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Awareness about the symptoms & risk factors of ovarian cancer among women in North Urban Bengaluru: A cross-sectional study
For correspondence: Dr Mackwin Kenwood Dmello, Department of Public Health, Nitte Institute of Allied Health Sciences (NIAHS), Nitte (Deemed to be University), Mangaluru 575 018, Karnataka, India e-mail: mackwin@nitte.edu.in
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Received: ,
Accepted: ,
Abstract
Background & objectives
In low or medium Human Development Index (HDI) nations, late-stage ovarian cancer diagnosis in 75 per cent of women is known to hinder treatment outcomes. However, knowledge and awareness can significantly impact disease progression and outcomes. This study was conducted to determine ovarian cancer awareness, risk factors, and symptoms among women in a community-based setting.
Methods
This study was conducted in Yelahanka, North Urban Bengaluru, between October 2023 and July 2024. A validated questionnaire, Ovarian Cancer Awareness Measure (OCAM), was used to interview the women. Household data were collected through systematic sampling using the Epicollect-5 mobile application and analysed with Jamovi software version 2.3.28.
Results
A total of 375 women were interviewed during the study, of which 28.5 per cent were aware of ovarian cancer. With median scores of 4 out of 10 for symptoms and 5 out of 12 for risk factors, there was a general lack of awareness of symptoms and risk factors. Commonly identified symptoms included extreme fatigue (61.7%), pelvic pain (54.2%), abdominal enlargement (51.4%), and back pain (43.9%). The socioeconomic class was significantly associated with symptom awareness (P<0.05). On identifying risk factors of ovarian cancer, the most recognised were a history of ovarian cysts (71%), smoking (64.48%), age >50 yr (55.54%), and being overweight (47.6%). Age, marital status, education, and socioeconomic class (P<0.05) influenced awareness of risk factors.
Interpretation & conclusions
This study found low ovarian cancer awareness among women in North Urban Bengaluru, emphasising the necessity for focused awareness programmes to enhance early diagnosis and improve health outcomes.
Keywords
Awareness
gynaecological cancers
knowledge
ovarian cancer
risk factors
symptoms
Cancer remains a leading cause of death worldwide, with approximately 9.7 million fatalities and 20 million new cases reported globally in 20221. Asia, a region home to 59.2 per cent of the global population, accounted for nearly half of all global cancer cases (49.2%) and most cancer-related deaths (56.1%)2. Global Cancer Observatory (GLOBOCAN) projections estimate that cancer cases in India will rise by 57.5 per cent from 2020 to 2.08 million by 20403. The most common cancers among Indian women are those of the breast (28%), cervix (10.6%), ovaries (6.2%), and uterus (3.7%). Cancer ranks among the foremost causes of death globally4. The rising cancer incidence among females in India underscores the need for preventive measures.
Ovarian cancer comprises a group of diseases that originate in the ovaries, fallopian tubes, or peritoneum5.In 2022, ovarian cancer affected 3,24,398 women globally, resulting in 2,09,830 deaths2. Over a lifetime, women have a one in 75 risk of developing ovarian cancer and a one in 100 risk of dying from it6. Despite being less frequent than breast cancer, ovarian cancer is three times more deadly, and estimates indicate that by 2040, the death rate from ovarian cancer will have significantly increased7,8. Globally, India ranks second in ovarian cancer incidence, following China, and is responsible for 76.5 per cent of ovarian cancer cases and 77.5 per cent of deaths in South Central Asian nations9. Data from 28 Population-Based Cancer Registries under the National Cancer Registry Programme show an alarming rise in ovarian cancer diagnoses from 2012 to 2016. The highest age-adjusted incidence rates per 1,00,000 population were observed in Delhi at 9.5, Bengaluru at 9.4, Hyderabad at 9.2, Chennai at 8.9, and Bhopal at 7.910.
The incidence of ovarian cancer rises after the age of 35 and reaches its highest level between the ages of 55 and 64 yr11. Approximately 75 per cent of ovarian cancer cases are detected in the later stages, making treatment more challenging12. Early diagnosis of ovarian cancer is challenging due to the lack of effective screening tests and the presence of vague, nonspecific symptoms. These symptoms are often mistaken for gastrointestinal issues by both the women experiencing them and their physicians, leading to delayed diagnosis13-16. Due to the lack of reliable screening techniques, the best approach to detect ovarian cancer is by maintaining ‘appropriate clinical suspicion’ of its indicators and manifestations. The symptoms include discomfort or pain in the pelvic or abdominal area, swelling or enlargement of the abdomen, persistent bloating, and challenges with eating or feeling full quickly, which typically occurs about 10-12 times a month17.
