Cancer screening research in Bangladesh: Insights from a scoping review

ABSTRACT

This scoping review summarises the findings of research conducted on cancer screening in Bangladesh, including the prevalence, awareness, barriers, and evaluation of screening programmes, by performing a comprehensive search of electronic databases and gray literature. 25 studies that met inclusion criteria were included in the final analysis. Most of the studies were about screening for cervical cancer, were quantitative, were cross-sectional, and were conducted in hospital settings. The main challenges to screening uptake were shyness, fear, a lack of knowledge, and an inadequate understanding of the concept of screening. Visual inspection with acetic acid (VIA) was found to be a simple and cost-efficient way to detect early-stage cervical cancer. However, breast self-examination (BSE) was reported to be insufficient. Education was found to have a positive impact on cancer screening knowledge and practice, but more needs to be done to improve screening rates, such as the utilisation of media, particularly in rural areas. The results of this scoping review highlight Bangladesh's low cancer screening prevalence and uptake and suggest that targeted awareness campaigns and enhanced access to screening services are required to increase cancer screening uptake and reduce the cancer burden in Bangladesh.

KEYWORDS:

• Cancer
• screening
• Bangladesh

Introduction

Cancer is one of the top causes of death in Bangladesh (The World Health Organization (WHO), 2018; Vos et al., 2020). Twelve percent of total deaths in Bangladesh are due to cancer, which is estimated to be the number one cause of death by 2040 (Sung et al., 2021; The World Health Organization (WHO), 2018). The cancer incidence and mortality rates per 100,000 people in Bangladesh are 106.2 and 75.3, respectively (Sung et al., 2021). While the global cancer incidence is projected to double by 2070, as of 2018, Bangladesh is estimated to have a 400% increase in cancer incidence (Soerjomataram & Bray, 2021). The five most common cancers in Bangladesh are: breast (12.10%), esophagus (11.30%), cervix uteri (9.70%), lung (8.80%), and lip and oral cavity (8.70%) (Sarker et al., 2018).

Screening is the cornerstone of cancer control. Screening refers to the investigation and/or physical examination of individuals without symptoms who are at high risk of developing cancer. Screening plays a role on two levels, i.e. prevention and early diagnosis (Wardle et al., 2015). It detects precancerous disease, e.g. cervical intraepithelial neoplasia, and removal of those precancerous tissues prevents the development of cancer and is therefore termed primary prevention. On the other hand, it diagnoses cancer at a very early stage before developing symptoms, which makes the disease curable and improves the prognosis; hence, it is labelled as secondary prevention (Wardle et al., 2015).

Researchers have conducted numerous studies on various aspects of cancer screening in different countries and regions worldwide. Sankaranarayanan's (Sankaranarayanan, 2014) review describes the current state of cancer screening programmes in low- and middle-income countries (LMIC). His findings show that while population-based Papanicolaou testing programmes have reduced cervical cancer incidence and death in high-income nations, their impact in LIMCs has been hampered by poor organisation, coverage, and quality assurance. Due to the difficulty in establishing high-quality cytology screening in LMICs, experts have investigated visual inspection with acetic acid (VIA) and human papillomavirus (HPV) testing-based screening. Clinical breast examination screening in LMICs should await trial outcomes; nonetheless, the resources and infrastructure required for a mammography screening programme may be prohibitively expensive for many LMICs. Existing data do not support population-based screening for stomach, lung, ovarian, and prostate cancer in LMICs. Schreuders et al. (Schreuders et al., 2015) conducted a comprehensive assessment of the current status of colorectal cancer screening initiatives on a global scale. It has been noted that colorectal cancer screening is only provided to a limited percentage of the intended population globally. Additionally, there are significant disparities in the implementation and approach to colorectal cancer screening due to variations in colorectal cancer occurrence, economic resources, healthcare structure, and infrastructure required for screening support. The persistent disparity between the occurrence of colorectal cancer and the availability of organised or opportunistic screening is a continuing cause of worry. They suggested a thorough cooperation among many stakeholders to achieve the best outcomes of the colorectal cancer screening programme. When formulating a colorectal cancer screening approach, it is important to consider not only the occurrence of colorectal cancer, but also its significance in relation to other health issues and the ability to provide treatment. Additionally, it is crucial to report the screening measures and quality indicators to enable national assessment and international benchmarking, thereby enhancing the quality of colorectal cancer screening. Devarapalli et al. (2018) conducted a comprehensive review to identify the barriers that hinder the adoption of cervical cancer screening in LIMCs and to provide effective strategies to overcome these barriers and increase the acceptance of cervical cancer screening in the community. They found a total of 22 barriers, with insufficient knowledge about cervical cancer and its treatment, embarrassment or shyness, lack of time, and lack of family support being the most frequently mentioned obstacles. The authors suggested the implementation of policies to enhance the progress of cervical cancer screening programmes in LMICs. These policies should prioritise improving the accessibility and cost of screening, increasing cervical cancer education, and emphasising the importance of screening to boost the uptake of cervical cancer screening in LMICs. In their systematic review, Wang et al. (Wang et al., 2022) provide a comprehensive analysis and comparison of cervical cancer screening guidelines and clinical practices in 11 countries spanning North America, Europe, and Asia-Pacific. Out of the 11 countries evaluated, only six have implemented population-based screening programmes. Significant variations endure among countries’ screening guidelines. They believed that a strong and comprehensive screening data infrastructure, such as a national screening registry, is a crucial element for assessing and enhancing the effectiveness of cervical cancer screening programmes worldwide. Lu et al. (Lu et al., 2012) conducted a review to integrate knowledge concerning the efficacy of cancer screening strategies for Asian women. The efficiency of existing interventions to improve breast and cervical cancer screening uptake among Asian women may depend on a number of factors, including the type of intervention and study population characteristics, as well as ethnicity, programme delivery techniques, and study environment. They discovered that using a combination of several strategies is more likely to be effective than single interventions. Combining cultural awareness training for healthcare professionals with outreach workers who may assist healthcare providers in overcoming linguistic and cultural obstacles is expected to increase cancer screening uptake. Vieira et al. (da Costa Vieira et al., 2017) conducted a study to assess breast cancer screening methodologies and indicators in developing countries. Their objective was to discover metrics that could indirectly represent the status and progression of public health systems in relation to breast cancer screening and diagnosis. They discovered prospective indicators pertaining to epidemiology, diagnostic intervention, quality of intervention, comparisons, and survival across different countries that might be utilised for comparing disparities and assessing enhancements in public health systems. Mandal and Basu (2018) conducted a review of the present state of cancer screening and early diagnosis in LMICs. They found that implementing mass-scale mammography-based breast cancer screening is not practical or viable in most LMICs. However, LMICs can utilise clinical breast examination (CBE) for screening while ensuring sufficient quality. LMICs may opt for either HPV detection-based screening or a cost-effective option VIA for cervical cancer detection. To address colorectal cancer, countries can carry out demonstration projects to conduct screening using fecal immunochemical testing. Oral cancer screening can be conducted using oral-visual examinations. LMICs were not advised to have screenings for other types of cancer. LMICs should enhance their ability to promptly diagnose prevalent cancers by implementing community education, educating frontline health workers, supporting timely referrals, and enhancing the infrastructure for cancer detection and treatment. In their systematic study, Chua et al. (Chua et al., 2021) aimed to investigate the barriers and facilitators of cervical cancer screening among women residing in Southeast Asia. The barriers and facilitators discovered encompassed various elements, including demographics, socio-economic position, social support, knowledge, attitudes, views, financial access, the health system, and psychological or emotional concerns. The predominant barriers observed were feelings of humiliation, limited availability of time, and inadequate understanding of screening procedures. Conversely, the primary factors that facilitated participation were age-related considerations, getting guidance from healthcare professionals, and educational attainment. According to their research, patient education-based interventions play a crucial role in raising cervical cancer screening uptake in Southeast Asia. The paper by Dowling et al. (Dowling et al., 2010) provides a detailed analysis of the organisation and features of cervical and breast screening programmes in the 16 countries that are part of the International Cancer Screening Network (ICSN) and have operational population-based cancer screening programmes or registries. In 63% of these nations, the structure of the cervical cancer screening programme closely resembled that of the breast cancer screening programme within the same country. Programme characteristics varied in terms of their establishment year and the age groups they catered to. The implementation of novel screening technologies, such as liquid-based Pap tests, HPV-triage testing, and digital mammography, was apparent. Significant disparities existed in the rates of engagement for both types of programmes, with cervical cancer screening programmes generally exhibiting higher participation rates compared to breast cancer screening programmes. In general, there were both parallels and variations in the structure of breast and cervical cancer screening programmes across ICSN nations. Sano et al. (Sano et al., 2016) provided a comprehensive overview of the present state and prospects of colorectal cancer screening among the general population in East Asian and South-East Asian nations. The fecal occult blood test has been recognised as a widely used and efficient method for colorectal cancer screening in these nations. However, the adoption of colorectal cancer screening colonoscopy as a key population-based screening tool is hindered due to limitations in personnel, escalated medical expenses, and the possibility of adverse incidents. The low rate of participation in colorectal cancer screening programmes is a prevalent issue in these nations. However, this problem can be addressed by enhancing public awareness and promoting colorectal cancer screening through the efforts of physicians.

