Awareness of Prostate Cancer among the Sportsmen in the Republic of Serbia

Prostate cancer is the second most commonly occurring cancer in men. Regardless of statistics, screening for prostate cancer is an individual decision and most male patients come for their first examination with an already developed disease, as they are not adequately informed. The study aimed to emphasize the importance of preventive tests for urological diseases in the Republic of Serbia, raise awareness about urinary problems, and present social marketing strategies for prevention. The results confirm the generally lower awareness of respondents under the age of 30, followed by those who finished university, go to the doctor two or three times a year, and receive information other than by watching TV. Implemented research indicates the influence of the marketing principles and social marketing strategies on possible target groups of the male population over 50, which is aimed at raising awareness of the importance of prevention of urological diseases and the expected changes in the health behavior of the target population.


Introduction
According to a major global study on the causes of death and disease, published in the medical journal Te Lancet − Te Global Burden of Disease, an important barrier to increase life expectancy in every country in the world is cancer. It is the second leading cause of death, with nearly 10 million deaths in 2020 [1]. As a global disease, cancer spreads rapidly, with a prediction estimate of 30.2 million new cases and 16.3 million deaths by 2040 [2,3].
On the other hand, cancer results in an economic burden on countries, healthcare systems, patients, and their families. Tis burden refers to healthcare spending and productivity losses from morbidity and premature mortality. Data on the amount of expenditures caused by cancer are unknown; however, some countries have economic analyses that indicate resource allocation decisions and investments in cancer control programs. Mentioned programs include the raising of awareness, prevention, early detection, treatment, survivorship, and end-of-life care. Te amount spent on cancer in 2017, in the US, was 1.8% of gross domestic product (GDP), detailed US$161.2 billion; US$30.3 billion, and US$150.7 billion (healthcare, loss in productivity from morbidity, and premature mortality, respectively). Data for the European Union in 2018 show a total burden of €141.8 billion or 1.07% of GDP. Te explanation for the mentioned burden lies in healthcare spending of €57.3 billion, productivity losses due to morbidity and premature death, €10.6 billion and €47.9 billion, respectively, and informal care costs of €26.1 billion. In summary, it means that the economic burden of lost productivity due to morbidity and premature death from cancer is nearly 60% of the total economic burden associated with cancer in the European Union countries [4][5][6]. Intending to tackle this issue, worldwide healthcare systems are facing stif challenges.
According to existing data, by applying existing evidence-based prevention strategies and avoiding risk factors, between 30 and 50% of cancers can currently be prevented. Screening, early detection of cancer, and appropriate treatment and care of patients can also contribute to reduce the cancer burden since many cancers have a high chance of being cured if they are diagnosed early and treated appropriately [2]. A delay in seeking help for cancer symptoms is the main factor and reason consistently shown to be associated with late diagnosis and treatment [7]. As poor awareness may lead to poor uptake of screening modalities and delay in diagnosis, cancer awareness is the key to early detection and better health-seeking behavior [7].
Te emphasis in this paper is on prostate cancer, as the fourth leading cause of death among men, with an estimated almost 1.4 million new cases and 375,000 deaths worldwide in 2020 ( Figure 1). Prostate cancer has been diagnosed in over one-half of the countries of the world (112 of 185) with an incidence rate 3fold higher in transitioned than in transition countries. Te highest rates are found in Northern and Western Europe, the Caribbean, Australia/New Zealand, Northern America, and Southern Africa (around 83.4 per 100,000 men). Te new observatory and prediction rate until 2040, based on GLO-BOCAN ( Figure 2), is 2,29 million new cases with a small variation in mortality rate (an increase of 1.05%) [8][9][10][11].
In cancer deaths, the Republic of Serbia is an inglorious leader in Europe. In 2020, out of the population of 8.74 million, 49,043 new cases and 28,107 deaths have been recorded. During 2020, Serbia's prostate cancer mortality rate is ranked third and its incidence rate is ranked fourth, according to the Global Cancer Observatory. It is a malignant disease that afects the male population, and if not detected and treated in time, certainly leads to death. Statistics show that only 40% of patients are detected in the curable phase of the disease. What distinguishes prostate cancer from other malignancies is its slow progression, and medical research indicates that the disease can appear as early as the age of 30 but rarely shows the frst signs before the age of 50 (in less than 1%). Most patients develop a clinically detectable form of the disease after the age of 55, and the largest number of patients is in their 60s. It is not known when the disease begins to progress in a person with a clinically nonmanifest (latent) form. Te revolution in prostate cancer discovery and treatment began in the late 1980s and 1990s with the discovery of PSA (prostate-specifc antigen), whose elevated values in the blood most likely indicate the existence and progression of the disease (levels rise with increasing cancer mass) [12][13][14][15][16][17][18][19][20].