Age, family history of breast or ovarian cancer, obesity, hormone replacement medication, null parity, late menopause, endometriosis, smoking, and the use of talcum powder in the vaginal area are key risk factors associated with ovarian cancer development18-20. Studies suggest that eliminating or reducing these risk factors could prevent up to 40 per cent of all cancer cases8. Ovarian cancer primarily affects postmenopausal women, with older age being associated with a higher risk, more advanced disease at diagnosis, and lower survival rates19,21,22. Studies worldwide indicate that women generally have low awareness of the symptoms and risk factors associated with ovarian cancer16,23-27. During the literature search, we found two studies on ovarian cancer awareness, one based in a hospital setting in Goa and the other at Panjab University, Chandigarh28. There have been no community-based studies on this topic in India as per our knowledge. Hence, this study was conducted to determine the awareness of ovarian cancer, risk factors, and symptoms among women in a community-based setting.
Materials & Methods
Study design and setting
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.
Study population & estimation of sample size
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=Z21-α/2p (1-p)/d2 [where, Z1-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 10th 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.
Data collection
The study used the Ovarian Cancer Awareness Measure (OCAM) questionnaire, a validated tool with a reliability (Cronbach’s alpha) score of 0.7129. 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.
Statistical analysis
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.
Results
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 characteristics | n | % |
|---|---|---|
| Age (yr) | ||
| 19-28 | 91 | 24.3 |
| 29-38 | 131 | 34.9 |
| 39-48 | 76 | 20.3 |
| ≥49 | 77 | 20.5 |
| Marital status | ||
| Married | 355 | 94.7 |
| Single | 20 | 5.3 |
| Number of children | ||
| 0 | 37 | 9.9 |
| 1 | 124 | 33.1 |
| 2 or more | 275 | 57 |
| Education* | ||
| Professional degree | 70 | 18.7 |
| Graduate | 102 | 27.2 |
| Intermediate | 51 | 13.6 |
| High school | 74 | 19.7 |
| Middle school | 18 | 4.8 |
| Primary school | 28 | 7.5 |
| No formal education | 32 | 8.5 |
| Occupation* | ||
| Professionals | 40 | 10.6 |
| Associate professional | 28 | 7.5 |
| Skilled workers and shop | 32 | 8.5 |
| Elementary occupation | 25 | 6.7 |
| Unemployed | 250 | 66.7 |
| Socio economic status** | ||
| Class I (≥9130) | 227 | 60.6 |
| Class II (4565–9129) | 89 | 23.7 |
| Class III (1369–4564) | 59 | 15.7 |
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).
| Variables | n | Percentage of study participants (%) |
|---|---|---|
| Heard about cancer | ||
| No | 5 | 1.3 |
| Yes | 370 | 98.7 |
| Know anyone with cancer (n=370) | ||
| No | 267 | 72.16 |
| Yes | 103 | 27.84 |
| Heard about any gynaecological cancers* (n=370) | ||
| Cervical cancer | 156 | 42.6 |
| Ovarian cancer | 107 | 29.2 |
| Endometrial / Uterine cancer | 272 | 74.3 |
| Vaginal cancer | 23 | 6.3 |
| Don’t know | 74 | 20 |
| Source of information of ovarian cancer (n=107) | ||
| Family/Friends | 30 | 28 |
| Health worker | 11 | 10.3 |
| Newspaper/Magazine | 5 | 4.7 |
| Social media | 51 | 47.7 |
| Others | 10 | 9.3 |
| Diagnosis of ovarian cancer at an early stage | ||
| Yes | 87 | 81.3 |
| No | 20 | 18.7 |
| Most likely age (yr) | ||
| 30 | 26 | 24.3 |
| 50 | 31 | 29 |
| 70 | 4 | 3.7 |
| Unrelated to age | 46 | 43 |
| Ovarian cancer is preventable | ||
| Yes | 85 | 79.4 |
| No | 22 | 20.6 |
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).
