Awareness about the symptoms & risk factors of ovarian cancer among women in North Urban Bengaluru: A cross-sectional study.

A cross-sectional study was carried out in the Kodigehalli ward of the Yelahanka zone, North Urban Bengaluru, between October 2023 and October 2024. In terms of urban governance, Yelahanka and Malleshwaram zones together constitute North Bengaluru Mahanagara Palike. The Yelahanka zone comprises 15 wards with a total population of 68,807. Among these, Kodigehalli ward was conveniently selected, with a population of 15,248, of which approximately 7,202 were females. The study was conducted among women residing in the localities of Kodigehalli ward of North Urban Bengaluru. There were 18 localities in Kodigehalli ward, of which four were chosen using the lottery method. We estimated the sample using the formula, n = Z 2 1-α/2 p  (1- p )/d 2 [where, Z 1-α/ is 1.96 with a confidence level of 95%,’d’- a margin of error of 4%, and ‘p’- representing the proportion of females aware of ovarian cancer risk factors and symptoms (16.9%)] 27 . The estimated sample size was 338, and after accounting for potential non-responses of 10 per cent, the required sample came up to 375. The total number of households in the four localities were 3,717, from which every 10 th house was selected for the study. If multiple eligible women were present in a household, the oldest woman was selected to participate in the study. The inclusion criteria were women aged 18-65 yr residing in the selected ward. Women with a personal history of ovarian cancer or those who had undergone salpingo-oophorectomy or hysterectomy were excluded from the study. The study used the Ovarian Cancer Awareness Measure (OCAM) questionnaire, a validated tool with a reliability (Cronbach’s alpha) score of 0.71 2 9 . Since OCAM had not been validated in the Indian context, the content validation was done by five subject experts. The OCAM includes questions that assess the knowledge of ovarian cancer symptoms and risk factors. The questionnaire was translated into the vernacular language, Kannada, and underwent a translation-back translation process conducted by a language expert. An interview method was used after obtaining informed consent from the participants to collect the data. The tool has three parts containing a total of 37 questions. The first part involved socio-demographic data and assessed awareness about cancer. The second part involved ten questions evaluating knowledge of ovarian cancer symptoms, using a 3-point scale (Yes, No, or I do not know). Higher scores indicated greater knowledge of ovarian cancer symptoms. The third part involved 12 questions evaluating knowledge of ovarian cancer risk factors, using a 5-point Likert scale (1=strongly disagree, 5=strongly agree). Correct answers (agree or strongly agree) received one point, with scores ranging from 0 to 12. Higher scores indicated greater knowledge of ovarian cancer risk factors. The analysis was done using Jamovi statistical software, version 2.3.28. Categorical variables were summarised as frequencies and percentages. To assess the normality of the data, the Shapiro-Wilk test was performed. Knowledge of ovarian cancer symptoms and risk factors was reported in terms of frequencies and percentages, with the overall median and interquartile range (IQR) calculated. Non-parametric tests, such as the Kruskal-Wallis and Mann-Whitney U tests, were used to compare the median scores of symptoms and risk factors across different socio-demographic categories. A P value of 0.05 or less was considered statistically significant.

This study included 375 women aged 18 to 65 yr from North Urban Bengaluru. The majority (34.9%, n=139) were aged 29-38 yr, with a mean age of 38.3±12.1 yr. For analysis purposes, the married category also included widowed (n=4) and divorced (n=1) individuals, and Class III (encompassed both Class III and IV. Most participants (94.7%, n=355) were married, while 5.3 per cent (n=20) were unmarried/single, primarily in the 19-28 yr age group. Among the education categories, 27.2 per cent (n=102) had completed their graduation. Most homemakers were graduates (20.5%, n=77). The majority (60.6%, n=227) belonged to Class I socioeconomic status, largely consisting of homemakers (40.5%, n=152). Participants aware of cervical, endometrial, and ovarian cancer mostly had professional degrees (43.2%, n=32) or were graduates (32.4%, n=24), and all belonged to Class I socioeconomic status. Awareness of ovarian cancer was highest among those aged 29-38 yr (35.5%, n=38), followed by 39-48 yr (25.2%, n=27), with all being homemakers. The primary sources of information about ovarian cancer were social media (47.7%, n=51) and family/friends (28%, n=30; Table I ). Socio-demographic profile of the study participants (n=375) * Classification based on Kuppuswamy Scale 2023, ** Classification based on B. G. Prasad scale, 2023 Table II shows the distribution of respondents based on their awareness about the signs and contributing factors of ovarian cancer. Out of 370 respondents, only 28 per cent (n=107) were aware of ovarian cancer. The majority, 81.3 per cent (n=87), believed that ovarian cancer could be diagnosed at an early stage. Most of those who held this belief had professional degrees (34.6%, n=37) or were graduates (25.2%, n=27). Frequency distribution of participants based on awareness about cancer * Multiple responses Extreme fatigue (61.7%), persistent pain in the pelvis (54.2%), an increase in abdomen size (51.4%), and persistent pain in the abdomen (49.5%) were commonly identified symptoms. On an average, participants (49%) could correctly identify about 4 out of 10 symptoms ( Fig. 1 ). Participants’ knowledge about the symptoms of ovarian cancer. Among participants, 43 per cent (n=46) believed ovarian cancer is unrelated to age, while 29 per cent (n=31) thought it is most likely to occur at the age of 50. However, 79 per cent (n=85) of those aware of ovarian cancer believed it was preventable. Most respondents were unsure about the risk factors that could increase the likelihood of developing ovarian cancer, including IVF treatment (56.1%, n=60), history of hormone replacement therapy (55.1%, n=59), use of talcum powder in the genital area (50.5%, n=54), endometriosis (47.7%, n=51), having no children (47.7%, n=51), history of breast cancer (44.9%, n=48), post-menopause (39.3%, n=42), and having an immediate family member diagnosed with ovarian cancer. (37.4%, n=40; Fig. 2 and Supplementary Table IA and B ). Supplementary Table IA Supplementary Table IB Participants’ knowledge about the risk factors of ovarian cancer. The Shapiro-Wilk test was performed for knowledge of symptoms and risk factor scores and found to be not normally distributed ( P <0.05) and hence non-parametric tests were applied to compare the scores across the groups. Table III depicts the knowledge scores of symptoms across various socio-demographic factors. Individuals with intermediate and no formal education showed higher median scores [6 (4, 8) and 7 (7, 7.5), respectively] compared to individuals with professional degrees and graduates, suggesting that factors other than formal education may influence knowledge levels in these groups. However, it was not statistically significant. The median knowledge score of ovarian cancer symptoms was highest among those skilled workers (7) (6.25, 8) compared to professionals (4.5) (2.25, 7). Despite the differences in median scores among the occupational subgroups, there was no statistically significant difference between occupations with regard to symptom scores. A statistically significant difference in median scores was found across various socioeconomic classes ( P =0.008). Comparison of Socio-demographic factors with participants’ knowledge scores on ovarian cancer symptoms (n=107) # Kruskal Walis test, ## Mann-Whitney U test. P * ≤0.05 considered statistically significant Table IV depicts the knowledge score of risk factors across various socio-demographic factors. Significant differences existed in the knowledge of ovarian cancer risk factors and demographic groups. Younger respondents (19-28 yr) had a higher knowledge score compared to other age categories [median=7, (5,8)], and the difference was statistically significant ( P =0.004). Single participants significantly scored higher [median=7, (5.5,9)] than married ones ( P =0.029). Unemployed respondents had the highest median score [6.5, (4.25,9)], compared to professionals [median=3, (1.75,5.5)], but occupation was not associated with the knowledge scores. Lower socioeconomic status classes (Class II and III) showed higher awareness [median=6.5 (3,7.75); median=7, (7-9)] compared to Class I, with a significant difference ( P =0.013). Comparison of sociodemographic factors with participants’ knowledge scores on ovarian cancer risk factors (n=107) 0.004 * 0.107 0.013 * # Kruskal Walis test, ## Mann-Whitney U test, P * ≤0.05 considered statistically significant

The study determined factors associated with risk and evaluated women’s awareness of ovarian cancer symptoms and risk factors in Urban Bengaluru. About 28 per cent of participants were aware of ovarian cancer, comparable to studies in Nigeria (33%) and Goa (35.4%) 15 , 27 . While a study conducted at a Punjab university, Chandigarh reported a higher awareness level (85.9%), with 47.6 per cent comprising students, 38.9 per cent in educational roles, and 13.5 per cent in non-teaching roles 29 . Key symptoms recognised by the majority, particularly those aged 29-38 yr, included extreme fatigue (61.7%), persistent pain in the pelvis (54.2%), an increase in abdominal size (51.4%), and back pain (43.9%). Similar studies reported recognition rates for extreme fatigue at 66.1 per cent in Syria and 56.5 per cent in Oman 30 , 31 , persistent pelvic pain was identified by 64.7 per cent in Goa and over 60 per cent in Syria and Oman, compared to 54.2 per cent in the present study 27 , 30 , 31 . Increased abdominal size was identified by 47.6 per cent in Oman and about 60 per cent in Goa and Palestine, while back pain was noted by around 42 per cent in Jordan and Goa 16 , 27 , 31 , 32 . A study from the United States of America (USA) found pelvic and/or abdominal swelling, bloating, and/or feeling of fullness were more commonly identified (47%), and weight loss was highly recognised in Nigeria (43.8%) and Palestine (66.7%) 15 , 32 , 33 . These findings show the need for consistent awareness of ovarian cancer symptoms across regions, highlighting the need for targeted global awareness campaigns to improve early detection. Most participants missed critical symptoms such as difficulty in eating (28%), feeling persistently full (32.7%), persistent bloating (34.6%), passing more urine than usual (35.5%), and changes in bowel movement (37.4%), consistent with findings from Syria 30 . Lower percentages were also noted in studies from Jordan and Nigeria, likely due to symptom overlap with gastrointestinal issues 15 , 16 . However, reportedly these symptoms are more frequent and intense in women with ovarian cancer. This study found a significant difference in ovarian cancer symptom awareness between socioeconomic classes. The upper class had a median (IQR) score of 3(0-5.5) compared to the middle class with a median (IQR) score of 7(4-8). However, the Jordan study found higher awareness among women with high family incomes (3.8±2.9) compared to those with lower incomes (3.1±2.6) 16 . Education of the participants was not significantly associated with symptom awareness in the present study, when compared with other studies that found a significant association between education and awareness 15 , 16 , 27 , 32 . This study found that, with a median (IQR) score of 5(2-7) out of 12 risk factors, the most accurately identified risk factors were ovarian cysts (71%), smoking (64.48%), being over 50 (55.54%), being overweight (47.6%), and being post-menopausal (43.92%). This is similar to findings from a study in Jordan where the mean score was 5.2±2.8 16 . Other studies reported similar recognition percentages: around 60 per cent in Goa and Palestine identified ovarian cysts 27 , 32 , while 71.3 per cent in Oman 31 ; smoking was recognised as a risk factor by 68 per cent in Jordan and Oman, and 74 per cent in Palestine 16 , 31 , 32 . The least commonly identified risk factors were not having children (18.69%), undergoing IVF treatment (23.3%), and using talcum powder (28%). In Jordan, Oman, and Palestine, higher percentages recognized the risk factor of not having children (34%, 26%, and 31%, respectively) 16 , 31 , 32 . Studies in Nigeria and Goa reported even lower recognition percentages for these risk factors 15 , 27 . Among the socio-demographic factors, age ( P =0.004), marital status ( P =0.029), education ( P =0.05), and socio-economic class ( P =0.013) were significantly associated with understanding the risk factors for ovarian cancer. Studies in Malaysia and Goa also found significant associations with age ( P =0.047 and P =0.01, respectively) and education ( P =0.039 and P =0.011, respectively) 23 , 27 . This study’s strength lies in being one of the first community-based assessments in India to evaluate women’s awareness of ovarian cancer symptoms and risk factors. However, it did have some limitations, such as insufficient representation of the working population and potential for socially desirable responses despite direct interviews. The study was conducted in a single urban ward; its findings can only be generalised to similar urban settings. This study highlights the need for improved awareness and educational interventions about ovarian cancer among women in North Urban Bengaluru. The community-based assessment revealed that only 28.5 per cent of participants were aware of symptoms and factors contributing for ovarian cancer, indicating significant gaps in public health. Enhanced outreach efforts are essential to educate women about this deadly disease and its early warning signs through existing National Breast and Cervical Cancer Awareness Programmes within the National Programme-Non-Communicable Disease framework. To bridge this awareness gap, it is crucial to train Accredited Social health Activist (ASHAs), Auxillary Nurse Midwife (ANMs), and primary health centre (PHC) staff to incorporate ovarian cancer education into their regular health sessions on women’s health. Strengthening early identification strategies through PHCs and Community Health Centres can help detect high-risk women, ensuring timely referral to district hospitals for further evaluation. It is vital to ensure that both women and healthcare providers can distinguish ovarian cancer symptoms from gastrointestinal issues to prevent misdiagnosis and ensure timely treatment. Identifying key risk factors for ovarian cancer will aid in implementing effective preventive measures and targeted prevention strategies, particularly for high-risk populations. Given the increasing prevalence of reproductive health issues and the strong link between a personal or family history of breast cancer and ovarian cancer, further community-based studies across India are necessary to enhance awareness and improve women’s understanding of ovarian cancer.