currently encouraged, women often exhibit significant reluctance to undergo the procedure( 32 ). Whether or not the patient had undergone colonoscopy before, the results of this study indicate that concerns about laxatives, pain, and embarrassment are the main concerns about colonoscopy (Fig. 4 , 5 ). Informing patients that healthcare facilities address these issues could motivate them to participate in a second screening. In the United States, embarrassment (75%) is the primary reason for female patients selecting a female endoscopist( 33 ), and it is well documented that female patients exhibit a stronger preference for female examiners than male patients globally( 33 – 36 ). Additionally, the scarcity of female endoscopists presents a significant challenge, with 87% of patients in the U.S. willing to wait > 30 days for a female endoscopist and 14% willing to pay more for a female endoscopist( 33 , 37 ). There is currently a lack of data regarding this preference in Japan. Our findings reveal, for the first time, that 24% of Japanese women express gender preferences (Fig. 4 ). However, the proportion of female endoscopists in Japan is only 13%, and that in Nagasaki is the same ( https://www.jges.net/medical ) [cited December 3, 2024]. One factor contributing to the low number of female endoscopists is the challenging work and training environment for female physicians( 37 , 38 ). Therefore, it is imperative to provide female endoscopists with enhanced opportunities to work in well-equipped facilities and advance their professional careers. Furthermore, increasing and promoting the presence of female endoscopists in facilities may serve as a valuable strategy to encourage examinations among women. Limitation This study has several limitations. Focusing on Japan may limit the generalizability of these findings to other nations and cultural contexts. A disproportionately small number of participants from rural areas compared to those from urban areas could result in the underrepresentation of rural perspectives. This study may not have fully captured the nuanced differences in experiences between urban and rural inhabitants, possibly by overlooking specific cultural elements. All patients visited medical facilities, and their awareness of healthcare was likely higher than that of the general female population. Conclusion In Nagasaki Prefecture, knowledge about CRC is low (approximately 40%), and there are regional disparities in the awareness of secondary screening. Regardless of experience, the most common concerns regarding colonoscopy are pain, embarrassment, and bowel preparation. Among those who had never undergone the procedure, 24% showed a gender preference for the examiner. Abbreviations CRC, colorectal cancers; FITs, fecal immunochemical tests; CS, colonoscopy Declarations Statement of Ethics This study adhered to the Declaration of Helsinki. Study approval statement: The study protocol was reviewed and approved by the Ethics Committee of Nagasaki University Graduate School of Biomedical Sciences (approval number: 2412602). The participants provided written informed consent. Consent for publication Not applicable. Availability of data and materials The data supporting the findings of this study are available from the corresponding author, Maiko Tabuchi, upon reasonable request. Competing interest The authors declare no conflicts of interest with respect to this research study and paper. Funding This research received no external funding. Author Contributions MT and YA conducted the research and wrote the article. IS, YA and KN supervised the whole project. AM, HI, JS, TA, KH cooperated in data collection. MK, HM, KM, and HM conducted a thorough examination of the questionnaire. IS mainly assisted with statistical analysis and figure preparation. 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Supplementary Files SupplementaldataQuestionnaire20250408.docx SupplementalTable1.docx SupplementalTable2.docx SupplementalfigureBMC.pptx Supplemental Figure 1. Subsequent steps after positive FITs a resulted in middle-aged adults. This figure compares the main and rural areas in terms of the percentage of answers to questions that asked respondents to choose their behavior toward secondary health checkups among people aged 40 years to 69 years. a FITs, fecal immunochemical tests Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 03 Jun, 2025 Reviews received at journal 23 May, 2025 Reviewers agreed at journal 18 May, 2025 Reviewers agreed at journal 15 May, 2025 Reviewers invited by journal 15 May, 2025 Editor assigned by journal 13 May, 2025 Editor invited by journal 16 Apr, 2025 Submission checks completed at journal 15 Apr, 2025 First submitted to journal 15 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6426323","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":458068868,"identity":"b4afa35e-f3ee-43ad-be66-64119790709a","order_by":0,"name":"Maiko Tabuchi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDElEQVRIiWNgGAWjYJACZiBOYGNvgPAkmKHCjA24NUC08BwgVQuDRAJUCyFH6TbwH/xc2GaXxyf59uDHLzV18pLtDGwSDDV2DMyzsVtjdoCZWXpmW3Ixm3ResrTMscOGs5lBWo4lMzDOOYBLC4M0b9uBxDbpHANpCbYDjPOY+b9JMLAdYGCckYDTlt9gLZJnjH9L/Kuznwe25R9eLWwQWyR4zCQ/tjEngh3G2IZHy2FmM+sZ55IT23hyzKwZ+w4nz2xmYLZI7EvmwemX442PbxeU2SXObz9jfPPHtzrbGecPMN748M1OzhBHiDEwI7N5YCygk3gMZ2DXgQIYfyDz5AlG6igYBaNgFIwQAAA4E1PlRiumvQAAAABJRU5ErkJggg==","orcid":"","institution":"Nagasaki University Graduate School of Biomedical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Maiko","middleName":"","lastName":"Tabuchi","suffix":""},{"id":458068869,"identity":"15601ce7-15a2-4bee-ad22-cc6a902be91d","order_by":1,"name":"Yuko Akazawa","email":"","orcid":"","institution":"Nagasaki University Graduate School of Biomedical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Yuko","middleName":"","lastName":"Akazawa","suffix":""},{"id":458068870,"identity":"8b0919fe-9968-4395-abd5-431256f57a3e","order_by":2,"name":"Ayako Mine","email":"","orcid":"","institution":"Nagasaki University Graduate School of Biomedical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Ayako","middleName":"","lastName":"Mine","suffix":""},{"id":458068871,"identity":"0dca79fe-922b-45a4-856a-93fdb86f758b","order_by":3,"name":"Hiroko Inomata","email":"","orcid":"","institution":"Nagasaki University Graduate School of Biomedical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Hiroko","middleName":"","lastName":"Inomata","suffix":""},{"id":458068872,"identity":"dd6e1a19-5af5-4640-9ccf-bd1f4440266d","order_by":4,"name":"Siota Junya","email":"","orcid":"","institution":"Nagasaki University Graduate School of Biomedical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Siota","middleName":"","lastName":"Junya","suffix":""},{"id":458068873,"identity":"9fa32f1e-2765-4aa5-b474-6e1bbf5037a5","order_by":5,"name":"Taro