cancer is a leading cause of death worldwide  . colorectal cancer ( crc ) ranks fourth in the most common cause of death due to cancers worldwide . in usa , crc is the second leading cause of cancer - related deaths in cancers affecting both male and female . according to the saudi cancer registry , crc ranks second in the most common cancers among saudis after breast cancer and first among saudi males with constant rise in the incidence for the past few years . furthermore , the overall survival rate ( 44.6% ) is generally lower than the typically reported survival rates all over the world . crc in saudi arabia present late with metastasis and obstruction in percentages more than what is reported in western communities . nearly , 40% of crc diagnosed were equal to or below 50 years of age with mean age of 58 years , which is lower than developed countries [ 48 ] . crc is an ideal tumor for screening , with its high incidence and long time between adenomatous polyp and carcinoma , and early diagnosis by screening can reduce incidence and mortality of the disease [ 914 ] . family physicians have a key role in screening practice due to frequent contact with large proportion of population . furthermore , the involvement of family physicians in screening program implementation has been recommended by several guidelines . however , physicians - reported crc screening recommendation rates in the literature are still below the demand if a major impact on crc mortality is targeted . moreover , this is the first local study in saudi arabia that is looking for data regarding crc screening practice . the aim of this study is to explore the current knowledge , attitude and practice of family physicians toward crc screening and to identify the barriers of conducting such a screening . a cross - sectional descriptive study was carried out among family physicians working in family medicine clinics in national guard health affairs ( ngha ) , riyadh , saudi arabia between february and march 2013 . a validated questionnaire was adopted from the national cancer institute in usa , customized by adding and eliminating questions to be in line with the institution ( ngha ) characteristics . a pilot study on 10 physicians was conducted to check understanding of the questionnaire , resulted in some vocabularies replacement and format enhancing to avoid confusion . then the questionnaire was reviewed and approved by tow reviewers from king abdulla international medical research center ( kaimrc ) . it contains demographic characteristics , questions to assess the knowledge , attitude , current practice and barriers of crc screening . questionnaires were handed out to the physicians during working hours by the researcher or an assigned nurse and collected in the next following day . data management and statistical analysis were carried out using statistical package for social sciences ( spss ) software version 20.0 . categorical variables were presented as frequencies and percentages , chi - square test (  ) used to explore the association between variables . knowledge score was computed on the basis of 11 questionnaire items , the answers were evaluated according to the centers for disease control and prevention ( cdc ) and united states preventive services task force ( uspstf ) guidelines recommendations . attitude score : answers with positive attitude marked with 1 and negative attitude marked with 0 . means of scores were compared between groups using student t - test ( t ) . questionnaire cover sheet of the study explained that the participation of the physicians considered as a consent form of agreement . out of 130 physicians , 68 ( 52.3% ) were females , 51 ( 39% ) were family medicine board certified , and 56 ( 43% ) were mbbs holders ( table 1 ) . the mean value results for the knowledge score was founded to be 5.02 with standard deviation of 2.73 and ranged between 011 ( table 2 ) . board certified physicians had higher knowledge score than other physicians ( t = 2.6 ; p = 0.009 ) . physicians who reported practicing crc screening scored more on the knowledge score than those not practicing , ( t = 2.7 ; p = 0.007 ) . physicians influenced by uspstf recommendations achieved better knowledge score compared to those who were not ( t = 3.1 ; p = 0.002 ) . physicians influenced by their patients ' preference for crc screening also achieved better knowledge score when compared to those who were not ( t = 3.2 ; p = 0.002 ) . although not statistically significant , male physicians had higher knowledge score than female ( t = 1.8 ; p = 0.071 ) ( table 3 ) . among the sample studied , 123 physicians ( 94.6% ) considered crc screening for asymptomatic average - risk patients to be effective and 106 ( 81.5% ) prefer having structured screening program over opportunistic screening . among the screening modalities , flexible sigmoidoscopy was considered  very effective  by 58 ( 44.6% ) and 42 ( 32.3% ) only for fecal occult blood testing ( fobt ) . the mean value of the attitude score was