Cancer awareness among community pharmacist: a systematic review

The WHO recognises that community pharmacists are the most accessible healthcare professionals to the general public. Most patients regularly visit community pharmacies for health information and also seek advice from pharmacists with respect to signs and symptoms of cancer. As readily accessible health care professionals, community pharmacists are also in the best position to include cancer-screening initiatives into their practice. Pharmacists are therefore in a good position to raise awareness when they counsel people who buy over-the-counter medication for the control of possible cancer-related symptoms. The aim of this review was to critically appraise evidence gathered from studies that; (1) explore or assess knowledge of community pharmacist on signs and symptoms of cancer, (2) explore or assess knowledge of community pharmacist on cancer screening. EMBASE (ovid), CINAHL (EBSCOhost) and MEDLINE (EBSCOhost) were systematically searched for studies conducted between 2005 to July 2017. Studies that focused on knowledge of community pharmacist in cancer screening, signs and symptoms were included. A total of 1538 articles were identified from the search, of which 4 out of the 28 potentially relevant abstracts were included in the review. Findings of the selected studies revealed lack of sufficient knowledge on breast cancer screening, signs and symptoms. Both studies attributed knowledge limitation as the cause of reason for the key findings of their studies. The selected studies focused largely on breast cancer, which hinder the generalizability and transferability of the findings. Hence there is a need for more studies to be conducted in this area to draw a better conclusion.


Background
Cancer now causes more deaths than all coronary heart disease or strokes, according to World Health Organisation (WHO) estimates for 2011 [27]. This is likely as a result of late presentation of the disease [16] which have been attributed to a number of factors such as poor awareness of the signs and symptoms of cancer, cancer risk factors, poor availability of tests or screening programs [9,12,13].
The continuous global demographic and epidemiological evolution shows an increasing cancer burden over the next decades, especially in low and middle income countries (LMIC), with over 20 million new cancer cases expected annually as early as 2025 [5].
Contemporary pharmacy practice reflects an emerging paradigm from one in which the pharmacist primarily supervises medication distribution and counsels patients, to a more expanded role providing patient-centered medication therapy management, health improvement, health education, health promotion activities and disease prevention services [25]. The role of the pharmacist in cancer care is now growing with community pharmacists advocating, promoting, supporting and providing cancer related health promotion [6].
The WHO recognises that community pharmacists are the most accessible healthcare professionals to the general public [1]. Studies have shown that community pharmacies provide easy and equitable access to healthcare [22]. Most patients regularly visit community pharmacies for health information and also seek advice from pharmacists with respect to signs and symptoms of cancer [15]. Pharmacists are therefore in a good position to raise awareness when they counsel people who buy over-the-counter medication for the control of possible cancer-related symptoms. To be able to achieve this, as healthcare providers in the community, pharmacist must be able to differentiate between conditions that require selfmedication and those that need the attention of a physician. They must be able to identify the common signs and symptoms of cancer. As readily accessible health care professionals, community pharmacists are in the best position to include cancer-screening initiatives into their practice. A number of organizations including the US Preventive Services Task Force [24], American Cancer Society [21], and National Comprehensive Cancer Network [17], have developed cancer screening recommendations. Because clinicians may use different guidelines, pharmacists need a working knowledge of basic recommendations [20].
Studies that have assessed knowledge on screening, signs and symptoms of cancer among community pharmacist have been conducted, however, no systematic review have been conducted to pool findings from these studies to inform practice. The aim of this review was to critically appraise evidence gathered from studies that; (1) explore or assess knowledge of community pharmacist on signs and symptoms of cancer, (2) explore or assess knowledge of community pharmacist on cancer screening [23].

Sources and search strategy
Search of EMBASE (ovid), CINAHL (EBSCOhost) and MEDLINE (EBSCOhost) were done to identify evidence. The search period was from 2005 to July, 2017. The MEDLINE search strategy (Appendix 1) used key words such as cancer, community pharmacist, knowledge, awareness, signs and symptoms, screening. This search strategy was adopted for other databases search. Additional search from reference lists of articles selected for full text review yielded no results. The review was designed and carried out following established guidelines on good conduct and reporting of systematic reviews [14]. The protocol was registered with PROSPERO [23], registration number 2017:CRD42017071390.

Eligibility criteria and study selection
Two investigators (KM and FO) independently read the titles and abstracts of all records retrieved and assessed them against the set criteria (Table 1). Data from the included studies were extracted by the primary reviewer (KM) using a standardized research matrix [10], and later checked by another reviewer (AB). Author's name, year of publication, country and setting, study design, type of cancer, sample size, findings, where the data collected (Appendix 2). The search results were independently reviewed by two authors (KM and FO). The database search identified 1538 records. A total of 349 duplicate records were deleted. One thousand one hundred and eight nine (1189) articles were independently screened on title and abstract by two authors (KM and FO) and irrelevant articles were excluded. The authors evaluated 32 full-text articles for eligibility. After exclusion of 28 articles, 4 studies met the criteria for inclusion in the review. A flow chart summarising the selection procedure is shown in Fig. 1.