The most commonly screened cancers worldwide are breast, cervix, colorectal, lung, prostate, and skin cancers. Guidelines for screening vary from country to country (Ebell et al., 2018). As such, as one of the first countries, Bangladesh introduced VIA as the screening test in a national cervical cancer screening programme (Basu et al., 2010). VIA is a simple, affordable test with moderate sensitivity and specificity (Basu et al., 2010). Likewise, CBE was adopted for breast cancer screening in Bangladesh (Sarker et al., 2018). The effectiveness of CBE as a screening test is, however, controversial. In high-income countries, mammography is the test of choice for breast cancer screening. Considering the limited resources, the World Health Organization (WHO) does not recommend mammography over CBE in low-to-middle-income countries (Ngan et al., 2020).

Bangladesh has developed a national cervical and breast cancer screening programme with the technical assistance of Bangabandhu Sheikh Mujib Medical University (BSMMU) and the United Nations Population Fund (UNFPA). By 2020, the program had established a total of 503 VIA and CBE centres throughout the country, ranging from the primary to the tertiary level. Twenty-five medical college hospitals, along with BSMMU, work as referral points for VIA- and CBE-positive patients for further testing and management (Hossain et al., 2022). Different centres performed a total of 2,772,908 VIA tests from 2005 to 2020. Of the screened women, 120,166 (4.33%) were found VIA-positive (Hossain et al., 2022). On the other hand, a total of 2,576,992 CBE tests were performed from 2007 to 2020 under the national cancer screening programme in Bangladesh, and among them, 40,555 (1.57%) women were CBE-positive (Hossain et al., 2022).

The Global Cancer Observatory reports that breast, cervical, lip and oral cavity, esophagus, and lung cancers are the most common and frequently occurring types of cancer in Bangladesh for both males and females (The Global Cancer Observatory, 2021). Apart from cervical and breast cancer, which are among the top five most common cancers in Bangladesh (Hussain, 2013; Sarker et al., 2012; Sharmin et al., 2022; The Global Cancer Observatory, 2021), there is no other population- or institution-based cancer screening programme in Bangladesh. The breast and cervical cancer screening programmes are only designed for females, and there are no screening programmes expressly aimed at male cancer types such as prostate or colorectal cancer. This lack of screening is a cause for concern. Although screening the general public for esophageal cancer is not yet well recommended by any professional organisation, additional cancer screening programmes, specifically for lung and colorectal cancer, should be established in Bangladesh due to their significant occurrence rates among males.

Despite the importance and benefits of cancer screening in the early detection and treatment of cancer, as well as the existence of some national-level cancer screening programmes, there seems to be a paucity of research on different aspects of cancer screening in the Bangladeshi community. There is a need for more information on the performance of existing programmes, the challenges encountered in executing them, the extent to which these programmes have been sustained, and the outcomes of the programmes in terms of reducing the respective cancer burden. With this backdrop, we aimed to conduct this scoping review to summarise the current research with respect to screening for any type of cancer in Bangladesh. Through this, we will be able to identify the gaps and scope of future research on various aspects of cancer screening.