Usually, patients are unaware that prostate cancer does not cause any complaints until it reaches the preterminal phase and they are not informed that tumor markers (PSA) can help in the early detection of the disease. Descendants of a person who has prostate cancer are at great risk of getting prostate cancer, but in much earlier years, which is another fact unknown to the male population. [15,17] Tere is no direct evidence that any form of behavior or adequate nutrition can prevent cancer, which is not a popular belief.
Modern health care policies use social marketing strategies to infuence the target group's behavior and promote social welfare activities [21] and in that way, prevent and decrease malignant diseases. As a modern and universal communication tool for infuence on urologic diseases, social media is used [22]. Adequate social marketing implementation can increase patients' awareness and the number of preventive examinations that will result in early detection and treatment of prostate cancer and reduce the overall prostate cancer mortality rate [23]. Adequately provided information from the chosen physician can also lead to a greater number of early-detected prostate cancers [24].
Central issues of health policy are related to the development of healthy lifestyles and strengthening the individual responsibility for behavior and attitudes toward health. Healthy, responsible behavior promotion, along with all measures for the healthcare system's development, contributes to eliminating the consequences of risky behavior and reducing population mortality [25].
Adequate social marketing aims to inform the population about preventive examinations that can detect malignant diseases in the early (curable) phase, as well as inform about the symptoms and signs of the disease that should make the patient visit the doctor. Also, adequate social marketing strategies can indicate healthy habits and patterns of behavior, all with the aim of preventing diseases that are the leading causes of illness and death [26][27][28][29][30].
Te idea for the research came from the fact that the number of prostate cancer patients in Serbia is increasing, the nonexistent screening program, the sporadic publication of newspaper articles in terms of warning and awareness among the male population, and the overall poor informational status of the population. Another reason for the aforementioned research is the presence of other cancers, with the highest mortality rate, and their visibility at a signifcantly higher level, both through screening programs conducted by the Institute for Public Health of Serbia "Dr. Milan Jovanovic Batut," media publication and appearance of the experts in the feld.
Te main goal of the work was to examine the awareness of adult sportsmen from urban areas in the Republic of Serbia about risk factors, diagnosis, and treatment of prostate cancer and further, based on the results, to indicate possible ways to improve this information. In order to obtain this information, two tests for data analysis were applied in the paper:-T-test and ANOVA, all with the aim of checking the set hypotheses. Te aim of the present paper is to raise awareness of prostate cancer risks and symptoms and to explain the importance of sportsmen's involvement in informing the population and their call for testing.

Materials and Methods
Te sample involved 98 respondents, sportsmen from urban regions of Serbia for the period July-September 2019: Novi Sad, Belgrade, and Pančevo, using the data collection method PAPI (Paper and Pencil Interviewing)-face-to-face feld research in the participants' homes. Of the 15 questions, 8 considered sociodemography and their general attitudes and habits regarding health and 7 were for specifc medical conditions. It was created by the authors in collaboration with specialists and experts in the feld of urogenital medicine. With the aim of understanding the details of the prevention of urologic diseases and how well patients are informed and instructed after a urological disease is diagnosed, six urologists from the General Hospital of Pančevo were involved.
In order to get one index of awareness about urologic diseases, a couple of steps were performed.
(1) Each question from the set regarding specifc urologic diseases was recorded depending on what the most accurate answer was (according to urologists). 1 represents that the person is informed, and 0 represents that the person is not informed. Six questions were used in the creation of the awareness index. (2) Te sum score was transformed on a scale of 0 to 1, and the new variable representing the awareness index was obtained.
Te awareness index is used as a dependent variable, while sociodemographic variables and general variables ( Table 1) related to healthcare habits are used as independent variables.
Data were processed in accordance with high standards in order to provide relevant information. Te software used for data analysis was IBM SPSS (Version 26.0, Chicago, IL, USA).
