Cancer Screening Profile of the Iranian Population: Findings from STEPS 2021 survey

doi:10.21203/rs.3.rs-5133681/v1

Background

Cancer is a pressing global health concern, making effective cancer control planning crucial. This is emphasized by the objectives in target 3.4 of the Sustainable Development Goals and the CanScreen 5 project from the International Agency for Research on Cancer (IARC). The objective of this study was to provide a comprehensive overview of breast, cervix, prostate, colorectal cancer screening practices within the Iranian adult population in the year 2021.

Methods

Using nationally and sub-nationally representative STEPS 2021 data, this study included 27,874 participants aged 18 and above from urban and rural Iran. Participants were asked if they had ever undergone screening for breast, cervical, colorectal, or prostate cancer. Socio-demographic factors such as age, sex, employment, marriage status, education, and wealth index were included. Weighted prevalence, mean, SD, and 95% CIs were reported. The 2016 National Population and Housing Census was used for direct age standardization. Univariate and multiple logistic regression estimated crude and adjusted ORs with 95% CIs for cancer screening participation.

Results

The age standardized prevalence of participating in cancer screening programs is as follows: breast cancer (24.99%, 95% CI: 24.22–25.76), cervical cancer (42.16%, 41.29–43.02), colorectal cancer in females (7.50%, 7.03–7.98), colorectal cancer in males (6.16%, 5.69–6.63), and prostate cancer (12.29%, 11.64–12.95). For all cancers, complementary health insurance coverage was associated with higher cancer screening participation. Additionally, for all cancers except breast cancer, basic health insurance was also linked to higher screening participation. In cervical cancer screening, human papillomavirus vaccination and urban residency were associated with higher participation, while for colon cancer in both men and women, rural residency was linked to higher participation, based on the adjusted model.

Conclusion

Cancer screening participation rates in Iran fall below expectations, particularly in meeting targets set by the World Health Organization Cervical Cancer Elimination Initiative for 2030 emphasizing to screen at least 70% of women between the age of 35 and 45. Implementing best-buy interventions from the Global Action Plan for Noncommunicable Diseases, scaling up prevention, prioritizing screening and early diagnosis, and strengthening cancer services are essential for improving coverage and participation in cancer screening programs.

Early Detection of Cancer

Iran

Breast cancer

Cervix cancer

Colorectal cancer

Prostate cancer

Health Policy

Cancer is a pressing global health concern, with an estimated 19.96 million global new cases and 9.7 million deaths in 2020[1]. These numbers are expected to rise significantly, reaching 30.2 million new cases and 16.3 million deaths by 2040[2, 3]. Notably, between 1990 and 2021, cancer surged from the sixth to the third leading cause of death [4]. Cancer is a major challenge in the Eastern Mediterranean region (EMR), with the incidence of cancer cases predicted to double in the next two decades[5]. This underscores the urgent need for effective national cancer planning in this region, which aligns with the Sustainable Development Goals (SDGs) of reducing premature mortality from non-communicable diseases (NCDs) by a third by 2030 and World Health Organization (WHO) Cervical Cancer Elimination Initiative for 2030 of screening at least 70% of female population aging between 35 and 45 years with a high-performance test[6, 7]. This region grapples with the difficulty of obtaining high-quality data to assess cancer screening to design national policies[5]. Acknowledging the substantial income disparities among EMR countries and recognizing the heightened cancer burden, especially in low- and middle-income countries (LMICs), which strains already vulnerable healthcare and economic systems, highlights the necessity for customized strategies[8]. In Iran, a 2013 study assessed the quality of the National Cancer Registry to align with a global framework, the findings of this study suggested improving the measurement of all types of cancer incidence rates[9]. Advancements in this area have been made since 2013; however, similar advancements have not been made in measuring cancer screening levels, particularly for breast, cervical, and colorectal cancers, which are the focus of the CanScreen5 initiative.

The WHO Package of Essential Noncommunicable Diseases Interventions (WHO PEN) focuses on implementing cost-effective interventions, with a growing emphasis on cancer screening in middle-income countries[10]. Given the success of similar programs for cardiovascular disease in these settings, attention to cancer screening is crucial. WHO PEN tools support an integrated approach to early detection and management of major NCDs, including cancer, cardiovascular diseases, diabetes, and chronic respiratory diseases[11]. Their effective implementation can help resource-limited settings reduce premature mortality and achieve global health targets. Expanding these efforts to cancer screening, based on experiences in comparable countries, can significantly enhance outcomes. Additionally, the inappropriate application of cancer control program experiences from high-income countries (HICs) to LMICs underscores the importance of tailoring approaches to the unique challenges of each region[12]. To design an applicable cancer control program, first, there is a need to gain knowledge via high-quality and nationally representative studies. On a global scale, the importance of effective cancer control planning is stressed by the World Health Assembly Resolution in 2017. This resolution highlighted the necessity of integrating cancer control plans within a country's broader healthcare infrastructure to alleviate the burden of cancer. Such plans play a vital role in helping nations achieve international targets related to non-communicable diseases, aligning with the objectives set out in target 3.4 of the SDGs. Iran is a country with National Cancer Control Plans (NCCP) with a specific timeframe of 2013–2025, and cancer screening is part of national cancer control plans and there is a pressing need to report the cancer screening profile of the Iranian population to know the current status and plan for the future[13]. Moreover, gaining knowledge about profile of screening in Iran is of value for policy makers in Low to middle income countries and other countries in the Mediterranean region.

The objective of this study is to provide a comprehensive overview of major cancer screening practices within the Iranian adult population in the year 2021, with a particular emphasis on socio-demographic and geographical determinants.