Materials and methods

We followed the five-stage methodological framework proposed by Arksey and O’Malley (Arksey & O’Malley, 2005) to conduct this scoping review.

Stage 1. Identify the research question

Developing an appropriate research question is the key starting point for conducting a scoping review. As the primary objective of this scoping review was to summarise the existing literature available on cancer screening in Bangladesh, we formulated our research question as follows: what information is available regarding screening of any type of cancer in Bangladesh from the existing literature?

Stage 2. Identify relevant studies

We conducted a comprehensive search of MEDLINE, EMBASE, and BanglaJOL for studies on cancer screening in Bangladesh from their inception through April 26, 2021. We also performed a gray literature search using Google Scholar. To find more studies, we also looked through the reference lists of all applicable papers. Studies published in other languages than English were not considered due to time and resource limitations. There were three primary concepts that guided the search: screening, cancer, and Bangladesh. To ensure a comprehensive literature search, we used an extensive set of key words and Medical Subject Headings (MeSH) on the aforementioned primary concepts and connected them by using the Boolean operators ‘OR’ and ‘AND’. Table 1 lays out the search methodology in full.

Table 1. Search strategy used in different databases.

MEDLINE	EMBASE	BanglaJOL
screening.mp exp Mass Screening/ preventive test*.mp preventive investigation*.mp early diagnosis.mp exp Early Diagnosis/ 1 or 2 or 3 or 4 or 5 or 6 tumour.mp. exp Neoplasms/ cancer.mp malignancy.mp neoplasm.mp. 8 or 9 or 10 or 11 or 12 Bangladesh.mp exp Bangladesh/ 14 or 15 7 and 13 and 16	screening.mp exp cancer screening/ exp screening/ exp mass screening/ preventive test*.mp preventive investigation*.mp early diagnosis.mp exp early diagnosis/ 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 tumour.mp. exp neoplasms/ cancer.mp exp malignant neoplasm/ malignancy.mp. neoplasm.mp. 10 or 11 or 12 or 13 or 14 or 15 Bangladesh.mp exp Bangladesh/ 17 or 18 9 and 16 and 19	(Screening OR Mass Screening OR Preventive test* OR Preventive investigation* OR Early diagnosis) (Tumour OR Cancer OR Malignancy OR Neoplasm) (Bangladesh)

Stage 3. Study selection

• We developed a set of specific inclusion and exclusion criteria to exclude any irrelevant studies and ensure the comprehensiveness of the review. We primarily included the studies if they fulfilled all of the following criteria: The study discussed anything relevant to cancer screening, such as diagnosis, awareness, barriers, prevention, or policies.

• The study was original research or an abstract that provided an original study on cancer screening.

• The study was conducted in Bangladesh.

• The language of the study was English.

The studies were excluded if:

• They were not related to cancer screening.

• They were conference papers, editorials, or reviews.

• They were non-human studies.

• The study population consisted of expatriate Bangladeshis.

Two reviewers independently identified potentially eligible articles following a two-step method using the inclusion and exclusion criteria mentioned above. The reviewers screened titles and abstracts first. At this point, the reviewers retained an abstract if they agreed it should be or if there was ambiguity about eligibility based solely on the title and abstract. Second, a full-text review of the selected articles was performed by the reviewers, and the same set of inclusion and exclusion criteria were used to confirm the article’s inclusion in the final selection. To provide a comprehensive overview of the topic, there were no constraints on the study type (e.g. cohort study, cross-sectional study), geographical region (e.g. urban, rural), time period, or age groups. Furthermore, there were no limitations on the diagnostic criteria used to define cancer. We measured the level of agreement among reviewers using the kappa statistic (Chowdhury et al., 2019; Sim & Wright, 2005). Reviewers settled any disagreements through consensus.

Stage 4. Data extraction, charting, and synthesis

The following data was gathered from each of the selected studies: Author and year of publication; study type (qualitative or quantitative); study design (e.g. cohort, cross-sectional, RCT); study setting (urban or rural and/or hospital-based or community-based); study period; number of study participants; sex (male or female or both); age of the study participants (mean or median age); primary aim of the study; and major findings from the study. Two reviewers independently retrieved data using a predetermined standardised form, and they compiled the data into charts using Microsoft Excel and Word.

Stage 5. Interpretation and reporting results

A scoping review aims to provide a broader and more general overview of the research conducted on a particular topic (Arksey & O’Malley, 2005). We undertook a thematic synthesis approach to develop a description of the research landscape and present an overview of cancer screening research conducted in Bangladesh.

Results

Literature search overview

Using an electronic search, we discovered 356 cancer screening studies in Bangladesh, and another 7 potentially relevant studies using a gray literature search. Following the removal of duplicates and the assessment of titles and abstracts, 65 articles were selected for full-text screening. The primary reason for excluding papers at the preliminary screening stage was their lack of relevance to our study purpose. For the following reasons, 40 of the 65 full-text articles were excluded: 15 were conference abstracts, 8 were not screening-focused, 8 were published in extremely local publications that were not available online or on any open public platform, 4 were editorials, 4 were review papers, and 1 was conducted in multiple countries, including Bangladeshi; however, no data on Bangladesh was provided. As a result, 25 studies were eventually chosen for this scoping review. The primary articles eligible for inclusion had high agreement (81.25%) among reviewers. Figure 1 depicts the article selection procedure.

Figure 1. PRISMA diagram for the scoping review of studies that evaluated cancer screening in Bangladesh.