- Participants’ knowledge about the risk factors of ovarian cancer.
Comparison of socio-demographic factors with participants’ knowledge scores on ovarian cancer symptoms and risk factors
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).
| Variables | n | Median | Q1, Q3 | P value |
|---|---|---|---|---|
| Age (yr) # | ||||
| 19-28 | 18 | 5 | 1.5, 7 | 0.541 |
| 29-38 | 38 | 4.5 | 2, 8 | |
| 39-48 | 24 | 4 | 0, 7 | |
| ≥49 | 27 | 4 | 2, 7 | |
| Marital status## | ||||
| Married | 96 | 4 | 1, 7.25 | 0.776 |
| Single | 11 | 5 | 3, 7 | |
| Education# | ||||
| Professional degree | 43 | 3 | 1, 5 | 0.094 |
| Graduate | 36 | 3.5 | 0, 8 | |
| Intermediate or below | 25 | 6 | 4, 8 | |
| No formal education | 3 | 7 | 7,7.5 | |
| Occupation# | ||||
| Professionals | 30 | 4.5 | 2.25, 7 | 0.161 |
| Associate professional | 11 | 4 | 0.5, 6 | |
| Skilled workers and shop | 10 | 7 | 6.25, 8 | |
| Unemployed | 56 | 4 | 0.75, 7.25 | |
| Socio economic status# | ||||
| Class I (≥9130) | 83 | 3 | 0, 5.5 | 0.008* |
| Class II (4565-9129) | 14 | 7.5 | 5.5, 8 | |
| Class III (1369-4564) | 10 | 7 | 4, 8 |
#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).
| Variables | n | Median | Q1, Q3 | P value |
|---|---|---|---|---|
| Age (yr)# | ||||
| 19-28 | 18 | 7 | 5, 8 |
0.004* |
| 29-38 | 38 | 3.25 | 3.25, 8.75 | |
| 39-48 | 24 | 4 | 2, 6.5 | |
| ≥49 | 27 | 3.5 | 1, 5.25 | |
| Marital status## | ||||
| Married | 96 | 5 | 2, 7 | 0.029* |
| Single | 11 | 7 | 5.5, 9 | |
| Education# | ||||
| Professional degree | 43 | 5 | 2, 7 | 0.05* |
| Graduate | 36 | 5 | 2, 7 | |
| Intermediate or below | 25 | 7 | 4, 9 | |
| No formal education | 3 | 11 | 9, 11.5 | |
| Occupation# | ||||
| Professionals | 30 | 3 | 1.75, 5.5 |
0.107 |
| Associate professional | 11 | 6 | 4, 4 | |
| Skilled workers and shop | 10 | 6 | 2, 6.5 | |
| Unemployed | 56 | 6.5 | 4.25, 9 | |
| Socio economic status# | ||||
| Class I (≥9130) | 83 | 5 | 2, 7 |
0.013* |
| Class II (4565-9129) | 14 | 6.5 | 3, 7.75 | |
| Class III (1369-4564) | 10 | 7 | 7, 9 |
#Kruskal Walis test, ##Mann-Whitney U test, P *≤0.05 considered statistically significant
Discussion
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 roles29. 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 Oman30,31, 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 study27,30,31. 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 Goa16,27,31,32. 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 Syria30. Lower percentages were also noted in studies from Jordan and Nigeria, likely due to symptom overlap with gastrointestinal issues15,16. 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 awareness15,16,27,32.
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±2.816. Other studies reported similar recognition percentages: around 60 per cent in Goa and Palestine identified ovarian cysts27,32, while 71.3 per cent in Oman31; smoking was recognised as a risk factor by 68 per cent in Jordan and Oman, and 74 per cent in Palestine16,31,32.
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 factors15,27.
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.
Acknowledgment
Authors acknowledge the ASHA workers, frontline health workers, and community leaders for their invaluable support in making this study possible. Their dedication and collaboration were instrumental in reaching out to the community and ensuring the smooth conduct of this research.
Financial support & sponsorship
None.
Conflicts of Interest
None.
Use of Artificial Intelligence (AI)-Assisted Technology for manuscript preparation
The authors confirm that there was no use of AI-assisted technology for assisting in the writing of the manuscript and no images were manipulated using AI.
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