found to be 6.95 with standard deviation of 1 and ranged between 4 and 8 ( table 4 ) . male physicians scored better on attitude score than female ( t = 2.3 ; p = 0.025 ) . physicians aged 40 years and above had better attitude than younger physicians ( t = 2 ; p = 0.047 ) . physicians who reported having a reminder system for crc screening scored better attitude than those who did not , ( t = 3.4 , p = 0.001 ) ( table 5 ) . around more than half ( 56.2% ) of fobt is discussed more as screening modality ( 80.8% ) in comparison with colonoscopy ( 76.90% ) and flexible sigmoidoscopy ( 35.4% ) . majority of the physicians conduct fobt by delivering stool samples to the labs ( 90% ) . board certification contributed significantly to practicing crc screening when compared to other physicians (  = 7.65 ; p = 0.005 ) . physicians whose practice was influenced by uspstf and and american cancer society recommendations reported practicing crc screening more than those who were not influenced by these resources (  = 4.86 ; p = 0.025 ) and (  = 3.92 ; p = 0.041 ) , respectively . although lacking statistical significance , male physicians reported practicing crc screening more than female physicians (  = 2.9 ; p = 0.063 ) ( table 6 ) . when asked about barriers to practice crc screening , 80% of physicians who did not perform the screening believed time was a barrier compared to 56% of those who actually practice the crc screening (  = 9.29 ; p = 0.002 ) . also , 70% of physicians who did not practice the screening thought that the patients do not want to discuss colorectal cancer . this belief was noted among only 49% of physicians who practiced crc screening (  = 5.78 ; p = 0.013 ) . nearly , 77% of physicians who did not practice the screening reported that patients are having difficulty understanding the information about crc screening , compared to only 45.6% of physicians who do practice the screening (  = 13.29 ; p < 0.00 ) . moreover , 60.3% of physicians not practicing crc screening believed that patients do not perceive crc as a serious health threat , compared to only 36.8% of physicians who practice crc screening ( =7.03 ; p = 0.007 ) . when asked about having a clear policy and procedure for crc screening in their workplace , 86.3% of physicians not practicing crc screening reported that there is no policy in their workplace compared to 65% of physicians who practice crc screening (  = 8.25 ; p = 0.004 ) . also , physicians who do not practice the screening were more to report shortage of trained providers to conduct further screening procedures other than fobt ( 77.8% compared to 54.4% of those who practice crc screening ) (  = 7.93 ; p = 0.004 ) ( table 7 ) . among patients related barriers for crc screening , 92.4% of physicians reported that patients are not aware of crc screening and ( 63.1% ) commented that their patients have difficulties understanding the information about crc screening . in relation to workplace related barriers , not having a reminder system was the top barrier on the list with ( 86% ) followed by unavailability of crc screening policy and procedure ( 76.9% ) . seventy percent of physicians reported that they do not have enough time to discuss crc screening with their patients ( table 8) . several studies have been done in saudi arabia in regard to crc , and all of them concluded and highlighted the importance of screening [ 4 , 5 , 7 , 8 ] . this is the first study that looked at the current knowledge , attitude , practice , and perceived barriers of physicians in saudi arabia in order to close the gap for a better screening . the response rate was 76% , higher than that obtained from similar studies which involved more centers and more than one city [ 9 , 16 , 17 ] . this study found that crc screening is underutilized since around more than half of the study subjects were not practicing crc screening despite a strong evidence supporting the effectiveness of the screening , physicians ' knowledge , and their positive attitude toward its effectiveness , which is in accordance with findings in the literature [ 9 , 17 , 18 ] . knowledge of the physicians was acceptable , and main deficiency was on the age of stopping crc screening which is similar to klabunde et al . board certified physicians achieved higher knowledge score than physicians with lower certification , which highlights their role in educating other physicians about the importance of screening . physicians influenced by uspstf recommendations achieved better knowledge score compared to those who were not , and this goes in line with considering the cdc guideline as a reference for knowledge evaluation in this study and also reflects the importance of uspstf as a trusted source of information . physicians with a higher knowledge score were more patient - oriented in considering their patients ' preference for screening , which will increase patient involvement in decision making , and that will help build a stronger doctor patient relationship . result showed significant