Study characteristics overview

Table 2 contains an overview of the characteristics of the selected cancer screening studies in Bangladesh. Various types of cancer were mentioned in the studies that were identified. 15 of the 25 studies addressed cervical cancer, 5 addressed breast cancer, 2 addressed both cervical and breast cancer, and one addressed colorectal, oral, and prostate cancer. With 23 studies, the majority were quantitative, with the remaining two being qualitative. The majority of the study designs were cross sectional, with 11 papers reporting this type. Three studies reported prospective study designs, whereas one study was retrospective. The study design of the ten studies was not reported (NR). The majority of the research was done in urban centres, with 10 studies being conducted entirely in urban centres. Seven studies were carried out in rural areas. Four studies reported both urban and rural study settings, whereas four studies did not mention their study settings. With 17 studies, the majority were hospital-based, with only one study being community-based. One study was carried out in both community and hospital settings. Dhaka had the most studies (8 in total), followed by Rajshahi (3 in total), and Manikganj (2 in total). Narayanganj, Faridpur, Rangpur, and Khulna each had one study. Six studies were being conducted with national participants, while two studies were multi-national in nature and included Bangladesh. The number of participants in the study ranged from 30 to 104,098. With 20 research studies, most of the studies were conducted on females. One study focused on men, whereas the other examined both males and females. In three studies, participants’ sex was not disclosed. The participants’ age was greater than 30 years old in the larger part of the research (7 studies).

Table 2. Study characteristics.

Study	Study Type	Study Design	Study Setting	The location of the Study	Study Period	Number of Participants	Sex	Age of the Participants (mean or median)	Type of Cancer Discussed
(Begum et al., 2019)	Quantitative	Cross Sectional	Urban and Hospital-based	Dhaka	Jul-2013 to Jun-2014	500	Female	> 20 years (36.16 year)	Breast Cancer
(Yusuf et al., 2012)	Quantitative	Prospective	Urban and Hospital-based	Rajshahi	Jul-2008 to Dec-2009	540	Female	> 30 years (36.17 year)	Cervical Cancer
(Villain et al., 2021)	Quantitative	NR	NR	Nation-wide	Mar-2020 to May-2020	NR	NR	NR	Cervical and Breast Cancer
(Rasu et al., 2011)	Quantitative	Cross Sectional	Urban and Hospital-based	Dhaka	NR	152	Female	> 40 years (47 year)	Breast Cancer
(Nessa et al., 2013)	Quantitative	NR	Urban and Hospital-based	Dhaka	Oct-2008 to Oct-2010	650	Female	30-45 years	Cervical Cancer
(Nessa et al., 2013)	Quantitative	NR	Rural and Community-based	Manikganj and Narayanganj	Jan-2011 to Aug-2011	80 (Manikganj) and 96 (Narayanganj)	Female	(32-39 years)	Cervical Cancer
(Nessa et al., 2010)	Quantitative	NR	Both Urban and Rural, as well as Hospital and Community-based	Nation-wide	Jan-2005 to Jun-2008	104098	Female	> 30 years	Cervical Cancer
(Mustari et al., 2019)	Quantitative	NR	Urban and Hospital-based	Dhaka	Jul-2016 to Dec-2016	400	Female	20-79 years	Cervical Cancer
(Islam et al., 2016)	Quantitative	Cross Sectional	Both Urban and Rural and Hospital-based	Nation-wide	Sep-2013 to Mar-2014	1590	Female	30-59 years (42.3 year)	Breast Cancer
(Basu et al., 2010)	Quantitative	NR	Urban and Rural	Nation-wide	Jan-2005 to Jun-2008	104098	Female	> 29 years	Cervical Cancer
(Amin et al., 2020)	Quantitative	NR	Urban and Hospital-based	Dhaka	Apr-2019 to Jun-2019	500	Female	> 18 years (37.13 year)	Breast Cancer
(Akinyemiju, 2012)	Quantitative	Cross Sectional	NR	Multi-national	NR	30509 (Cervical Cancer)/ 10860 (Breast Cancer)	Female	18–69 years (cervical cancer) and 40–69 years (breast cancer)	Cervical and Breast Cancer
Ahmed et al., 2008 (Ahmed et al., 2008)	Quantitative	NR	Both Urban and Rural and Hospital- based	Nation-wide	Aug-2004 to Dec-2005	11145	Female	> 30 years	Cervical Cancer
(Khatun & Khatun, 2019)	Quantitative	Cross Sectional	Urban	Dhaka	Jul-2016 to Jun-2017	100	Female	20-50 years	Cervical Cancer
(Parvin et al., 2018)	Quantitative	NR	Rural and Hospital-based	Faridpur	Jan-2014 to Dec-2014	2000	Female	18-60 years	Cervical Cancer
(Jahan et al., 2009)	Quantitative	Cross Sectional	Rural and Hospital-based	Rajshahi	Jul-2006 to Jun-2008	115	Female	21-60 years	Cervical Cancer
(Yusuf et al., 2018)	Quantitative	Prospective	Rural and Hospital-based	Rajshahi	Jul-2008 to Dec-2009	540	Female	> 30 years	Cervical Cancer
Lipi et al., 2018 (Lipi et al., 2018)	Qualitative	Cross Sectional	Urban and Hospital-based	Dhaka	Jul-2015 to Dec-2015	229	Female	18-60 years (34.07 ± 7.92 year)	Cervical Cancer
(Rahman & Bhattacharjee, 2019)	Quantitative	Cross Sectional	Rural and Hospital-based	Manikganj	Jun-2017 to Oct-2017	50	Female	(24.18 ± 6.63 year)	Cervical Cancer
(Islam et al., 2019)	Qualitative	NR	NR	NR	NR	NR	NR	NR	Colorectal Cancer
(Begum et al., 2019)	Quantitative	Retrospective Observational	Rural and Hospital-based	Rangpur	Aug-2005 to Aug-2016	11792	Female	> 10 years	Cervical Cancer
(Islam et al., 2015)	Quantitative	Cross Sectional	Both Urban and Rural and Hospital-based	Nation-wide	Sep-2013 to Mar-2014	1590	Female	30-59 years (42.3 year)	Cervical Cancer
(Pengpid & Peltzer, 2014)	Quantitative	Cross Sectional	NR	Multi-national	NR	10810	NR	16-30 years (20.7 year)	Breast Cancer
(Kamruzzaman et al., 2020)	Quantitative	Prospective	Rural and Hospital-based	Khulna	Jul-2017 to Jul- 2019	30	Both	39-77 years (60.5 year)	Oral Cancer
(Miah et al., 2017)	Quantitative	Cross Sectional	Urban and Hospital-based	Dhaka	Jan-2012 to Apr-2013	105	Male	51-92 years (66.87 ± 10.13 years)	Prostate Cancer