Comprehensive details of the Iran STEPS Survey 2021 are provided elsewhere in a study protocol[14]. This survey had two main phases of design and implementation, including three steps of data collection via questionnaires, anthropometric measurements, and laboratory assessments. The first step of the survey was designed based on the latest version of the WHO STEPS instrument, version 3.2[15]. The second step measured participants' anthropometric measurements. The third step involved laboratory measurements.

Sampling and Population

To make this survey nationally representative, a systematic clustered sampling method was used to recruit samples among Iranian adults aged ≥ 18 years from urban and rural areas of all 31 provinces of Iran. A total of 28,821 individuals were calculated for inclusion in the survey, of whom 27,874 completed the first step (questionnaire step). More detailed information about the study population and the sampling method for the 2021 STEPS survey can be found in a separate publication[14]. For breast cancer screening, 282 individuals did not answer the question related to screening in the STEPS 2021 questionnaire; for cervical cancer, 312; for prostate cancer, 295; for male colon cancer, 374; and for female colon cancer, 402.

Variables

In order to evaluate the contributing factors of participation in cancer screening programs, the outcome variables were defined by asking the question of having ever undergone related cancer screening with a yes/no answer. For Prostate Cancer (PC), males were asked, "Have you ever had a prostate-specific antigen (PSA) blood test for PC screening?" For Colorectal Cancer (CRC), both males and females were asked, " Have you ever had a colon cancer screening test (colonoscopy or occult blood test)?" For Breast Cancer (BC), females were asked, "Have you ever undergone a mammography?" For Cervical Cancer (CC), females were asked, "Have you ever undergone a Pap smear and Human Papilloma Virus (HPV) test?" These questions aimed to determine the participation in respective cancer screening tests.

Age, residence area (rural/urban), province of residence, marital status, years of education, employment status, health insurance coverage (basic/complementary insurance), national wealth index (WI), risk and preventive factors for each type of cancer including (appropriate fruit consumption (at least 2 serving in week), appropriate vegetable consumption(at least 3 serving in week), appropriate physical activity (base on Metabolic Equivalent of task (MET) score and International Physical activity Questionnaire (IPAQ) , score more than 600 is considered appropriate), current cigarette smoking (any number in the last 12 months), current alcohol consumption (any amount in the last 12 months), anxiety level, pain level, menopause status, HPV vaccination status, and body mass index levels) and also comorbidities including cardiovascular diseases (history of stroke or myocardial infarction), respiratory diseases (only asthma and Chronic obstructive pulmonary disease (COPD) were included in the questionnaire) , diabetes mellitus (fasting blood glucose of more than 126 or current medication use including oral agents or insulin), hypertension(systolic blood pressure equal to or more than 140, diastolic blood pressure equal to or mor than 90, and current antihypertensive medication use), cancer diagnosis in the last twelve months, high cholesterol (total cholesterol>200), and obesity (body mass index equal to over 30) were included in the current study. WI was calculated using a questionnaire that assessed household assets through 36 questions covering various dimensions of participants' assets. Principal component analysis (PCA) was utilized to summarize the collected data, resulting in the creation of new descriptive variables known as principal components. The first component, which contained most of the data, was designated as the WI and categorized into five quintiles, with the first representing the poorest and the fifth representing the wealthiest segments of the population.

Statistical Analysis

Weighted prevalence, mean, and standard deviation (SD) were used to describe the data. 95% confidence interval (95% CI) for each quantitative variable was reported. The weighting procedure in this survey, conducted after cleaning the gathered data, consisted of four stages. First, weighting for overall non-response addressed individuals who refused to participate, especially considering the impact of the COVID-19 outbreak, with specific calculations for different age groups. Second, non-response weighting was applied at each survey step, using equations to mitigate data loss and measurement bias from incomplete responses. Third, samples from each province were weighted based on age, sex, and area of residence to ensure representativeness across demographics. For further details on the weighting process, please refer to the study protocol[14]. We used the National Population and Housing Census 2016 conducted by Iran's Statistical Center as the standard population for direct age standardization in order to compare provinces. Univariate and multiple logistic regression analyses were conducted to estimate crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for cancer screening participation. Initially, each variable was assessed using a univariate logistic regression model. Variables with a p-value < 0.2 in the univariate analysis were subsequently included in the multiple logistic regression model to calculate adjusted ORs. All data analyses were conducted using R statistical package version 4.4.0 and “Survey” Package[16]. P-value less than 0.05 was considered as statistically significant. Regarding the handling of missing data, if the response to the primary question in each part of the questionnaire, typically the first question in each section, was not provided, the entire section was considered as missing data.

Ethical Considerations

This survey protocol was approved by the National Institute for Health Research under reference number IR.TUMS.NIHR.REC.1398.006. Every participant was granted written informed consent before taking part in the study. Additionally, the data employed in the research did not contain any personally identifiable information about the participants, and strict measures were in place to ensure the confidentiality of both the data and the study results.

This study provides data for the Iranian cancer screening profile from all 31 provinces of Iran. The socio-demographic characteristics of the 27874 participants are shown in Table 1.