Akashi","email":"","orcid":"","institution":"Nagasaki University Graduate School of Biomedical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Taro","middleName":"","lastName":"Akashi","suffix":""},{"id":458068874,"identity":"e49eb066-eec7-4c25-80b4-e20a8b5d3e94","order_by":6,"name":"Moto Kitayama","email":"","orcid":"","institution":"Nagasaki University Graduate School of Biomedical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Moto","middleName":"","lastName":"Kitayama","suffix":""},{"id":458068875,"identity":"3e33e83c-4f92-477f-8aa4-9dedde70cec1","order_by":7,"name":"Keiichi Hashiguchi","email":"","orcid":"","institution":"Nagasaki University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Keiichi","middleName":"","lastName":"Hashiguchi","suffix":""},{"id":458068876,"identity":"1a94d695-b346-4b62-b956-8bcd522b992f","order_by":8,"name":"Kayoko Matsushima","email":"","orcid":"","institution":"Nagasaki University Graduate School of Biomedical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Kayoko","middleName":"","lastName":"Matsushima","suffix":""},{"id":458068877,"identity":"1c16d5c8-4585-4d38-9541-68000234caef","order_by":9,"name":"Hitomi Minami","email":"","orcid":"","institution":"Nagasaki University Graduate School of Biomedical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Hitomi","middleName":"","lastName":"Minami","suffix":""},{"id":458068878,"identity":"5af9f1e7-0843-4839-9540-89498bc77178","order_by":10,"name":"Hisamitsu Miyaaki","email":"","orcid":"","institution":"Nagasaki University Graduate School of Biomedical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Hisamitsu","middleName":"","lastName":"Miyaaki","suffix":""},{"id":458068879,"identity":"c33e0fd4-2d66-46b2-9d13-f4c019d76d5e","order_by":11,"name":"Izumi Sato","email":"","orcid":"","institution":"Nagasaki University Graduate School of Biomedical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Izumi","middleName":"","lastName":"Sato","suffix":""},{"id":458068880,"identity":"be62be7d-cc09-4e98-8ee0-ca44fcdf922f","order_by":12,"name":"Kazuhiko Nakao","email":"","orcid":"","institution":"Nagasaki University Graduate School of Biomedical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Kazuhiko","middleName":"","lastName":"Nakao","suffix":""}],"badges":[],"createdAt":"2025-04-11 08:23:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6426323/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6426323/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83128837,"identity":"489734c6-080c-41ea-8708-0eb42b7ed304","added_by":"auto","created_at":"2025-05-20 09:58:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":69706,"visible":true,"origin":"","legend":"\u003cp\u003eCorrect response of colorectal cancer and screening knowledge across ages and regions\u003c/p\u003e\n\u003cp\u003eThis figure shows the percentage of correct answers to questions on colorectal cancer knowledge.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003eCC, colorectal cancer; \u003csup\u003eb\u003c/sup\u003eFITs, fecal immunochemical tests; \u003csup\u003ec\u003c/sup\u003eCS, colonoscopy\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6426323/v1/f116e6d88f96ea1a231dbe2d.png"},{"id":83129346,"identity":"99aa27e3-9619-4598-ab1c-61f54d56f32e","added_by":"auto","created_at":"2025-05-20 10:06:33","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":45832,"visible":true,"origin":"","legend":"\u003cp\u003eIntended next steps after a positive FITs\u003csup\u003ea\u003c/sup\u003e result\u003c/p\u003e\n\u003cp\u003eThis figure compares the main and rural areas in terms of the percentage of answers to questions that asked respondents to choose their behavior toward secondary health checkups.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003eFITs, fecal immunochemical tests\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6426323/v1/71f79a155bbd3117ed82f86b.png"},{"id":83128840,"identity":"8ac4956a-8120-4b80-9d18-b8e11c7a83f3","added_by":"auto","created_at":"2025-05-20 09:58:34","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":91493,"visible":true,"origin":"","legend":"\u003cp\u003eReasons for not undergoing colonoscopy\u003c/p\u003e\n\u003cp\u003eThis figure shows the reasons for the absence of colonoscopy. Multiple choices were also allowed.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-6426323/v1/44feef2815092d686c4e407c.png"},{"id":83129356,"identity":"e1d47299-b0ce-461d-af10-c27c87219c6d","added_by":"auto","created_at":"2025-05-20 10:06:34","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":71842,"visible":true,"origin":"","legend":"\u003cp\u003ePerceptions of colonoscopy\u003c/p\u003e\n\u003cp\u003eThis figure shows the individual impressions of colonoscopy. Multiple choices were also permitted.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-6426323/v1/9cd627565a1e22f9fd4da3a0.png"},{"id":83130456,"identity":"8cea197c-a8aa-4e10-b1b9-66be539721af","added_by":"auto","created_at":"2025-05-20 10:14:34","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":65205,"visible":true,"origin":"","legend":"\u003cp\u003ePatient-reported experience with a past colonoscopy.\u003c/p\u003e\n\u003cp\u003eThis figure presents a summary of patient perceptions following colonoscopy.\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-6426323/v1/ff2865996cda44ad05d9f8b3.png"},{"id":83131938,"identity":"c1d87689-91d7-49eb-b872-37325bf38bf3","added_by":"auto","created_at":"2025-05-20 10:30:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1089226,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6426323/v1/6e7ef584-ce86-4890-887e-68baf6e4e259.pdf"},{"id":83129350,"identity":"a0f17562-32f6-45fa-ba5e-26f8719fc8d0","added_by":"auto","created_at":"2025-05-20 10:06:34","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":38106,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaldataQuestionnaire20250408.docx","url":"https://assets-eu.researchsquare.com/files/rs-6426323/v1/027e5e6b7b9abca95332bb49.docx"},{"id":83131032,"identity":"04f0646f-e383-4689-89d9-12c166d197e7","added_by":"auto","created_at":"2025-05-20 10:22:34","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":20975,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalTable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6426323/v1/8c8fe7e0e7f97a6efbc0c81a.docx"},{"id":83129351,"identity":"e3ba5568-13d0-4580-8e02-da15bfe4663a","added_by":"auto","created_at":"2025-05-20 10:06:34","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":26710,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalTable2.docx","url":"https://assets-eu.researchsquare.com/files/rs-6426323/v1/b65dda27b01ab0763af195a3.docx"},{"id":83131033,"identity":"f6fdc164-a554-4b2a-8cd8-c968af6a79a3","added_by":"auto","created_at":"2025-05-20 10:22:34","extension":"pptx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":49376,"visible":true,"origin":"","legend":"\u003cp\u003eSupplemental Figure 1. Subsequent steps after positive FITs\u003csup\u003ea\u003c/sup\u003e resulted in middle-aged adults.