NR = Not Reported

Themes derived from the selected studies

We thematically categorise the evidence in accordance with the study objective of our scoping review. We did not have any preconceived topics, and we organised the information into several categories based on the findings of our scoping review (Chowdhury & Turin, 2019; Kazi et al., 2021). We attempted to identify gaps in existing research and convey them to the readers in order to provide them with knowledge of the landscape of what has been done and what future research should be conducted. We identified three major themes under which cancer screening research studies in Bangladesh could be categorised: (1) Knowledge, attitude, and practice (2) Visual inspection with acetic acid (VIA) test (3) Evaluation of markers and screening programmes, along with the current screening trend.

Theme 1. Knowledge, attitude, and practice of cancer screening in Bangladesh

We found a total of 12 studies that assessed different aspects of knowledge, attitude, and practice of cancer screening in Bangladesh, which we further categorised into two subthemes based on the specific focus of the studies. Within this category, Table 3 presents a summary of the objectives and significant findings of the selected studies within each of the two sub-themes.

Table 3. Studies related to knowledge, attitude, and practice.

Study	Primary Aim of the Study	Major Findings from the Study
Knowledge, awareness, attitude, practice, and barriers for cancer screening
(Begum et al., 2019)	Assessing knowledge, attitude, and practice towards breast cancer	Community dwelling women in Bangladesh have poor knowledge of breast cancer
(Mustari et al., 2019)	Getting a sense of what urban Bangladeshi women think about the Pap test as a screening tool	Respondents possess good knowledge of the Pap test and its purpose
(Islam et al., 2016)	Investigating the awareness of breast cancer and barriers to breast cancer screening uptake among women at midlife in Bangladesh	The primary impediment to the early diagnosis of breast cancer in Bangladeshi women is a lack of understanding of the role of screening to detect early-stage disease
(Amin et al., 2020)	To assess knowledge, awareness, and perceived barriers among women in Bangladesh regarding breast cancer	The participants had a severe lack of knowledge and awareness and perceived barriers regarding breast cancer screening. Shyness, fear, lack of knowledge, and deficient awareness programmes were the major perceived barriers
(Lipi et al., 2018)	To assess the knowledge and awareness regarding cervical cancer and its prevention among women attending the outpatient department of Dhaka Medical College Hospital	The study population showed poor knowledge about cervical cancer and was unaware of the concept of prevention.
(Rahman & Bhattacharjee, 2019)	To assess the level of awareness regarding cervical cancer among the women attending the outpatient department of Manikgonj's 250-bedded district hospital	The majority of respondents in this study did not know clearly about cervical cancer, especially its risk factors, vaccination, prevention, and clinical profile
(Islam et al., 2015 )	Investigating the barriers to cervical cancer screening uptake among women at midlife in Bangladesh	Lack of awareness of cervical cancer and an understanding of the concept of screening are the key barriers to screening uptake in women at midlife in Bangladesh
(Pengpid & Peltzer, 2014)	To investigate the knowledge, attitude, and practice of breast self-examination (BSE) among female university students from 24 low-, middle-, and emerging economy countries.	BSE importance or a positive attitude were highly associated with BSE practice. BSE practices were found to be inadequate.
(Nessa et al., 2013)	To explore the role of print materials and electronic media to improve cervical cancer screening and prevention	Television should be used to raise national awareness. The government can easily employ cable line advertising, microphone announcements, and health education at Uthan Baithaks/EPI sessions for local awareness generation
Effects of different factors on cancer screening
Rasu et al., 2011 (Rasu et al., 2011)	Effect of educational level on breast cancer screening knowledge and practice	Education showed a positive impact on knowledge and practice of breast cancer screening activities in Bangladeshi women
(Akinyemiju, 2012)	To assess the influence of household socio-economic status (SES), healthcare access and country level characteristics on breast and cervical cancer screening among women in developing countries	Much more has to be done in poor nations to enhance screening rates for breast and cervical cancer, such as boosting health expenditure (particularly in rural areas), allocating more funding to the provision of more, better educated health personnel, and improving infrastructure
(Villain et al., 2021)	Impact of Covid-19 on cancer screening programmes in some low- and middle-income countries (LMICs)	Almost all the countries included in the study reported a month-long suspension of cancer screening due to restrictions associated with lockdown, shifting of health priorities to manage SARS-CoV-2 infections, and public reluctance to visit health facilities. Cancer services generally reopened at significantly reduced capacities

Subtheme 1. Studies on knowledge, awareness, attitude, practice, and barriers

The primary goal of the eight selected studies was to assess Bangladeshi people's knowledge, awareness, attitude, practice, and barriers related to cancer, cancer screening, and cancer screening tools, particularly among women (Amin et al., 2020; Begum et al., 2019; Islam et al., 2015, 2016; Lipi et al., 2018; Mustari et al., 2019; Pengpid & Peltzer, 2014; Rahman & Bhattacharjee, 2019). Most of these studies found poor knowledge and a lack of awareness among the participants about cancer, cancer screening, and its prevention (Amin et al., 2020; Begum et al., 2019; Islam et al., 2016; Lipi et al., 2018; Rahman & Bhattacharjee, 2019). The main challenges found to screening uptake are shyness, fear, a lack of knowledge, a lack of awareness, and an inadequate understanding of the concept of screening (Amin et al., 2020; Islam et al., 2015). The use of screening tools such as breast self-examination (BSE) was also found to be insufficient (Pengpid & Peltzer, 2014). However, one study found that participants had high awareness of the screening tool, the pap test (Mustari et al., 2019).