Breast Cancer Screening

The national age-standardized prevalence of breast cancer screening, stood at 24.99% (95% CI: 24.22-25.76) (Figure 1 and Table S1). The highest prevalence of breast cancer screening among different age groups was observed within the 50-59 years group, standing at 41.16% (39.11-43.21) (Figure 2). As for major breast cancer risk factors, there was no statistically significant difference in cancer screening participation between current cigarette smoking and alcohol consumption but the difference was significant for physical activity (26.87% (25.64 - 28.1) in appropriate physical activity and 23.89% (22.87 - 24.92) in low physical activity group) (Table 2). In individuals with obesity, there is a significantly higher participation prevalence compared to normal weight individuals (50.11% (48.51 - 51.72) in obese patients versus 32.12% (30.57 - 33.66) in normal weight patients) (Table 3). Regarding current smoking there is no significant difference in the odds of participation in breast cancer screening between current smokers and non-smokers in either the crude or adjusted models (aOR 1.24(0.60-2.55), crude OR 1.37(0.85-2.22)). Refer to Table 4 for more information. In the adjusted logistic regression model, several factors were significantly associated with breast cancer screening participation among females (Table S2). Possession of complementary health insurance was strongly associated with increased participation in breast cancer screening (adjusted OR = 2.07, 95% CI: 1.85–2.32; P < 0.001). Females with a previous cancer diagnosis had higher odds of participating in screening (aOR = 2.69, 95% CI: 1.81–4.01; P < 0.001). High cholesterol levels were significantly associated with increased screening participation (aOR = 1.46, 95% CI: 1.31–1.63; P < 0.001). Additionally, hypertension was linked to higher odds of participating in breast cancer screening (aOR = 1.33, 95% CI: 1.19–1.49; P < 0.001).

Cervical Cancer

The national prevalence of cervical cancer screening stood at 42.16% (95% CI: 41.29-43.02) (Figure 1 and Table S1). The highest prevalence of cervical cancer screening among different age groups was observed within the 40-49 years group, standing at 54.86% (52.97-56.76) (Figure 2). As for major cervical cancer risk factors, there was no statistically significant difference in cancer screening participation between current cigarette smoking but the difference was significant for physical activity 45.18% (43.82-46.55) in appropriate physical activity and 40.13% (38.96-41.3) in low physical activity group and 51.85% (43.83 - 59.87) alcohol consumption group and 42.06% (41.19 - 42.94) in no alcohol consumption group (Table 2). In the adjusted logistic regression model, several factors were significantly associated with cervical cancer screening participation (Table S3). Females residing in urban areas had higher odds of participating in cervical cancer screening compared to those in rural areas (aOR = 1.14, 95% CI: 1.03–1.26; P = 0.011). Possession of basic health insurance was associated with increased screening participation (aOR = 1.38, 95% CI: 1.15–1.65; P = 0.001), as was having complementary health insurance (aOR = 1.45, 95% CI: 1.30–1.61; P < 0.001). A history of lung disease was significantly associated with higher screening participation (aOR = 1.35, 95% CI: 1.10–1.65; P = 0.003). Females with high cholesterol levels also had increased odds of participating in cervical cancer screening (aOR = 1.13, 95% CI: 1.02–1.25; P = 0.019). Interestingly, hypertension was associated with lower odds of screening participation (aOR = 0.84, 95% CI: 0.76–0.93; P = 0.001). Alcohol consumption within the past 12 months was linked to higher participation rates (aOR = 1.84, 95% CI: 1.03–3.28; P = 0.038). Receiving the HPV vaccination was strongly associated with increased cervical cancer screening participation (aOR = 2.00, 95% CI: 1.16–3.45; P = 0.012).

Colorectal Cancer (Males and Female)

The national prevalence of female CRC screening, stood at 7.50% (95% CI: 7.13-7.98) (Figure 1 and Table S1). The highest prevalence of female colorectal cancer screening among different age groups was observed within the 60-69 years group, standing at 16.46% (14.64-18.28) (Figure 2). The national prevalence of male colorectal cancer screening, encompassing all age groups, stood at 6.2% (95% CI: 5.8-6.6). The highest prevalence of male colorectal cancer screening among different age groups was observed within the 60-69 years group, standing at 13.92% (12.07-15.77). Regarding major risk factors, such as current smoking, alcohol consumption, and physical activity, there was no significant difference between those who participated and those who did not participate in cancer screening (Table 2). In patients with comorbidities of diabetes and high cholesterol, the odds of participation in cancer screening were significantly higher for females. For males, the odds of participation were significantly higher in patients with comorbidities of diabetes (Table 4). In the adjusted logistic regression models for colon cancer screening participation among both males and females, several significant associations were observed (Table S4 and Table S5). Residing in urban areas was associated with higher odds of participating in colon cancer screening compared to rural areas for both sexes (males: aOR = 0.53, 95% CI: 0.43–0.66, P < 0.001; females: aOR = 0.61, 95% CI: 0.51–0.73, P < 0.001), indicating that rural residency was linked to lower screening participation. Possession of complementary health insurance significantly increased screening participation in both males (aOR = 1.87, 95% CI: 1.51–2.32, P < 0.001) and females (aOR = 1.94, 95% CI: 1.63–2.32, P < 0.001). Additionally, high cholesterol levels were associated with higher odds of participating in colon cancer screening among both sexes (males: aOR = 1.27, 95% CI: 1.03–1.57, P = 0.027; females: aOR = 1.82, 95% CI: 1.53–2.16, P < 0.001). Hypertension was also linked to increased screening participation in males (aOR = 1.44, 95% CI: 1.17–1.77, P = 0.001) and females (aOR = 1.72, 95% CI: 1.44–2.05, P < 0.001).In males specifically, having a prior cancer diagnosis significantly increased the likelihood of screening participation (aOR = 2.88, 95% CI: 1.58–5.26, P = 0.001), as did a history of cardiovascular disease (aOR = 1.69, 95% CI: 1.27–2.25, P < 0.001). Among females, possession of basic health insurance was associated with higher screening participation (aOR = 1.91, 95% CI: 1.19–3.05, P = 0.007).