Data analysis was done in two phases, which are as follows: (a) Descriptive statistics and simple percentage distribution of relevant questions (b) T-test and ANOVA analyses for comparing awareness about urological diseases among diferent groups

Results
In accordance with the obtained study, type of representative, and disease, the obtained results are separated into three tables. Te frst following,  treatment, and prevention are chosen doctors, doctor specialists, and the Internet. More than 60% of respondents assess their health as good or great, and the largest number of respondents (53.1%) believe that they are superfcially informed about urologic diseases. Table 3 shows the distributions of respondents related to sportsmen included in the awareness index. Two-thirds of the respondents believe prostate cancer occurs frequently or moderately in men. Te majority of respondents believe prostate cancer occurs among people older than 50 years. Te respondents have divided opinions when it comes to whether prostate cancer has clear symptoms or not. Most of them believe that prostate cancer could be diagnosed and treated and that they themselves should visit doctors preventatively regarding the prostate. People have divided opinions on whether taking supplements for the prostate on time can prevent prostate diseases.
Question 7 from Table 3 shows the distribution of the questions but was not included in the awareness index. A bit more than half of the respondents know what a PSA marker is.
For the sake of better categorization of respondents, we have made a permanent criteria regarding the awareness index score. We have categorized respondents into four groups regarding their awareness index score. Every respondent with a score below 0.4 was defned as "poor awareness," if a score is in the range of 0.41 to 0.60 was defned as "medium awareness," if it is in the range of 0.61 to 0.8, it was defned as "good awareness," and if a score is higher than 0.80, it was defned as "great awareness". Table 4 contains descriptive statistics for every independent variable used in research. Regarding age, the highest score we notice in this group is 51 to 60 years old and the lowest with the youngest (20 to 30 years old). If we compare the average scores of the awareness index regarding the education level of respondents, the highest score is noticed with those who fnished primary school, those who do not visit the doctor, and those who were informed about the disease through TV.

Discussion
Modern health care policies use social marketing strategies to infuence the target group's behavior and promote social welfare activities [27], and in that way, prevent and decrease malignant diseases. As a modern and universal communication tool for infuence on urologic diseases, social media is used [28]. Adequate social marketing implementation can increase patients' awareness and the number of preventive examinations. Te main result will be in early detection and treatment, with a reduced overall prostate cancer mortality rate [29]. Adequately provided information from the chosen physician can also lead to a greater number of early detected prostate cancers [30].
Early diagnosis of prostate cancer and every other type of cancer is refected through a high awareness of cancer. It is strongly emphasized and indicates a certain socially acceptable behavior that supports it. On the other hand, the absence of these patterns and the delay in seeking help are attributed to limiting factors, which include illiteracy, fnancial limitations, superstition, etc. [7].
An efective prostate cancer prevention strategy would provide many benefts to men with a signifcant positive impact on public health. Te mentioned strategy would have great potential to reduce the high risk of developing prostate cancer and the morbidity associated with cancer treatment. It would be particularly efective in newly diagnosed patients with biologically indolent prostate cancer who are still undergoing therapy with curative intent instead of active surveillance and ultimately, the inability to eradicate life-  In that case, lifestyle modifcation can be a very good and highly cost-efective way to slow down the development of the disease [14].
Te high global incidence of prostate cancer indicates the necessity of strengthening existing tools for the identifcation of prostate cancer and the introduction of new prevention strategies to reduce the impact of this disease on public health in the future. A positive trend that played a revolutionary role in the diagnosis of prostate cancer is the identifcation of the PSA biomarker. Since 1980, a double incidence of prostate cancer has been noted in the USA and other countries, especially in the West [14,31,32]. However, PSA was not recommended for the screening program due to the relevant overdiagnosis and the severe side efects of treatments.
According to the study obtained by Mohammed Al-Azri et al. [33], similar results were found compared to the presented work. Te main reasons for the delay in early diagnosis, as well as poor results, are poor awareness of cancer symptoms and misinterpretation of these symptoms. Studies conducted in Oman have shown a low awareness of carcinoma in general, especially of the symptoms of prostate cancer. Te same or very similar fndings were reported in other Arab countries (Saudi Arabia, Egypt, and Jordan). In the main conclusion, it could be seen that in addition to their poor knowledge, the fair attitude of the participants toward prostate cancer examination and screening practices was also demonstrated. Te study also showed that younger participants had more knowledge about prostate cancer. Based on the conducted research, it was seen that the largest amount of knowledge of the participants are based on the knowledge obtained through social media, which is proof that social media is a part of a new trend in public health education. Also, individuals with a higher level of education and income showed greater awareness of PSA testing and reported attending routine annual examinations [34,35].