Subtheme 2. Effects of different factors

Four studies explored the effect or influence of many factors on cancer screening knowledge and practice, such as educational level, household socioeconomic status (SES), healthcare access, country-level characteristics, Covid-19, and print and electronic media (Akinyemiju, 2012; Nessa et al., 2013; Rasu et al., 2011; Villain et al., 2021). Two of them discovered that education has a positive impact on knowledge and practice of breast cancer screening activities in Bangladeshi women (Rasu et al., 2011), but much more needs to be done to improve screening rates for breast and cervical cancer, such as increasing health expenditure (especially in rural areas), allocating more funding to the provision of more, better educated health personnel, and improving infrastructure (Akinyemiju, 2012). One study examined the impact of Covid-19 on cancer screening programmes in some LMICs, including Bangladesh, and found that there was a nearly month-long suspension of cancer screening due to restrictions associated with lockdown, shifting of health priorities to manage SARS-CoV-2 infections, and public reluctance to visit health facilities in all of the countries included in the study (Villain et al., 2021). And the other study investigated the role of print and electronic media in enhancing cervical cancer screening and prevention and proposed that television be utilised to enhance public awareness (Nessa et al., 2013). The study also recommended that the government use cable line advertising, microphone announcements, and health education at Uthan Baithaks/EPI sessions to increase local awareness (Nessa et al., 2013).

Theme 2. Visual inspection with acetic acid (VIA) test

Multiple studies were undertaken in Bangladesh to assess the effectiveness of VIA for the early diagnosis of cervical pre-cancer and cancer. Table 4 summarises the objectives and significant findings of the selected studies that were found under this category. Seven studies focused primarily on the visual inspection with acetic acid (VIA) tool and investigated the diagnostic value of the VIA tool in detecting cervical intraepithelial neoplasia (CIN) (Yusuf et al., 2012), compared VIA to other screening tools in detecting cervical cancers (Jahan et al., 2009; Nessa et al., 2013), assessed the performance or results of VIA in detecting cervical cancers (Nessa et al., 2010; Parvin et al., 2018; Yusuf et al., 2018), or discussed the development of VIA programme and its implementation (Ahmed et al., 2008). According to the findings of VIA studies, VIA can differentiate a normal cervix from a precancerous cervix with reasonable accuracy (Yusuf et al., 2012; Yusuf et al., 2018), VIA is simple, effective and requires minimal infrastructure at a low cost and should be used as a primary screening tool in low resource countries like Bangladesh (Jahan et al., 2009; Nessa et al., 2013; Parvin et al., 2018). A VIA-based programme would facilitate the development of cervical neoplasia screening, diagnosis, and treatment, as well as improve cervical cancer prevention awareness in Bangladesh, and the programme should shift from opportunistic screening to population-based, systematic screening to reduce cancer rates (Ahmed et al., 2008; Nessa et al., 2010). The observed VIA screening test positivity rate varied among the investigations. In a limited-scale study carried out in two upazilas of Bangladesh, Nessa et al. identified a VIA positive rate of 5.32% and 4.14% among the 394 and 627 participants, respectively (Nessa et al., 2013). In a separate extensive study conducted by Nessa et al. from 2005 to 2008, covering 44 districts in Bangladesh and involving 104,098 people, the VIA test yielded a positive rate of 4.8% (Nessa et al., 2010). In a study conducted by Yusuf et al., involving 540 women, it was shown that the rate of positive results for VIA was 39.27% (Yusuf et al., 2012). Parvin et al. conducted a study in 2014 with 2000 women, where they discovered a VIA positive rate of 2.05% (Parvin et al., 2018). In their study, Jahan et al. reported a VIA positive rate of 26.09% among 115 subjects (Jahan et al., 2009). In a separate extensive study carried out in various districts of Bangladesh, involving thousands of participants, Ahmed et al. found that the rate of VIA positivity was 4.92% in 2004-05, 4.28% in 2006, and 4.70% in 2007 (Ahmed et al., 2008).

Table 4. Studies related to Visual Inspection with Acetic Acid (VIA) test.

Study	Primary Aim of the Study	Major Findings from the Study
(Yusuf et al., 2012)	Determining diagnostic value of visual inspection with acetic acid (VIA) in detecting cervical intraepithelial neoplasia (CIN)	VIA can differentiate a normal cervix from a precancerous cervix with reasonable accuracy
(Nessa et al., 2013)	Compare VIA and cytology-based screening procedure for screening cervical cancer	VIA should be used as a primary screening tool even with its low sensitivity and specificity in low resource countries like Bangladesh
(Nessa et al., 2010)	Assessing the organisation and result of the visual inspection with acetic acid (VIA) programme in detecting cervical cancer	A VIA-based programme would facilitate the development of screening, diagnosis, and treatment of cervical neoplasia and improve awareness of cervical cancer prevention in Bangladesh
(Parvin et al., 2018)	To evaluate the clinical performance of visual inspection of acetic acid (VIA) as a screening tool for early detection of cervical cancer	Screening for precancerous and cancerous cervical lesions using visual inspection with acetic acid (VIA) is simple and requires minimal infrastructure at a low cost. VIA is an effective alternative to cytological and HPV DNA testing
(Jahan et al., 2009)	To find out how well the visual inspection with acetic acid (VIA) and the Pap test (cervical cytology) work for screening and early diagnosis of cervix precancerous lesions.	Routine pap smear testing was better than VIA as a single screening test. Due to a lack of resources, VIA can be used as an effective cervical screening test. Where facilities are available, these two tests (the Pap test and the VIA) can be used as screening methods
(Yusuf et al., 2018)	To evaluate the performance of visual inspection of acetic acid (VIA) in detecting cervical pre-cancerous and early cancerous lesions	VIA can differentiate a normal cervix from a precancerous cervix with reasonable accuracy
(Ahmed et al., 2008)	Development of a visual inspection programme for cervical cancer prevention in Bangladesh	Following an evaluation of the pilot screening programme's performance, it was determined that the VIA programme should transition from opportunistic screening to population-based, systematic screening of women to lower cancer rates. More physicians must be trained, clinics must be better equipped, and the links between screening, diagnosis, and treatment must be strengthened

Theme 3. Evaluation of markers and screening programmes, along with the current screening trend in Bangladesh

Six studies that we included in this theme examined additional areas of cancer screening in Bangladesh that were not covered in previous studies, and we divided them into three subthemes based on the specific focus of the investigations. Table 5 highlights the objectives and noteworthy findings of the research chosen from each of the three sub-themes found in this category.