Prostate Cancer

The national prevalence of prostate cancer screening, stood at 12.29% (95% CI: 11.64-12.95) (Figure 1 and Table S1). The highest prevalence of prostate cancer screening among different age groups was observed within the 80 and above group, standing at 36.61% (30.36-42.85) (Figure 2). As for major risk factors current smoking, alcohol consumption, and physical activity there was no significant difference between those who participated and not participated in a cancer screening. (Table 2) When adjusted for other variables, these major risk factors (current smoking, alcohol consumption, and physical activity) still do not show a significant effect on the odds of participation in cancer screening (Table 4).In the adjusted logistic regression model, several factors were significantly associated with prostate cancer screening participation among males (Table S6). Possession of basic health insurance was associated with increased screening participation (aOR = 1.85, 95% CI: 1.26–2.72; P = 0.002), as was having complementary health insurance (aOR = 2.86, 95% CI: 2.43–3.36; P < 0.001). Males with a prior cancer diagnosis had higher odds of participating in prostate cancer screening (aOR = 2.30, 95% CI: 1.33–3.97; P = 0.003).

Having cardiovascular disease was significantly associated with increased screening participation (aOR = 2.16, 95% CI: 1.74–2.69; P < 0.001). Similarly, a history of lung disease was linked to higher odds of screening participation (aOR = 1.83, 95% CI: 1.36–2.48; P < 0.001). Males with high cholesterol levels also had increased odds of participating in prostate cancer screening (aOR = 1.21, 95% CI: 1.02–1.43; P = 0.026).Hypertension was associated with higher odds of screening participation (aOR = 1.72, 95% CI: 1.46–2.02; P < 0.001).

This nationwide study provides a comprehensive overview of cancer screening participation, offering valuable insights into the prevalence and determinants of screening for breast, cervical, colorectal, and prostate cancers. Our findings reveal significant variations in screening rates among different cancer types and highlight the influence of socio-demographic factors, health insurance coverage, and comorbidities on screening participation. For breast cancer, factors such as possession of complementary health insurance, high cholesterol levels, and hypertension were significantly associated with increased screening participation. Notably, prevalence of screening was higher in obese individuals compared to individuals with normal weight. In cervical cancer screening, urban residency, possession of basic and complementary health insurance, history of lung disease, high cholesterol levels, alcohol consumption, and HPV vaccination were positively associated with screening participation. Interestingly, hypertension was associated with lower odds of screening participation in this group. In colorectal cancer screening, rural residency was linked to higher screening participation among both males and females. Possession of complementary health insurance, high cholesterol levels, and hypertension were significant predictors of increased screening participation. Additionally, prior cancer diagnosis and cardiovascular disease were associated with higher screening rates among males. In prostate cancer screening, factors significantly associated with increased screening participation included possession of basic and complementary health insurance, cardiovascular disease, lung disease, high cholesterol levels, and hypertension. These findings underscore the crucial role of health insurance coverage, comorbid health conditions, and demographic factors in influencing cancer screening participation in Iran. The disparities observed in screening rates across different cancers and population groups highlight the need for targeted interventions and policies to enhance screening uptake.

This study highlights the underutilization of screening programs and indicates a need for more robust national strategies to improve cancer management and prevention. In comparison to developed countries, Iran's cancer screening participation rates are notably lower. For instance, BC screening rates in the United States for women aged 50–74 stand at 94.1%, while Iran's rates are considerably lower with 24.99%[17]. CC screening shows similar trends, with Sweden reporting an 81.4% participation rate, significantly higher than Iran with 42.2%[18]. This comparison could also be applied to countries in the Middle East and North Africa (MENA) region, where participation rates in cancer screening programs do not exceed 25% in the best cases[19]. These discrepancies suggest underlying systemic issues that need to be addressed.

Various factors contribute to these disparities, including residential area, wealth index, complementary insurance, marriage status, and age groups. Urban residents have higher odds of participating in cervical cancer screening programs compared to rural residents, which could be partly attributed to easier access to health facilities. However, rural areas demonstrate greater participation in colorectal cancer (CRC) screenings, indicating that the healthcare system in these regions may be more effective at reaching local population which echoes success of previously implemented programs such as IraPEN(part of WHO package of essential noncommunicable (PEN) disease interventions for primary health care) in these regios[10, 20]. Previous studies in other countries, higher socio-economic status was significantly associated with a greater contribution to cancer screening plans [21–23]. In our adjusted model, the wealth index did not yield statistically significant associations for any of the included cancers. While that may be the case both basic health insurance and complementary health insurance coverage were associated higher cancer participation. The results reflect the fact that financial problems could be among the barriers to an optimal participate uptake. In Iran, most of the costs for cancer screening are covered through basic insurance plans. However, due to the current economic challenges of Iran and being listed LMIC according to the World Bank's classification, out-of-pocket payments remain significant for the majority of the population. In contrast, individuals with complementary insurance plans are better covered for the screening service fees. By decreasing out-of-pocket payments and reducing financial barriers to service uptake, insurance plans can positively impact healthcare service utilization[24]. This reduction in financial barriers can help lower the social and financial burden of cancer incidence. Married women tend to participate more in BC and CC screening plans, duo to a higher general awareness by appearing more in healthcare centers for child and maternal health care[25].

There are also some more specific factors that need more attention in cancer screening profiles are highlighted in this study. According to national guidelines and the WHO Cancer Country Profile 2021, the target population for breast cancer screening in Iran starts at 30 years, which is younger than the global peak age of breast cancer prevalence[26]. However, participation in breast cancer screening among the 30–39 age group is almost half that of the 40–49 and 50–59 age groups. This is concerning, especially given that there is an operational screening plan for breast cancer in place.