\u003c/p\u003e\n\u003cp\u003eThis figure compares the main and rural areas in terms of the percentage of answers to questions that asked respondents to choose their behavior toward secondary health checkups among people aged 40 years to 69 years. \u003csup\u003ea\u003c/sup\u003eFITs, fecal immunochemical tests\u003c/p\u003e","description":"","filename":"SupplementalfigureBMC.pptx","url":"https://assets-eu.researchsquare.com/files/rs-6426323/v1/229a096e4392cb510f2d4f5b.pptx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Women’s Awareness of Colon Cancer Screening in Real-world Clinical Setting in Nagasaki, Japan: a descriptive cross-sectional study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eColorectal cancer (CRC) is the third most common cause of cancer-related death in women, after lung and breast cancers(\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). CRC has become the most common cause of cancer-related death in women in recent years in Japan(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Colon cancer mortality in Europe and North America has been decreasing significantly(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), while Japan has turned the tables to other countries since 2010.\u003c/p\u003e \u003cp\u003eFecal immunochemical tests (FITs) have emerged as valuable tools for CRC screening(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) with substantial evidence supporting their effectiveness. FITs detect the majority of CRCs, with pooled sensitivities ranging from 73% for stage I cancers to 82% for stage III cancers(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). They offer better sensitivity and comparable specificity compared to guaiac-based fecal occult blood tests with cross-sectional studies suggesting higher detection rates for advanced neoplasia(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSince 1992, 2-days fecal immunochemical tests (FITs) have been employed as an initial health screening program for individuals over the age of 40 years(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). In Japan, individuals requiring further evaluation are referred for colonoscopy as a secondary screening measure. Screening rates and subsequent follow-up examinations for CRC are of significant importance (Kamo et al. 2022)(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Nevertheless, the CRC screening rate for both men and women remains low nationally at 41.5% (Nagasaki: 35.8%, 6th worst), and the rate for women is lower than that for men (Nagasaki: 32.6% women, 39.6% men, 2022)(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). In 2020, the region of Nagasaki topped the nation's list of mortality rates from CRC among women(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRecommendations and awareness for CRC screening are challenging not only in Nagasaki prefecture but also nationwide(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). This lack of awareness is also observed in the U.S., where only 20% knew about colonoscopy screening and 13% knew about FITs(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). To date, no survey has been conducted to assess Japanese perspectives on CRC, especially in women.\u003c/p\u003e \u003cp\u003eWe hypothesized that there is a significant deficit in awareness and knowledge concerning CRC and its screening methods among women in Nagasaki, which contributes to the observed low screening rates. This study aimed to investigate the awareness and knowledge of CRC and colorectal examinations among women in Nagasaki and to identify factors that could enhance screening rates.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eObjective and Recruitment\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe target population was female patients who visited 107 facilities in Nagasaki Prefecture where colonoscopy was available. The survey was conducted from February 8 to 28, 2024. Patients who agreed to participate were asked to complete the questionnaire and place it in an individual envelope prior to collection. The inclusion criteria were defined as those who could understand Japanese through the questionnaire. Because the content of the responses could include allegations against the medical facility, the preface clearly stated 1) that the questionnaire should be submitted in a sealed envelope so that the content would not be disclosed to the facility personnel and 2) that the questionnaire could be submitted blank if the respondents did not wish to write anything in the questionnaire. \u003c/p\u003e\n\u003cp\u003eAge was defined as 20\u0026rsquo;s-30\u0026rsquo;s as not eligible for screening and \u0026ge; 40 years as eligible for screening. Individuals in their 20s and 30s were categorized as young adults, those in their 40s to 60s as middle-aged adults, and those aged 70 years and above as older adults.\u003c/p\u003e\n\u003cp\u003eJapan is an island nation and Nagasaki Prefecture is located in the western part of Kyushu Island, which consists of many islands of various sizes. Therefore, we divided the regional characteristics into urban areas, which are contiguous with Kyushu Island, and rural areas, which are separated from the island.\u003c/p\u003e\n\u003cp\u003eRegarding the regional analysis section (all figures and tables, except for Table 1 and Figure 5), 30 participants with unknown residency were excluded. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eQuestionnaire contents\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe survey first inquired about participants\u0026rsquo; age, followed by questions regarding their experience, knowledge, and impressions of CRC, CRC screening, and colonoscopy. The questions were presented in a choice-type, free-response, and multiple-choice format. Questions focused on this study, with unrelated inquiries and excluded outcomes, are presented below. The questionnaire is attached as supplemental data; however, it is a translation of the questionnaire (\u003cstrong\u003eSupplemental data\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003eQuestionnaire about knowledge of colorectal cancer screening (binary choice)\u003c/p\u003e\n\u003cp\u003e1. Do you think that these symptoms are common with colorectal cancer? (I think so, as incorrect; I do not think so, as correct; I have no idea, as incorrect)\u003c/p\u003e\n\u003cp\u003e2.Do you know that the 5-year survival rate of colorectal cancer is greater than 95% if the disease is detected at an early stage? (Yes, No)\u003c/p\u003e\n\u003cp\u003e3. Do you know that FITs are the first step in screening for colorectal cancer? (Yes, No)\u003c/p\u003e\n\u003cp\u003e4. What will you do if the first screening test is positive? (Take another FITs, as incorrect; colonoscopy, as correct; do nothing due to no symptoms. as incorrect; have no idea, as incorrect.) \u003c/p\u003e\n\u003cp\u003eQuestionnaire about prior history of colorectal cancer screening and colonoscopy (binary choice)\u003c/p\u003e\n\u003col\u003e\n\u003cli\u003ePrior FITs (options: every year, \u0026le; 2 years, \u0026ge; 2 years before, never, regular colonoscopy. Every year and regular colonoscopy options were represented as option under \u0026le; 2 years.)