Table 5. Evaluation of markers and screening programmes, along with the current screening trend in Bangladesh.

Study	Primary Aim of the Study	Major Findings from the Study
Evaluation of different markers
(Khatun & Khatun, 2019)	To screen patients suspected of having cervical cancer using liquid-based cytology and a traditional pap smear, followed by a colposcopic biopsy	Liquid-based cytology should be a more preferable method than the conventional Pap smear for the diagnosis of precancerous lesions of the cervix
(Kamruzzaman et al., 2020)	To examine the sensitivity, specificity, and accuracy of 1% tolonium chloride rinse in the detection of early oral cancer	Tolonium chloride rinse is a good screening test for oral cancer diagnosis
(Miah et al., 2017)	To detect the occurrence of prostate cancer at different level of serum PSA ≥ 2.5 ng/ml	A serum PSA cut-off value of 2.5 ng/ml may be used as an indication for prostate biopsy in the early detection of prostate cancer
Evaluation of screening programmes
(Basu et al., 2010)	To identify the strengths and weaknesses of Bangladesh's national cervical cancer screening programme and assist in the continuous improvement of quality in all aspects of cervical screening service delivery	The coverage of the target population at the end of four years was very low. The monitoring and quality assurance plan for the national programme is unstructured and poorly defined, especially in terms of how frequently quality assurance should be done and by whom
(Begum et al., 2019)	To assess the performance of the cervical cancer screening programme at Rangpur Medical College Hospital over an 11-year period	In developing countries, VIA-based screening at all levels of the health care system has potential benefits and is an adequate and acceptable screening method for cervical cancer at a low cost. So, it should be widely accepted globally, especially in low-resource countries
The current trend and feasibility of cancer screening tests
(Islam et al., 2019)	To find the current trend and feasibility of colorectal cancer screening tests	Several colorectal cancer screening tests appear to be feasible; however, the single best screening test cannot be determined due to limited data

Subtheme 1. Studies on the evaluation of different markers

Three of the 25 studies assessed various markers for cancer screenings (Kamruzzaman et al., 2020; Khatun & Khatun, 2019; Miah et al., 2017). Among them, one study compared liquid-based cytology to a regular pap smear for cervical cancer screening and concluded that liquid-based cytology should be preferred over the conventional pap smear for the diagnosis of precancerous lesions of the cervix (Khatun & Khatun, 2019). Another study looked at the sensitivity, specificity, and accuracy of 1% tolonium chloride rinse in detecting early oral cancer and came to the conclusion that it is a good screening test for oral cancer diagnosis (Kamruzzaman et al., 2020). Meanwhile, one study examined the occurrence of prostate cancer at various levels of serum PSA (2.5 ng/ml) and discovered that a cut-off value of 2.5 ng/ml may be utilised as an indicator for prostate biopsy in the early identification of prostate cancer (Miah et al., 2017).

Subtheme 2. Studies on the evaluation of screening programmes

Two studies evaluated cancer screening programmes in Bangladesh (Basu et al., 2010; Begum et al., 2019). Among them, one study examined the strengths and weaknesses of Bangladesh's national cervical cancer screening programme and discovered that, after four years, coverage of the target population was relatively low (Basu et al., 2010). The study also discovered that the national programme's monitoring and quality assurance plan is unstructured and poorly defined, particularly in terms of how frequently and by whom quality assurance should be performed (Basu et al., 2010). While the other study evaluated the performance of the cervical cancer screening programme over a period of eleven years and concluded that in developing countries such as Bangladesh, VIA-based screening has benefits and is an adequate and acceptable method for screening for cervical cancer at a low cost (Begum et al., 2019).

Subtheme 3. Studies on the current trend and feasibility of cancer screening tests

Out of the 25 selected studies, there was only one study that aimed to identify the current trend and feasibility of colorectal cancer screening tests and the viability of multiple tests; however, due to insufficient data, it was unable to select the single optimal test (Islam et al., 2019).

Discussion

This scoping review aimed to provide a comprehensive evaluation of the current state of cancer screening in Bangladesh by identifying and analyzing relevant studies. Among the select 25 studies included in this analysis, the majority focused on cervical and breast cancer, with a smaller number addressing both types of cancer or other forms of cancer, including colorectal, oral, and prostate cancers. The studies have various designs, settings, and time periods, and include both qualitative and quantitative research. In our synthesis, we found that the main challenges identified for screening include lack of knowledge, lack of awareness, shyness, fear, and an inadequate understanding of the concept of screening. Among females, the primary barriers to breast and cervical cancer screening include feelings of embarrassment when discussing cancer or its symptoms, concerns about societal judgment, the stigma associated with a cancer diagnosis, discomfort with undressing during screening, anxieties about screening results, and difficulties in discussing the sensitive issue with healthcare professionals. Occasionally, females may face obstacles to undergoing cancer screening in Bangladesh due to familial disapproval or religious concerns. These barriers are particularly pronounced in rural areas, where access to healthcare is often limited and awareness about cancer and cancer screening is low (Amin et al., 2020; Begum et al., 2019; Islam et al., 2016; Lipi et al., 2018; Rahman & Bhattacharjee, 2019). A significant proportion of these barriers can be attributed to the prevailing social and cultural norms in the country.