For cervical cancer, the absence of a national HPV vaccination program makes it crucial to have a more widespread screening program[27]. Currently, only about 4 in 10 adult females are screened for cervical cancer. Although there is an organized program for cervical cancer screening, it is not yet fully operational[28]. In the target population of 30–49 years, nearly one in two adult females have been screened at least once, which is better than the situation for breast cancer. Nonetheless, there is still a long way to go to meet the WHO 2030 strategy goal of having 70% of women screened with a high-performance test by 35 years of age and again by 45 years of age[6]. Currently, there is almost a 20% gap between the current situation and the 2030 goal.

Prostate and colorectal cancer screening also present areas of concern in the current study. Currently, only one in five individuals of the starting age for prostate cancer screening, and one in twenty for colorectal cancer screening, are being screened, which is insufficient considering population changes. In Iran, colonoscopy is predominantly used, but the health system lacks the infrastructure to support a national screening system that covers all individuals over the starting age for colon cancer screening. This is a costly intervention for Iran, given the current economic situation of Iran and being currently evaluated as LMIC [29].

Future Perspectives

Cancer control remains a top health priority in all low- and middle-income countries (LMICs), and early cancer detection is a crucial component of this effort. Effective planning and implementation of early cancer detection programs must integrate a comprehensive approach that includes prevention, screening, early diagnosis, treatment, and palliative care. These interventions should be carefully selected based on national priorities, available resources, feasibility, and cost-effectiveness in the local context.

Policymakers must understand that cancer screening will only achieve the desired outcomes when conducted through a population-based approach with appropriate quality assurance[8]. In LMICs, priority should be given to the interventions listed by the WHO as the ‘best buys’ for addressing NCDs, including cancer, as outlined in the updated Appendix 3 of the Global Action Plan for the Prevention and Control of NCDs 2013–2030[30]. Primary prevention strategies, such as implementing the WHO Framework Convention on Tobacco Control (FCTC), vaccination against hepatitis B and HPV, improving infrastructure to promote physical activity and healthy eating habits, and educating the population about various risk factors, are essential for cancer control in LMICs. To effectively scale up cancer screening rates for major cancers through national cancer control plans, several best-buy interventions and other recommended strategies can be employed. Vaccination against human papillomavirus (HPV) for girls aged 9–13 and screening women aged 30–49 for cervical cancer using visual inspection with acetic acid, Pap smears, or HPV tests are critical. Mammography every two years for women aged 50–69 can aid in early breast cancer detection. Additionally, colorectal cancer treatment at early stages and basic palliative care are essential. Further measures include liver cancer prevention via hepatitis B immunization, oral cancer screening in high-risk groups, and population-based colorectal cancer screening for those over 50 using fecal occult blood tests. These interventions should be linked with timely treatment and supported by policies, infrastructure, and public awareness initiatives to reduce the social and financial burden of cancer[31]. Additionally, scaling up cancer screening rates for major cancers requires addressing key barriers and implementing targeted solutions through national cancer control plans. Developing or updating national policies to include cancer screening as an essential service, establishing evidence-based guidelines, and engaging stakeholders ensures a coordinated approach. Aligning policies with regional and global recommendations and advocating for adequate financial support are vital. Investment in infrastructure and workforce, including diagnostic equipment, facilities, and trained healthcare providers, is essential. Community awareness and education campaigns, addressing myths and misconceptions with culturally sensitive messages, and utilizing social media and hotlines can enhance engagement. Ensuring access to high-quality screening services through population-based programs, mobile clinics, and reducing financial barriers is crucial. Integrating quality assurance, monitoring, and establishing robust information systems linked with cancer registries will help evaluate and improve screening programs[32–36]. These strategies can significantly increase cancer screening rates, leading to earlier detection and better outcomes.

Enhancing access to quality and timely diagnostic and treatment services for cancer not only improves survival rates for common cancers but also reduces health inequities, which are particularly pronounced in LMICs. While implementing cervical cancer screening with an appropriate algorithm is advisable for all LMICs with a high cancer burden, the decision to introduce screening for breast, oral, and colorectal cancers is more complex and requires thorough discussions among stakeholders to make an informed decision[37]. Further research at national level is needed to develop affordable, simple technology-based, point-of-care screening tests for these cancers. Screening for other cancer types is not recommended for countries with limited resources[8].

Strengths and Limitations

As a part of the most recent WHO STEPs project, this is the first study providing data for the cancer screening profile of the Iranian population from all 31 provinces. The most prominent strength of this survey was the use of a nationwide representative survey data of urban and rural participants aged 18 and above, which certified more confident inference. However, there were some limitations in the study. This study provides information solely on one-time participation in screening programs, with no data on the frequency or continuous participation in these programs. The breast cancer screening information only includes mammograms, with no data on ultrasound imaging of the breasts. As this study is based on a self-reported questionnaire, the results could be subject to recall bias. Finally, the information in this study comes from a national survey rather than an ongoing registry, which should be considered when interpreting the findings.

Cancer screening participation rates in Iran fall below expectations, particularly in meeting targets set by the WHO's Cervical Cancer Elimination Initiative for 2030. Given the current situation, there is a long way to go to reach these targets. Implementation of the best-buy interventions from the Global Action Plan for the Prevention and Control of Noncommunicable Diseases, along with scaling up prevention measures, prioritizing screening and early diagnosis, and strengthening end-to-end cancer services across the health system, is essential. Additionally, investing in data and digital infrastructure, collaborating to manage the economic burden, expanding access, and enacting financing reforms are crucial for sustaining equitable access and the efficient use of resources. These steps are vital to achieving higher coverage and participation in cancer screening programs.