\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e2. Prior colonoscopy (yes or no) \u003c/p\u003e\n\u003cp\u003eQuestionnaire on the reasons/impressions of individuals who have never undergone a colonoscopy (multiple and free choice)\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n\u003cli\u003eReasons for never undergoing a colonoscopy (health check normal, no symptoms, having regular defecation, constipation is usual, slight bleeding is likely hemorrhoids, hesitant to disclose health condition, busy or financial concerns).\u003c/li\u003e\n\u003cli\u003ePerceptions of colonoscopy (seems painful, embarrassing, resistant to laxative use, preference for female physicians, low awareness of colonoscopy, do not know where to get the colonoscopy, do not know where sedation is available, no information available online) \u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003ePerception regarding colonoscopy experience (free-response format）\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n\u003cli\u003eIf you have undergone a colonoscopy, what is your advice for the examination? \u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAnalysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive statistics were used to summarize the patients\u0026rsquo; characteristics and questionnaire responses based on their age and/or residential area. Additionally, we summarized the responses of the patients who underwent colonoscopy and those who did not. All statistical analyses were performed using JMP Pro, version 17.2.0 (SAS Institute, Inc.).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOf the 107 facilities, 72 responded to the survey. The survey response was 1262 of 2140 (response rate was 59.1%). The analysis was performed on 1210 cases, excluding three blank sheets and 49 partial responses. Respondents\u0026rsquo; characteristics are listed in \u003cstrong\u003eTable 1\u003c/strong\u003e. The age groups included 202 (17%) young, 743 (61%) middle-aged, and 265 (22%) older adults. The collection regions were Urban areas 1120 (92%), Rural areas 60 (5%), and Unknown 30 (2%) (\u003cstrong\u003eTable 1\u003c/strong\u003e).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFrom the FITs history of all age groups, 48% had undergone the test within 2 years and 52% had never undergone FITs or undergone the test more than 2 years ago (\u003cstrong\u003eTable 1\u003c/strong\u003e). The percentages of middle-aged and older adults who had never undergone FITs were 28% and 26%, respectively (\u003cstrong\u003eTable 1\u003c/strong\u003e). When asked if they had ever undergone colonoscopy, overall 37% answered yes, with a relatively high testing rate of 59% for older adults and 36% for middle-aged adults (\u003cstrong\u003eTable 1\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Patients\u0026rsquo; characteristics\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003en= 1,210\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003eYoung adults\u003c/p\u003e\n \u003cp\u003e20-39 years\u003c/p\u003e\n \u003cp\u003en=202\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003eMiddle-aged adults\u003c/p\u003e\n \u003cp\u003e40-69 years\u003c/p\u003e\n \u003cp\u003en=743\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003eOlder adults\u003c/p\u003e\n \u003cp\u003e\u0026ge; 70 years\u003c/p\u003e\n \u003cp\u003en=265\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003eResidence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e1,120 (92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e187 (92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e678 (91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e255 (96)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e60 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e6 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e44 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e10 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003eUnknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e30 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e9 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e21 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003eHistory of FITs\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026le; 2 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e579 (48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e38 (19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e416 (56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e125 (47)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026gt; 2 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e198 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e11 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e117 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e70 (26)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003enone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e433 (36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e153 (76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e210 (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e70 (26)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003eHistory of Colonoscopy\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026ge; 1 time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e443 (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e19 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e267 (36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e157 (59)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003enone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e767 (63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e183 (91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e476 (64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e108 (41)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003csup\u003ea\u003c/sup\u003eFITs, fecal immunochemical tests; \u003csup\u003eb\u003c/sup\u003eColonoscopy, a person who underwent colonoscopy at least once. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNext, we analyzed the percentage of correct knowledge of CRC and colorectal for each generation (\u003cstrong\u003eFigure 1\u003c/strong\u003e). When asked whether most CRCs have symptoms and who knew that CRC could lack symptoms (answer,\u0026rdquo; I do not think so\u0026rdquo;), the rate was\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eapproximately 40% for all ages, and this rate decreased with each successive generation. Only 40% of respondents were aware that early detection of CRC provides a high survival rate, with younger generations having the lowest knowledge retention rate (young adults, 29%; middle-aged, 41%; older adults, 45%) (\u003cstrong\u003eFigure 1\u003c/strong\u003e, \u003cstrong\u003eSupplemental Table 1\u003c/strong\u003e).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn Japan, only\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eFITs are recognized as a CRC screening method, and 83% of all respondents were aware\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eof it in the order of middle-aged adults (87%), older adults (82%), and young adults (72%), with young adults showing slightly lower knowledge (\u003cstrong\u003eFigure 2, Supplemental Table 1\u003c/strong\u003e). In addition, knowledge about secondary screening was declining, particularly in middle-aged rural areas (\u003cstrong\u003eFigure 2, Supplemental Table 1\u003c/strong\u003e).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo assess their understanding of secondary screening, the participants were asked about their actions following a positive primary screening result. In urban areas, 70% indicated that they would perform a colonoscopy, whereas in rural areas, only 53% indicated that they would conduct a colonoscopy, and 36% indicated that they would perform another FITs (\u003cstrong\u003eFigure 2\u003c/strong\u003e). Notably, more than 40% of middle-aged adults in rural areas prefer alternative FITs for secondary screening (\u003cstrong\u003eOnline Resource 1\u003c/strong\u003e).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTherefore, we surveyed the respondents\u0026rsquo; impressions of colonoscopy. A total of 747 respondents (excluding 30 with unknown region answers) who had never undergone colonoscopic screening were asked to provide reasons for undoing colonoscopy and their perceptions of colonoscopy through a multiple-choice questionnaire (\u003cstrong\u003eFigure 3, Supplemental Table 2\u003c/strong\u003e). The most prevalent reason was the absence of abnormalities in health checks (44%), whereas middle age was the most common factor (48%) (\u003cstrong\u003eFigure 3\u003c/strong\u003e, \u003cstrong\u003eSupplemental Table 2\u003c/strong\u003e). The absence of symptoms was observed in 39% of patients. Young adults and middle-aged individuals, representing the working population, were more likely than the elderly to cite busy or financial constraints as reasons. Young adults more frequently reported constipation as a usual occurrence (young: 11%, middle-older: 5-6%) and believed that minor bleeding was attributable to hemorrhoids (young: 11%, middle-older: 5-6%) (\u003cstrong\u003eFigure 3, Supplemental Table 2\u003c/strong\u003e). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe most common perceptions regarding colonoscopy were pain (34%), embarrassment (34%), and laxative resistance (33%) (\u003cstrong\u003eFigure 4\u003c/strong\u003e). Twenty-four percent of respondents expressed a preference for female physicians (\u003cstrong\u003eFigure 4, Supplemental Table 2\u003c/strong\u003e).\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eFurthermore, individuals aged 20s\u0026ndash;60s were twice as likely to prefer female endoscopists than their older counterparts (\u003cstrong\u003eFigure 4, Supplemental Table 2\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003eIn contrast, 462 patients who had undergone colonoscopy were asked to write freely about their impressions of the colonoscopy, of whom 66% were positive or had no claim (\u003cstrong\u003eFigure 5\u003c/strong\u003e). Resistance to laxatives was the most common issue (18%); 10% said it was painful, 6% wanted sedation, and 5% said it was embarrassing (\u003cstrong\u003eFigure 5\u003c/strong\u003e). \u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSituated on the western edge of Japan, Nagasaki Prefecture has a poor screening participation rate and a high mortality rate for CRC. Insufficient awareness and knowledge regarding colon cancer screening among women are significant public health concerns. Our study on women's awareness of CRC revealed that approximately 60% were unaware that the disease's early stages often presented with no symptoms (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Although the advanced stages of CRC have various symptoms(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), early-stage CRC may not present symptoms. For instance, a study found that positive predictive values for individual symptoms (such as bleeding, abdominal pain, weight loss, and anemia) were relatively low, ranging from 0.7\u0026ndash;4.5% of the patient(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). This highlights the challenge in diagnosing CRC based on symptoms alone. This lack of knowledge could potentially lead to a reluctance to undergo screening, as individuals might assume that the absence of symptoms indicates no need for testing.\u003c/p\u003e \u003cp\u003eIn this study, young adults awareness was lower for CRC than middle-aged and older adults, as reported in a similar study(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). However, the global rise in CRC cases among younger individuals has become a significant concern(\u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), prompting the United States to lower the recommended screening age from 50 to 45 years(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Other studies have indicated that educational interventions can play a crucial role in mitigating the risk of this disease(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Consequently, dissemination of information and raising awareness among young people have emerged as critical priorities for addressing this health concern.