Results
The database search found 1538 publications between 2005 and July 2017. A total of 349 duplicate records were removed. A further 1173 records were excluded based on their abstracts and titles. Following the exclusion criteria, another 28 records were also excluded. The remaining 4 articles which met the inclusion criteria were read in full. A flowchart summarising the selection process is shown in Fig. 1.

Study characteristics
The characteristics of the four studies are shown in Table 2. The studies were published from 2010 to 2016. The studies were conducted in Malaysia, Qatar, UAE and Jordan. Community pharmacists were recruited from commercial community pharmacies. The studies included a total of 1678 pharmacists. Breast cancer was the type of cancer discussed in the selected studies. The smallest sample size in the studies was 35 [3] and largest sample size was 1113 [2].

Quality assessment of selected studies
The quality of the selected studies was assessed using a quality assessment tool [19] Score from 0% -33.9% is regarded as weak, 34% -66.9% is regarded as moderate, and 67% -100% is regarded as strong (n = 4) based on [18] classification of quality level (Table 3).

Discussion
The data from the selected studies were heterogeneous; hence it was not possible to combine it for metaanalysis. Hence the outcomes of the studies were reported as a narrative synthesis. Findings of the four selected studies revealed lack of sufficient knowledge on breast cancer and screening recommendations. Scores of participants on items about knowledge on cancer signs and symptoms were moderate ( [2,11]. The other two studies [3,7] had only one item on cancer signs and symptoms which does not give a proper reflection about participants knowledge on signs and symptoms about breast cancer. With aging population in the world, the global burden of cancer is set to increase [4]. One of the approaches adopted by the World Health Organisation (WHO) is to raise awareness through education regarding warning signs of cancer [26]. Therefore much has to be done to improve the knowledge of community pharmacist on these warning signs. Scores were noticed to be low for items about knowledge on cancer screening recommendations for one of the studies [11]. All studies attributed knowledge limitation as the cause of reason for the key findings of their studies. Lack of continuous pharmacy education, nonattendance of continuous pharmacy education and different undergraduate pharmacy curricula contribute to knowledge limitations.
Through this systematic review it can be seen that there has not been many studies done to analyse the knowledge of community pharmacist on screening recommendations, signs and symptoms of cancer for the past 12 years. The selected studies focused on breast cancer only, which hinder the generalizability and transferability of the findings. Hence there is a need for more studies to be conducted in this area to draw a better conclusion which will inform policy.

Conclusion
In conclusion, community Pharmacists possess moderate knowledge on breast cancer signs, symptoms and screening recommendations. However, the findings of this systematic review were highly limited by the fact that only four studies met the review criteria, samples of studies were taken from only one geographic area, Middle East Region and sample size was relatively small. Hence findings may not be applicable to all community pharmacists in general. Further studies should be conducted in other sub regions of the World to generate results for future policy implementation.

Limitations
The search was limited to three databases and did not include data from grey literature. Also the search was restricted to studies conducted from 2005 to July, 2017 and studies published in English. These create opportunity for study selection bias.
Researcher-designed questionnaires were used in the selected studies, which led to heterogeneous results that could not be combined for meta-analysis or metasynthesis.
The studies were done in only breast cancer hence cannot be generalised for the other cancers. The review was limited to four studies only, and so worldwide survey is required to address certain perception aspects of breast cancer screening, signs and symptoms.

Appendix 1
An example of search strategy used in the Medline Ovid platform.   • Breast cancer knowledge was evaluated using 7 questions to be answered as yes, no or uncertain. More than half (50%) of the participants answered general questions related to breast cancer and its risk factors correctly. The mean percent score of correct answers was 72.6% ± 11. • Pharmacists' perception regarding breast cancer health promotion was assessed using 8 lickert scale type questions. The mean percent score for the pharmacists who strongly agree or agree with all the given statements was 90% ± 8.07. • 91.4% strongly agree or agree that there is a need to integrate breast cancer health promotion activities i to their daily practice and about 71.4% strongly agree or agree that there is a demand from the community to get advice on breast cancer screening and early detection. • The community pharmacists cite lack of time (80%), lack of breast cancer education materials (77.1%), and training (62.9%) as major barriers that limit their involvement in breast cancer promotion activities.
• The cross-sectional survey was confined to community pharmacists in two districts (Malaysia), hence the results could not be generalized to all community pharmacists in Malaysia.

Community Pharmacists' involvement in Breast Cancer
Health Promotion in United Arab Emirate (UAE).

UAE Community pharmacies 335
• About 47% of the pharmacists reported that they never provided patients with advice or • The study variables were assessed by self-report, which may be biased by an inclination to provide socially desirable