Ethics approval and consent to participate

The study methodology conformed to Helsinki Declaration standards as revised in 1989. All experimental protocols were approved by the National Institute for Health Research under reference number IR.TUMS.NIHR.REC.1398.006. All participants provided written informed consent prior to participation in the study. Moreover, the data used in the study did not include any identifiable personal information of participants, and the confidentiality of the data and the results are preserved.

Consent for publication

Not applicable.

Availability of data and materials

All requests for data and materials should be directed to the corresponding author.

Competing interests

The authors declare no competing interests.

Funding

This study was supported by I.R.IRAN'S National Institute of Health Research,Tehran University of Medical Sciences, Iran. Contract No:241/9839.

Authors' contributions

S.K. Writing Manuscript & Statistical Analysis

N.R. (Negar Rezaei) Idea Conceptualization, Revising Manuscript, Study Design

N.E. Statistical Analysis

S.A.N. Revising Manuscript & Study Design

S.R. Writing Manuscript

M.M.R. Revising Manuscript & Study Design

A.G. Revising Manuscript & Statistical Supervision

S.A.N. Revising Manuscript

N.R. (Nazila Rezaei) Idea Conceptualization & Study Design

E.G. Idea Conceptualization, Study Design, Statistical Supervision

N.A. Idea Conceptualization, Study Design, Statistical Supervision

Y.F. Idea Conceptualization & Study Design

A.K. Revising Manuscript

M.N. Revising Manuscript

M.Y. Idea Conceptualization, Study Design, Statistical Supervision

E.F. Revising Manuscript

R.H. Idea Conceptualization, Study Design, Project Management

A.M.R. Revising Manuscript

S.D. Idea Conceptualization & Study Design

F.K. Idea Conceptualization, Revising Manuscript

F.F. Revising Manuscript, Idea Conceptualization, Study Supervisor

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Table 1. Prevalence of cancer screening by socio-demographic status in 2021 in Iran. The data are represented as percent and 95% uncertainty intervals.

Socio-demographic variables	Breast cancer	Cervical cancer	Colorectal cancer (Female)	Colorectal cancer (Male)	Prostate cancer
Age Group
18-29	4.98% (4.05 - 5.92)	16.4% (14.81 - 17.98)	1.05% (0.61 - 1.49)	1.02% (0.54 - 1.5)	0.77% (0.36 - 1.18)
30-39	16.11% (14.73 - 17.49)	48.17% (46.32 - 50.02)	2.35% (1.77 - 2.94)	1.8% (1.23 - 2.36)	1.9% (1.35 - 2.46)
40-49	31.45% (29.67 - 33.22)	54.86% (52.97 - 56.76)	5.53% (4.65 - 6.42)	3.97% (3.11 - 4.84)	6.94% (5.81 - 8.07)
50-59	41.16% (39.11 - 43.21)	52.25% (50.18 - 54.33)	14.44% (12.96 - 15.92)	9.72% (8.35 - 11.09)	19.21% (17.37 - 21.06)
60-69	33.77% (31.46 - 36.08)	38.9% (36.53 - 41.27)	16.46% (14.64 - 18.28)	13.92% (12.07 - 15.77)	26.52% (24.12 - 28.92)
70-79	22.76% (19.31 - 26.21)	24.71% (21.22 - 28.21)	12.32% (9.59 - 15.05)	12.65% (10.1 - 15.19)	35.05% (31.35 - 38.75)
80 and above	16.26% (10.68 - 21.85)	12.86% (7.94 - 17.78)	4.98% (2.14 - 7.82)	11.07% (6.91 - 15.23)	36.61% (30.36 - 42.85)
Residence area
Rural	21.4% (19.98 - 22.82)	39.25% (37.58 - 40.92)	9.17% (8.14 - 10.2)	8.42% (7.33 - 9.51)	10.18% (9 - 11.36)
Urban	26.18% (25.26 - 27.09)	43.12% (42.1 - 44.14)	6.95% (6.41 - 7.48)	5.4% (4.89 - 5.92)	13% (12.22 - 13.79)
Marriage Status
Single	6.67% (5.37 - 7.97)	3.6% (2.63 - 4.56)	1.86% (1.18 - 2.54)	1.16% (0.66 - 1.66)	1.71% (1.08 - 2.34)
Married	27.98% (27.05 - 28.9)	50.13% (49.12 - 51.15)	8.04% (7.48 - 8.61)	7.29% (6.71 - 7.86)	14.55% (13.76 - 15.34)
Divorced/separate with partner	24.11% (19.54 - 28.68)	41.18% (35.95 - 46.4)	5.65% (3.09 - 8.22)	6.92% (2.32 - 11.51)	16.22% (9.42 - 23.01)
Widow	25.66% (23.22 - 28.11)	31.21% (28.63 - 33.8)	10.94% (9.2 - 12.69)	7.12% (2.29 - 11.95)	21.68% (13.48 - 29.88)
Education years
0 year	21.62% (19.85 - 23.39)	29.64% (27.7 - 31.58)	11.5% (10.14 - 12.86)	11.03% (8.95 - 13.11)	16.78% (14.32 - 19.23)
1 to 7 years	31.08% (29.46 - 32.69)	47.3% (45.57 - 49.03)	10.07% (9 - 11.14)	9.12% (7.88 - 10.37)	15.48% (13.93 - 17.03)
7 to 12 years	24.82% (22.92 - 26.73)	48.89% (46.71 - 51.07)	5.52% (4.48 - 6.56)	4.36% (3.5 - 5.23)	9.96% (8.68 - 11.24)
12 years and more	22.7% (21.49 - 23.9)	41.66% (40.25 - 43.06)	5.02% (4.38 - 5.65)	4.82% (4.2 - 5.43)	11.1% (10.17 - 12.03)
Employment status
Employed	22.48% (20.3 - 24.67)	39.11% (36.54 - 41.67)	5.46% (4.26 - 6.66)	4.74% (4.23 - 5.25)	7.55% (6.92 - 8.19)
Retired	56.82% (51.32 - 62.31)	57.15% (51.63 - 62.68)	18.61% (14.19 - 23.04)	13.24% (11.62 - 14.87)	33.98% (31.68 - 36.27)
Unemployed	5.97% (3.14 - 8.81)	9.55% (6.15 - 12.95)	3.18% (1.23 - 5.14)	6.27% (4.66 - 7.88)	11.86% (9.69 - 14.04)
Primary Insurance
No	17.05% (14.75 - 19.34)	35.61% (32.7 - 38.52)	3.18% (2.11 - 4.25)	2.68% (1.74 - 3.62)	3.61% (2.55 - 4.66)
Yes	25.79% (24.97 - 26.61)	42.93% (42.02 - 43.85)	7.91% (7.4 - 8.43)	6.66% (6.13 - 7.18)	13.47% (12.74 - 14.2)
Complementary insurance
No	19.92% (19.07 - 20.77)	39.19% (38.17 - 40.21)	5.72% (5.22 - 6.21)	5% (4.49 - 5.5)	7.75% (7.13 - 8.37)
Yes	37.52% (35.89 - 39.16)	49.89% (48.21 - 51.58)	11.87% (10.77 - 12.98)	9.24% (8.14 - 10.34)	24.14% (22.48 - 25.8)
Wealth index
Poorest	15.53% (14.07 - 16.99)	27.08% (25.3 - 28.86)	6.33% (5.33 - 7.32)	6.06% (4.94 - 7.19)	7.22% (6.02 - 8.41)
2^nd	24.39% (22.63 - 26.15)	39.48% (37.51 - 41.46)	7.89% (6.79 - 8.99)	6.01% (4.9 - 7.12)	12.94% (11.36 - 14.52)
Middle	22.99% (21.18 - 24.8)	42.48% (40.35 - 44.61)	7.46% (6.3 - 8.62)	5.78% (4.74 - 6.81)	10.3% (8.95 - 11.65)
4^th	27.69% (25.78 - 29.61)	48.44% (46.32 - 50.57)	7.5% (6.37 - 8.63)	6.65% (5.56 - 7.74)	14.25% (12.68 - 15.81)
Richest	33.67% (31.69 - 35.65)	50.59% (48.51 - 52.68)	8.21% (7.05 - 9.37)	6.37% (5.33 - 7.4)	16.46% (14.86 - 18.06)