\u003c/p\u003e \u003cp\u003eIn Western countries, 30%-50% of CRC cases are frequently identified at an advanced stage(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Research supporting the efficacy of FITs screening indicates that 5-year survival rates for CRC vary significantly depending on the stage at diagnosis and whether the cancer was detected through screening(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Regarding Stage I, screen-detected cases had a 92.4% survival rate (95% CI, 91.6\u0026ndash;93.1), compared to 86.7% (95% CI, 86.0-87.4) for non-screen-detected cases. Stage II survival rates were 87.9% (95% CI, 86.6\u0026ndash;89.1) for screen-detected cases and 79.2% (95% CI, 78.5\u0026ndash;80.0) for non-screen-detected cases(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Screening plays a crucial role in detecting CRC earlier than when it is discovered through other means, which significantly improves the chances of survival(\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). In this research, FITs in Nagasaki Prefecture were recognized as approximately 80%, yet they exhibit a significantly low rate (\u0026le;\u0026thinsp;50%) of adoption (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).Moreover, the regional disparities in misunderstandings about secondary screening become apparent(Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e). It is vital to educate the public about the benefits of FITs. However, merely informing them is insufficient; it is important to implement additional strategies, such as distributing FITs with a specified return deadline, as practiced in the United Kingdom(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough FITs exhibit high overall sensitivity, they may fail to detect approximately one-third of stage I CRC(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). This limitation is particularly pronounced for T1 tumors, with a sensitivity as low as 52% compared to 79%-93% for more advanced T stages(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). There remains potential for enhancement, particularly in early-stage cancer detection.\u003c/p\u003e \u003cp\u003eColonoscopy screening has emerged as a valuable method for detecting early CRC, with studies indicating that colonoscopy performed once every 10 years has a CRC detection rate equivalent to FITs conducted annually or biennially(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Moreover, there has been increasing focus on proximal CRC in women(\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), as cancers in the proximal colon may present fewer symptoms(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) challenging to identify with FITs due to anatomical factors(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Colonoscopy screening should be considered for detecting these lesions(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), although its safety as a medical examination remains a subject of debate(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). In our study, 66% of patients who had undergone colonoscopy had no claims, which may provide reassurance to patients undergoing colonoscopy (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough colonoscopy screening is currently encouraged, women often exhibit significant reluctance to undergo the procedure(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Whether or not the patient had undergone colonoscopy before, the results of this study indicate that concerns about laxatives, pain, and embarrassment are the main concerns about colonoscopy (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e4\u003c/span\u003e, \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Informing patients that healthcare facilities address these issues could motivate them to participate in a second screening.\u003c/p\u003e \u003cp\u003eIn the United States, embarrassment (75%) is the primary reason for female patients selecting a female endoscopist(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), and it is well documented that female patients exhibit a stronger preference for female examiners than male patients globally(\u003cspan additionalcitationids=\"CR34 CR35\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Additionally, the scarcity of female endoscopists presents a significant challenge, with 87% of patients in the U.S. willing to wait\u0026thinsp;\u0026gt;\u0026thinsp;30 days for a female endoscopist and 14% willing to pay more for a female endoscopist(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). There is currently a lack of data regarding this preference in Japan. Our findings reveal, for the first time, that 24% of Japanese women express gender preferences (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e4\u003c/span\u003e). However, the proportion of female endoscopists in Japan is only 13%, and that in Nagasaki is the same (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.jges.net/medical\u003c/span\u003e\u003cspan address=\"https://www.jges.net/medical\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) [cited December 3, 2024]. One factor contributing to the low number of female endoscopists is the challenging work and training environment for female physicians(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Therefore, it is imperative to provide female endoscopists with enhanced opportunities to work in well-equipped facilities and advance their professional careers. Furthermore, increasing and promoting the presence of female endoscopists in facilities may serve as a valuable strategy to encourage examinations among women.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eLimitation\u003c/h2\u003e \u003cp\u003eThis study has several limitations. Focusing on Japan may limit the generalizability of these findings to other nations and cultural contexts. A disproportionately small number of participants from rural areas compared to those from urban areas could result in the underrepresentation of rural perspectives. This study may not have fully captured the nuanced differences in experiences between urban and rural inhabitants, possibly by overlooking specific cultural elements. All patients visited medical facilities, and their awareness of healthcare was likely higher than that of the general female population.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn Nagasaki Prefecture, knowledge about CRC is low (approximately 40%), and there are regional disparities in the awareness of secondary screening. Regardless of experience, the most common concerns regarding colonoscopy are pain, embarrassment, and bowel preparation. Among those who had never undergone the procedure, 24% showed a gender preference for the examiner.