It is worth noting that we observed only a very small number of qualitative investigations, which is an issue to consider. Qualitative studies often reveal the underlying causes of observable phenomena, including those that may be hidden or unexpected. Conducting additional qualitative research on the factors that impede cancer screening participation, such as barriers and their underlying causes, can contribute to enhancing the rate of cancer screening in Bangladesh. Furthermore, researchers conducted only a few nationwide studies, leaving many areas of the country unexplored. The majority of studies were conducted in hospitals. More population-based research encompassing all regions of Bangladesh is required to comprehend the whole picture of cancer screening in Bangladesh. The overwhelming majority of the documented study focuses on female participants, highlighting the absence of cancer screening programmes specifically tailored for males in Bangladesh. This is a significant concern that requires urgent attention from health administrators and policymakers. The studies mostly focused on breast and cervical cancers, indicating a lack of cancer screening efforts and research for other types of cancers, notably those affecting males. Further investigation is necessary to understand why certain types of cancer screening programmes, especially those that are more common, are not present in Bangladesh. Identifying the factors hindering the implementation of cancer screening programmes at a national level and determining how to overcome these barriers is crucial for establishing effective population-based cancer screening programmes in the country.

It is also reported that education has a positive impact on the knowledge and practice of breast cancer screening activities among Bangladeshi women (Rasu et al., 2011). The impact is more evident as we see in one study that urban Bangladeshi women have good knowledge of pap tests as cervical cancer screening (Mustari et al., 2019) and female university students have satisfactory knowledge and a positive attitude towards the importance of BSE as a screening test for breast cancer (Pengpid & Peltzer, 2014). However, the practice of BSE in female university students was found to be inadequate (Pengpid & Peltzer, 2014). The studies recommended that VIA should be used as a population-based primary screening tool for cervical cancer in low-resource countries like Bangladesh due to its simplicity, effectiveness, minimal infrastructure requirements, low cost, and ability to distinguish between a normal cervix and a precancerous cervix with reasonable accuracy (Ahmed et al., 2008; Nessa et al., 2010; Nessa et al., 2013; Parvin et al., 2018; Yusuf et al., 2011; Yusuf et al., 2018; Zahan et al., 2019).

Regarding the national cervical cancer screening programme, the coverage of the target population at the end of four years was very low. The monitoring and quality assurance plans were unstructured and poorly defined (Basu et al., 2010). Targeted interventions are needed to increase awareness about available cancer screening options as well as access to screening facilities, particularly in rural areas. The involvement of community health workers in the delivery of screening services may also help to increase participation, as these healthcare providers are often better positioned to reach vulnerable and hard-to-reach populations. Furthermore, providing financial assistance to those who need it can play a key role in increasing participation (Akinyemiju, 2012; Nessa et al., 2013).

The main reason for females’ lack of awareness regarding cancer screening is their limited understanding of screening methods and their role in preventing cancer. The majority of individuals lack understanding regarding the purpose and necessity of undergoing screening, as well as the advantages associated with it. Additionally, their understanding of the etiology and symptoms of cancer is very lacking. Once again, the primary factor contributing to their lack of understanding is education, as the overwhelming majority of females, especially those residing in rural regions, have either no or very limited access to formal education. The majority of women who were knowledgeable about screening had never undergone an assessment, since they believed that breast examinations were only necessary for women experiencing symptoms. This suggests a lack of proper comprehension regarding the purpose of screening. Low levels of awareness and misconceptions regarding the need for screening were the main barriers identified in similar studies conducted in India, Nepal, Pakistan, Malaysia, and the Philippines (Domingo et al., 2008; Mahalakshmi & Suresh, 2020; Saeed et al., 2021; Shrestha et al., 2022). Studies in India reported a low level of knowledge and practice regarding BSE, even among teachers (Khokhar, 2009; Monica & Mishra, 2020). Likewise, about two-thirds (67%) of cervical cancer patients in Pakistan present in later stages, indicating a lack of knowledge and practice of cervical cancer screening (Batool et al., 2017). Our review reports similar findings that a low level of awareness of screening is the major barrier to screening utilisation. Therefore, health education is the key facilitator for increased cervical cancer screening participation. As such, national, international, governmental, and non-governmental programmes and strategies to improve cancer screening were observed; however, the effectiveness of these programmes remains unclear (Hussain, 2013). For instance, community health workers (CHWs) have been playing a critical role in improving overall health literacy and healthy practices in rural areas of Bangladesh. However, a recent study found that cancer screening-related knowledge among CHWs in Bangladesh is poor (Mubin et al., 2021). This indicates the need for developing newer and more effective strategies to improve literacy about cancer through further research and programme development. Furthermore, the majority of the studies were conducted in urban and semi-urban settings. On the other hand, majority of the Bangladesh population (approximately 60% in 2022, according to the World Bank) lives in the rural areas (Statista (2023). Share of rural population Bangladesh 2013-2022 [Dataset], 2023). This points toward the selective nature of the research that has been conducted so far.

To the best of our knowledge, this is the first comprehensive analysis in Bangladesh that systematically evaluates the scientific literature on cancer screening. Despite the comprehensive nature of this review, there are some limitations that should be noted. One such limitation is the exclusion of studies published in non-indexed local journals and in languages other than English, which may have resulted in the exclusion of some relevant studies. Additionally, this scoping review did not conduct any quality appraisal of the included studies, which may have some impact on the reliability of the results.

Conclusion

Cancer screening in Bangladesh is an area of ongoing research. The findings of this scoping review suggest that there are several barriers to cancer screening in Bangladesh, including a lack of awareness. To increase participation in cancer screening programmes, it will be important to address these barriers through targeted awareness campaigns, the expansion of screening facilities in underserved areas, and the provision of financial assistance to those in need. The involvement of community health workers in the delivery of screening services can also help to increase participation. A multi-faceted approach will be necessary to improve cancer screening rates in Bangladesh and reduce the burden of cancer in the country.

Contributors

MZIC directed the study. MZIC and TCT contributed to the study's concept and design. MZIC performed the search in databases, and MZIC, TM, TFC, AMHL, SS, and MR helped with finding additional papers through gray literature searches. TM and NC performed the screening and data extraction. MZIC performed the analysis and interpreted the results. MZIC, NM, TM, and TCT contributed to drafting the manuscript. All authors revised it critically for important intellectual content, read, and approved the final manuscript.

Patient and public involvement

Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Data availability statement

All data relevant to the study are included in the article or uploaded as online supplemental information.

Disclosure statement

No potential conflict of interest was reported by the author(s).