Table 2. Prevalence of cancer screening by life style factors in 2021 in Iran. The data are represented as percent and 95% uncertainty intervals.

Behavioral and lifestyle-related factors	Breast cancer	Cervical cancer	Colorectal cancer (Female)	Colorectal cancer (Male)	Prostate cancer
Appropriate Fruit Consumption
No	21.67% (20.74 - 22.6)	38.37% (37.28 - 39.45)	6.75% (6.18 - 7.32)	5.31% (4.76 - 5.86)	10.2% (9.45 - 10.95)
Yes	30.57% (29.22 - 31.93)	48.51% (47.06 - 49.96)	8.75% (7.91 - 9.58)	7.64% (6.76 - 8.51)	15.93% (14.7 - 17.16)
Appropriate Vegetable Consumption
No	24.45% (23.65 - 25.26)	41.6% (40.69 - 42.51)	7.43% (6.94 - 7.93)	6.03% (5.54 - 6.51)	12.04% (11.36 - 12.71)
Yes	30.31% (27.62 - 33)	47.73% (44.85 - 50.61)	8.15% (6.53 - 9.78)	7.85% (5.91 - 9.78)	15.52% (12.91 - 18.13)
Appropriate Physical Activity
No	23.89% (22.87 - 24.92)	40.13% (38.96 - 41.3)	7.37% (6.73 - 8.01)	6.58% (5.73 - 7.42)	14.33% (13.15 - 15.51)
Yes	26.87% (25.64 - 28.1)	45.18% (43.82 - 46.55)	7.46% (6.73 - 8.19)	6.09% (5.42 - 6.75)	12.31% (11.37 - 13.25)
Current Smoker
No	24.95% (24.18 - 25.73)	42.16% (41.29 - 43.03)	7.43% (6.96 - 7.91)	5.8% (5.26 - 6.34)	11.84% (11.09 - 12.59)
Yes	28.37% (20.57 - 36.18)	42.46% (34.01 - 50.92)	12.79% (7.21 - 18.37)	7.15% (6.14 - 8.15)	13.57% (12.22 - 14.91)
Alcohol Consumption
No	24.95% (24.17 - 25.73)	42.06% (41.19 - 42.94)	7.5% (7.03 - 7.98)	6.27% (5.76 - 6.79)	12.53% (11.82 - 13.25)
Yes	25.06% (18.04 - 32.09)	51.85% (43.83 - 59.87)	8.27% (3.77 - 12.77)	5.69% (4.41 - 6.96)	11.27% (9.49 - 13.04)
Stress
Not anxious or depressed	22.45% (21.47 - 23.43)	38.61% (37.48 - 39.74)	6.34% (5.76 - 6.92)	5.73% (5.19 - 6.26)	11.03% (10.29 - 11.76)
Somewhat anxious or depressed	27.78% (26.38 - 29.18)	47.31% (45.78 - 48.85)	8.85% (7.96 - 9.74)	7.35% (6.26 - 8.45)	15.13% (13.62 - 16.64)
Too anxious or depressed	31.71% (28.82 - 34.6)	46.96% (43.89 - 50.04)	10.47% (8.52 - 12.42)	7.79% (5.06 - 10.52)	19.99% (15.82 - 24.15)
Pain
No pain or discomfort	20.14% (19.19 - 21.1)	37.76% (36.61 - 38.91)	4.89% (4.37 - 5.41)	4.83% (4.32 - 5.34)	9.28% (8.58 - 9.99)
Some pain and discomfort	31.41% (30.05 - 32.78)	48.59% (47.15 - 50.04)	10.76% (9.84 - 11.67)	9.32% (8.21 - 10.43)	18.97% (17.48 - 20.46)
Too much pain and discomfort	31.16% (27.79 - 34.53)	44.78% (41.18 - 48.38)	12.28% (9.83 - 14.72)	9.57% (6.14 - 12.99)	23.76% (18.62 - 28.9)