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCRC, colorectal cancers; FITs, fecal immunochemical tests; CS, colonoscopy\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStatement of Ethics\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study adhered to the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eStudy approval statement: The study protocol was reviewed and approved by the Ethics Committee of Nagasaki University Graduate School of Biomedical Sciences (approval number: 2412602). The participants provided written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting the findings of this study are available from the corresponding author, Maiko Tabuchi, upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interest\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest with respect to this research study and paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthor Contributions\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMT and YA conducted the research and wrote the article. IS, YA and KN supervised the whole project. AM, HI, JS, TA, KH cooperated in data collection. MK, HM, KM, and HM conducted a thorough examination of the questionnaire. IS mainly assisted with statistical analysis and figure preparation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank all facilities in Nagasaki for their cooperation with this survey\u0026nbsp;and\u003c/p\u003e\n\u003cp\u003eEditage (www.editage.jp) for English language editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDonovan JM, Syngal S. Colorectal cancer in women: an underappreciated but preventable risk. J Womens Health. 1998 Feb;7(1):45\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eShaukat A, Levin TR. Current and future colorectal cancer screening strategies. Nat Rev Gastroenterol Hepatol. 2022 Aug;19(8):521\u0026ndash;31.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Global Cancer Observatory [Internet]. International Agency For Research on Cancer. [cited 2024 Oct 24]. Available from: https://gco.iarc.fr/en\u003c/li\u003e\n\u003cli\u003eCancer Statistics [Internet]. [cited 2024 Oct 24]. Available from: https://ganjoho.jp/med_pro/index.html\u003c/li\u003e\n\u003cli\u003eAllison JE, Fraser CG, Halloran SP, Young GP. Population screening for colorectal cancer means getting FIT: the past, present, and future of colorectal cancer screening using the fecal immunochemical test for hemoglobin (FIT). Gut Liver. 2014 Mar;8(2):117\u0026ndash;30.\u003c/li\u003e\n\u003cli\u003eImperiale TF. Noninvasive screening tests for colorectal cancer. Dig Dis. 2012 Nov 23;30 Suppl 2(Suppl. 2):16\u0026ndash;26.\u003c/li\u003e\n\u003cli\u003eNiedermaier T, Balavarca Y, Brenner H. Stage-specific sensitivity of fecal immunochemical tests for detecting colorectal cancer: Systematic review and meta-analysis: Systematic review and meta-analysis. Am J Gastroenterol. 2020 Jan;115(1):56\u0026ndash;69.\u003c/li\u003e\n\u003cli\u003eSaito Y, Oka S, Kawamura T, Shimoda R, Sekiguchi M, Tamai N, et al. Colonoscopy screening and surveillance guidelines. Dig Endosc. 2021 May;33(4):486\u0026ndash;519.\u003c/li\u003e\n\u003cli\u003eKamo K-I, Fukui K, Ito Y, Nakayama T, Katanoda K. How much can screening reduce colorectal cancer mortality in Japan? Scenario-based estimation by microsimulation. Jpn J Clin Oncol. 2022 Mar 3;52(3):221\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eTakahashi H, Honda H, Ibayashi M, Saitoh K, Akino K. Cancer screening rates and characteristics of low-participating groups in Sapporo city. Nihon Koshu Eisei Zasshi. 2021 Oct 6;68(10):695\u0026ndash;705.\u003c/li\u003e\n\u003cli\u003eCarnahan LR, Jones L, Brewer KC, Watts EA, Peterson CE, Ferrans CE, et al. Race and gender differences in awareness of colorectal cancer screening tests and guidelines among recently diagnosed colon cancer patients in an urban setting. J Cancer Educ. 2021 Jun;36(3):567\u0026ndash;75.\u003c/li\u003e\n\u003cli\u003eAstin M, Griffin T, Neal RD, Rose P, Hamilton W. The diagnostic value of symptoms for colorectal cancer in primary care: a systematic review. Br J Gen Pract. 2011 May;61(586):e231-43.\u003c/li\u003e\n\u003cli\u003eHamilton W, Lancashire R, Sharp D, Peters TJ, Cheng K, Marshall T. The risk of colorectal cancer with symptoms at different ages and between the sexes: a case-control study. BMC Med. 2009 Apr 17;7(1):17.\u003c/li\u003e\n\u003cli\u003eMueller NM, Hyams T, King-Marshall EC, Curbow BA. Colorectal cancer knowledge and perceptions among individuals below the age of 50. Psychooncology. 2022 Mar;31(3):436\u0026ndash;41.\u003c/li\u003e\n\u003cli\u003eWeinberg BA, Marshall JL. Colon Cancer in Young Adults: Trends and Their Implications. Curr Oncol Rep. 2019 Jan 18;21(1):3.\u003c/li\u003e\n\u003cli\u003eSung JJY, Chiu H-M, Jung K-W, Jun JK, Sekiguchi M, Matsuda T, et al. Increasing Trend in Young-Onset Colorectal Cancer in Asia: More Cancers in Men and More Rectal Cancers. Am J Gastroenterol. 2019 Feb;114(2):322\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eStoffel EM, Murphy CC. Epidemiology and Mechanisms of the Increasing Incidence of Colon and Rectal Cancers in Young Adults. Gastroenterology. 2020 Jan;158(2):341\u0026ndash;53.\u003c/li\u003e\n\u003cli\u003eDanpanichkul P, Moolkaew P, Kanjanakot Y, Polpichai N, Jaroenlapnopparat A, Kim D, et al. Rising incidence and impact of early-onset colorectal cancer in the Asia-Pacific with higher mortality in females from Southeast Asia: a global burden analysis from 2010 to 2019. J Gastroenterol Hepatol [Internet]. 2023 Aug 29; Available from: http://dx.doi.org/10.1111/jgh.16331\u003c/li\u003e\n\u003cli\u003eWang Y, Huang X, Cheryala M, Aloysius M, Zheng B, Yang K, et al. Global increase of colorectal cancer in young adults over the last 30 years: an analysis of the Global Burden of Disease Study 2019. J Gastroenterol Hepatol [Internet]. 2023 May 21; Available from: http://dx.doi.org/10.1111/jgh.16220\u003c/li\u003e\n\u003cli\u003eKnudsen MD, Hoff G, Tidemann-Andersen I, Bodin GE, \u0026Oslash;vervold S, Berstad P. Public awareness and perceptions of colorectal cancer prevention: A cross-sectional survey. J Cancer Educ. 2021 Oct;36(5):957\u0026ndash;64.\u003c/li\u003e\n\u003cli\u003eRenzi C, Odelli S, Morani F, Benitez Majano S, Signorelli C. Delays in cancer diagnosis: challenges and opportunities in Europe. Acta Biomed. 2023 Aug 30;94(S3):e2023161.\u003c/li\u003e\n\u003cli\u003eCardoso R, Guo F, Heisser T, Hackl M, Ihle P, De Schutter H, et al. Colorectal cancer incidence, mortality, and stage distribution in European countries in the colorectal cancer screening era: an international population-based study. Lancet Oncol. 2021 Jul;22(7):1002\u0026ndash;13.\u003c/li\u003e\n\u003cli\u003eBretthauer M, L\u0026oslash;berg M, Wieszczy P, Kalager M, Emilsson L, Garborg K, et al. Effect of colonoscopy screening on risks of colorectal cancer and related death. N Engl J Med. 2022 Oct 27;387(17):1547\u0026ndash;56.\u003c/li\u003e\n\u003cli\u003eKrul MF, Elferink MAG, Kok NFM, Dekker E, Lansdorp-Vogelaar I, Meijer GA, et al. Initial impact of national CRC screening on incidence and advanced colorectal cancer. Clin Gastroenterol Hepatol. 2023 Mar;21(3):797-807.e3.\u003c/li\u003e\n\u003cli\u003eRobb KA, Young B, Murphy MK, Duklas P, McConnachie A, Hollands GJ, et al. Behavioural interventions to increase uptake of FIT colorectal screening in Scotland (TEMPO): a nationwide, eight-arm, factorial, randomised controlled trial. Lancet. 