positive association between knowledge score and practicing crc screening which reflects the importance of physicians ' education for the improvement of crc screening , and this finding was in accordance with the literature . in general , physicians have a positive attitude toward crc screening reflected by the attitude score . positive attitude toward crc screening was associated with being male ; this might be due to the fact that , under the setting of ngha clinics , female physicians are almost exclusively treating female subjects . among female patients , other cancers ( e.g. , breast and cervical cancers ) are of greater significance than colorectal cancer which has higher incidence among male subjects . also , physicians aged 40 years and above had better attitude than younger physicians , which may indicate the importance of experience ; there is similar finding in greece . physicians who reported having a reminder system for crc screening scored better attitude than those did not ; this is supporting sarfaty and wender finding that crc screening can be improved by implementing a reminder system targeting both doctors and patients . in contrary to knowledge score , attitude score showed positive association with practicing crc screening but the result was statistically insignificant . most of the physicians consider colonoscopy to be the most effective screening test , followed by flexible sigmoidoscopy . only one - third of physicians found fobt to be  very effective . in contrary , fobt is the most used test followed by colonoscopy , which is similar to what klabunde et al . and federici et al . this might be due to more patients ' acceptance or the availability of the fobt in comparison to colonoscopy . the study found that barriers were cited in higher rates among physicians not practicing crc screening compared with practicing physicians . lack of patients ' awareness was the most cited barrier , which was also highlighted in the literature . not having a reminder system was reported by 86% . taking that into consideration , tackling and finding solutions to overcome these barriers might improve the crc screening . miles et al . concluded that the most effective way of achieving reduction in cancer related mortality is by providing screening as part of an organized program . the study was carried out in one institution in one city of saudi arabia and does not necessarily reflect general population.study design ( cross - sectional ) has limited internal validity and it is sensitive to a variety of biases.data collection tool was self - administered and lack of observation carries a risk of recalling bias or contamination by the participants . the study was carried out in one institution in one city of saudi arabia and does not necessarily reflect general population . study design ( cross - sectional ) has limited internal validity and it is sensitive to a variety of biases . data collection tool was self - administered and lack of observation carries a risk of recalling bias or contamination by the participants . unfortunately , large percentage of family physicians in this study do not recommend crc screening , despite the knowledge level and the positive attitude . this is pointing to the importance of increasing the attention of the doctors about their crucial rule in crc prevention . moreover , patients ' involvement and awareness are of a good impact on the crc screening process . therefore , we recommend increasing the patients ' awareness by the mass media and health campaigns and considering a national organized screening program that will help the physicians to achieve a desirable outcome .
objectives . 
 the objective of this study is to explore the current knowledge , attitude , and practice of family physicians working in family medicine clinics in national guard health affairs ( ngha ) , riyadh , toward colorectal cancer ( crc ) screening and to identify the barriers of the screening 
 . methods . 
 data were collected using a validated self - administered questionnaire adopted from the national cancer institute in usa , customized by adding and eliminating questions to be in line with the institution ( ngha ) characteristics . 
 results . of the 130 physicians , 56.2% of the physicians were not practicing crc screening 
 although 94.6% considered crc screening effective . 
 board certified physicians had higher knowledge score and were practicing crc screening more when compared to other physicians . 
 physicians who reported practicing crc screening scored more on the knowledge score than those not practicing . 
 male physicians scored better on attitude score than female physicians . 
 the study found that barriers were cited in higher rates among physicians not practicing crc screening compared with practicing physicians . 
 lack of patients ' awareness was the most cited barrier . conclusion . 
 large percentage of family physicians in this study do not practice crc screening , despite the knowledge level and the positive attitude .