Table 3. Prevalence of cancer screening by medical conditions in 2021 in Iran. The data are represented as percent and 95% uncertainty intervals.

Underlying diseases or conditions	Breast cancer	Cervical cancer	Colorectal cancer (Female)	Colorectal cancer (Male)	Prostate cancer
Cancer Diagnosis
No	24.63% (23.85 - 25.4)	41.89% (41.02 - 42.77)	7.42% (6.94 - 7.89)	5.98% (5.51 - 6.45)	12.04% (11.38 - 12.69)
Yes	54.6% (46.71 - 62.5)	60.38% (52.6 - 68.16)	14.6% (8.96 - 20.23)	21.6% (14.02 - 29.17)	32.34% (23.62 - 41.05)
Cardiovascular Diseases
No	24.57% (23.78 - 25.36)	42.18% (41.29 - 43.07)	7.18% (6.7 - 7.66)	5.59% (5.12 - 6.06)	10.6% (9.96 - 11.24)
Yes	32.3% (28.7 - 35.89)	41.75% (37.99 - 45.52)	13.19% (10.55 - 15.82)	12.43% (10.14 - 14.73)	31.11% (27.86 - 34.36)
Respiratory Diseases
No	24.64% (23.86 - 25.43)	41.72% (40.83 - 42.61)	7.33% (6.85 - 7.82)	6.01% (5.53 - 6.49)	11.76% (11.1 - 12.42)
Yes	32.22% (28.36 - 36.09)	50.4% (46.28 - 54.52)	11.1% (8.5 - 13.71)	9.78% (6.9 - 12.66)	24.31% (20.07 - 28.54)
Diabetes Mellitus
No	26.1% (25.07 - 27.13)	47.13% (45.97 - 48.3)	7.48% (6.85 - 8.11)	7.09% (6.4 - 7.78)	12.88% (11.97 - 13.78)
Yes	34.12% (31.34 - 36.9)	44.4% (41.51 - 47.29)	14.04% (11.99 - 16.09)	12.11% (9.81 - 14.41)	23.94% (20.96 - 26.92)
Hypertension
No	21.51% (20.61 - 22.41)	41.59% (40.52 - 42.65)	5.18% (4.69 - 5.67)	4.61% (4.11 - 5.11)	8.3% (7.63 - 8.97)
Yes	32.2% (30.75 - 33.66)	43.44% (41.91 - 44.97)	12.29% (11.26 - 13.32)	9.6% (8.55 - 10.66)	21.21% (19.75 - 22.68)
High Cholesterol (Cholesterol>200)
No	23.48% (22.34 - 24.62)	45.72% (44.4 - 47.04)	6.11% (5.46 - 6.76)	6.92% (6.17 - 7.66)	12.76% (11.78 - 13.74)
Yes	34.51% (32.71 - 36.31)	48.61% (46.73 - 50.49)	12.82% (11.54 - 14.1)	10.01% (8.56 - 11.47)	18.56% (16.67 - 20.46)
Abdominal Obesity
No	15.71% (14.58 - 16.83)	32.63% (31.19 - 34.07)	4.49% (3.84 - 5.14)	5.4% (4.89 - 5.92)	10.62% (9.9 - 11.33)
Yes	29.76% (28.76 - 30.77)	47.08% (45.99 - 48.16)	9.04% (8.4 - 9.67)	8.42% (7.31 - 9.53)	17.46% (15.94 - 18.97)
Body mass index
Underweight	7.28% (4.71 - 9.86)	15.74% (12.11 - 19.37)	4.09% (2.13 - 6.05)	4.26% (2.22 - 6.3)	7.68% (4.94 - 10.42)
Normal	17.82% (16.53 - 19.11)	32.12% (30.57 - 33.66)	5.42% (4.67 - 6.18)	5.57% (4.85 - 6.3)	10% (9.02 - 10.97)
Overweight	26.15% (24.85 - 27.44)	45.55% (44.09 - 47.01)	7.53% (6.74 - 8.32)	6.91% (6.1 - 7.71)	14.32% (13.2 - 15.43)
Obesity	32.01% (30.5 - 33.51)	50.11% (48.51 - 51.72)	9.69% (8.73 - 10.66)	6.17% (5.03 - 7.31)	13.96% (12.31 - 15.62)

Table 4 is available in the Supplementary Files section.

No competing interests reported.

Cancer Screening Profile of the Iranian Population: Findings from STEPS 2021 survey

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