2025 Mar 29;405(10484):1081\u0026ndash;92.\u003c/li\u003e\n\u003cli\u003eMenees SB, Fenner DE. Colon cancer screening in women. Womens Health. 2007 Mar;3(2):163\u0026ndash;72.\u003c/li\u003e\n\u003cli\u003eLi Q-L, Ma X-Y, Yu L-L, Xue F, Ma W-L, Yao K-Y. Age-specific detection rates of colorectal neoplasms by colonoscopic screening in high-incidence rural area. Zhonghua Zhong Liu Za Zhi. 2013 Feb;35(2):154\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eTanaka Y, Arai T, Uegaki S, Sasaki M, Kanazawa N, Inamatsu T. Characteristics of colonoscopic findings in the very elderly. Geriatr Gerontol Int. 2016 Dec;16(12):1319\u0026ndash;23.\u003c/li\u003e\n\u003cli\u003eHoltedahl K, Borgquist L, Donker GA, Buntinx F, Weller D, Campbell C, et al. Symptoms and signs of colorectal cancer, with differences between proximal and distal colon cancer: a prospective cohort study of diagnostic accuracy in primary care. BMC Fam Pract. 2021 Jul 8;22(1):148.\u003c/li\u003e\n\u003cli\u003eCastells A, Quintero E, \u0026Aacute;lvarez C, Bujanda L, Cubiella J, Salas D, et al. Rate of detection of advanced neoplasms in proximal colon by simulated sigmoidoscopy vs fecal immunochemical tests. Clin Gastroenterol Hepatol. 2014 Oct;12(10):1708-16.e4.\u003c/li\u003e\n\u003cli\u003eLiang PS, Williams JL, Dominitz JA, Corley DA, Zauber AG. Age-Stratified Prevalence and Predictors of Neoplasia Among U.S. Adults Undergoing Screening Colonoscopy in a National Endoscopy Registry. Gastroenterology. 2022 Sep;163(3):742-753.e4.\u003c/li\u003e\n\u003cli\u003eBestari MB, Joewono IR. Screening colonoscopy for colon cancer in women during COVID-19 pandemic. Acta Med Indones. 2021 Jan;53(1):132\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eMenees SB, Inadomi JM, Korsnes S, Elta GH. Women patients\u0026rsquo; preference for women physicians is a barrier to colon cancer screening. Gastrointest Endosc. 2005 Aug;62(2):219\u0026ndash;23.\u003c/li\u003e\n\u003cli\u003eVaradarajulu S, Petruff C, Ramsey WH. Patient preferences for gender of endoscopists. Gastrointest Endosc. 2002 Aug;56(2):170\u0026ndash;3.\u003c/li\u003e\n\u003cli\u003eChong VH. Gender preference and implications for screening colonoscopy: impact of endoscopy nurses. World J Gastroenterol. 2012 Jul 21;18(27):3590\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eSchneider A, Kanagarajan N, Anjelly D, Reynolds JC, Ahmad A. Importance of gender, socioeconomic status, and history of abuse on patient preference for endoscopist. Am J Gastroenterol. 2009 Feb;104(2):340\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003ePerez Gutierrez O, Anandasabapathy S. Endoscopist gender and patient impact: much more than meets the eye. Gastrointest Endosc. Elsevier BV; 2021 May;93(5):1169\u0026ndash;70.\u003c/li\u003e\n\u003cli\u003eKim N. Sex/gender differences in gastrointestinal endoscopy from the perspective of patients and gastroenterologists. Clin Endosc. 2023 May;56(3):268\u0026ndash;82.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Colorectal cancer, Screening, Awareness, Women, Japan","lastPublishedDoi":"10.21203/rs.3.rs-6426323/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6426323/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eColorectal cancer (CRC) is a global health concern and the first cause of cancer-related mortalities among women in Japan. Despite the effectiveness of fecal immunochemical tests (FITs), screening rates for colorectal cancer in Nagasaki, Japan remain suboptimal. Investigating the determinants of CRC screening rates and awareness among women in Nagasaki may improve screening.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis study included female patients with CRC knowledge and screening questionnaires at facilities conducting colonoscopy in Nagasaki Prefecture, Japan. Participants were categorized into three age groups: young (20s-30s), middle-aged (40s-60s), and older (over 70 years), and two areas (Urban and Rural). Descriptive statistics were used for analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eOf 107 facilities surveyed, 72 responded. The analysis was conducted on 1210 cases after excluding 52 incomplete responses. Overall, 83% of those qualified for screening were over the age of 40 years. Moreover, 92% of respondents were from urban areas and 5% from rural areas. Although the awareness on FITs was 83%, only 48% underwent FITs within 2 years. Knowledge on CRC (regarding the existence of asymptomatic CRC and importance of early detection) was approximately 40%. Regarding the second screening, 36% of patients opted for another FITs. Gender preference for colonoscopy was observed at 24%, and common concerns about colonoscopy were “pain,” “laxatives,” and “embarrassment.”\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eIn Nagasaki Prefecture, knowledge on CRC and second colonoscopy screening remains low. It is crucial to disseminate accurate information about CRC, its screening, and address patients' concerns regarding colonoscopy screening. \u003cbr\u003e\n \u003cstrong\u003eTrial registration\u003c/strong\u003e: The study protocol was approved by the Ethics Committee of Nagasaki University Graduate School of Biomedical Sciences (approval number: 2412602, approval date: 8, February 2024).\u003c/p\u003e","manuscriptTitle":"Women’s Awareness of Colon Cancer Screening in Real-world Clinical Setting in Nagasaki, Japan: a descriptive cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-20 09:58:29","doi":"10.21203/rs.3.rs-6426323/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"251329727910037384484705938264024878225","date":"2025-06-03T06:57:46+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-23T04:00:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"167203845808323897455522940348102634499","date":"2025-05-19T03:29:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2581321907181644894813222483755553258","date":"2025-05-15T08:37:37+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-15T08:07:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-13T07:29:55+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-04-16T05:31:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-15T07:18:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-04-15T07:17:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3f6c87fd-8dd5-4c40-a8b2-9d36318ae6be","owner":[],"postedDate":"May 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-05-20T09:58:29+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-20 09:58:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6426323","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6426323","identity":"rs-6426323","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}