In addition to the abovementioned observations, the results of a large independent survey conducted in six European countries (France, Germany, Italy, Spain, Sweden, and the UK) and the USA clearly show a lack of awareness about prostate cancer, the PSA test, and early treatment among the general population. Out of the total number of people tested, 39% of men and 28% of women had general awareness of prostate cancer, while 97% of respondents said they had heard of the disease when asked directly. What also turned out to be interesting is that men mentioned breast cancer more often than prostate cancer (46% vs. 39%, respectively). Regarding urinary problems, they recognized them as possible symptoms, but very few understood that the disease can be asymptomatic. Also, respondents who stated that they had prostate cancer or that someone from their close or distant environment had a problem had very low knowledge about the PSA test. Regarding the diference in levels of prostate cancer awareness between the countries in Journal of Environmental and Public Health the survey, almost twice the diference in the level of spontaneous awareness was observed between men living in Germany and those living in France (54% vs. 29%, respectively). In Great Britain, men and women were equally informed, while in other countries, men were more informed than women. In the end, it can be concluded that the awareness of prostate cancer and the PSA test was almost 3 times higher between the USA and Germany (48% vs. 17%, respectively), as well as between the USA and all six mentioned European countries [36]. Te theme of this paper is about awareness and symptoms of prostate cancer among sportsmen, and supporting the data, there is scientifc evidence that confrms the claim that women are more concerned about family health. Te conducted study indicated faster and better reactions in women in the following aspects of cancer, recognition of early manifestations of various cancers, timely detection of obstacles to seeking help, and timely reporting of perceived obstacles. Women with a higher level of education were ready to face breast and cervical cancer and thus take control of their health. Also, women showed a deep interest in the health of their partners and noticed changes that men themselves did not see in themselves. Tey have also been proven to play a key role in making decisions in the treatment of their spouse or partner diagnosed with prostate cancer, as well as in screening. However, few studies have been conducted on women's knowledge of prostate cancer, and it is necessary to map the evidence to establish their knowledge as a public health tool to reduce the disease [37][38][39][40][41][42].
One of the most recent reports about the involvement of sportsmen in prostate cancer awareness [43] was from the UK charity, Prostate Cancer UK, which provides diferent types of supports for example, for men, funds research, and lobbies for drug availability, as well as many other things. Te charity has done great work by implementing public fgures to talk openly about their health problems from the beginning of prostate cancer detection throughout the whole healthcare journey. Many of them publicized their diagnosis and persuaded other men to get themselves tested by telling their personal stories. Teir involvement and talk had an extremely high impact on public awareness and its raising [43].
Common to all these studies is the need to see the level of information about prostate cancer in terms of its frequency, symptoms, prevention, treatment, and PCA test. A study conducted on 98 athletes confrmed the basic knowledge of the term and indicated that the majority of respondents believe that prostate cancer occurs in people over 50 years old (69.4%). What is worrying is that only a third of respondents are aware that prostate cancer does not always give clear symptoms (33.7%) and that almost half of respondents have never heard of the PCA test (46.9%).
On the other hand, the vast majority are aware that prostate cancer can be diagnosed and treated (86.7%), as well as the positive efect of preventive visits to the doctor (87.8%).
In our study, the majority of men had adequate knowledge about prostate cancer in terms of whether prostate cancer be diagnosed and treated with 86.7% and have the similar value compared with other studies of 82.1% and 64%, respectively [44,45]. A similar fnding has also been observed in another study conducted in Jamaica, with 96% of men correctly responding to questions about prostate cancer [46]. By contrast, in comparison with other studies from diferent countries, this rate was better than that which has been reported in South Africa (45.7%) among men attending a urologic outpatient clinic [47] and in Uganda (54.1%) [48]. Regarding knowledge of the PSA test, we found that 53.1% had heard of it before, compared to 72.7% and 41.8% [44,45]. Tis value is a little bit higher than a survey conducted in Uganda in 2013 reported 52.1% [48]. Amongst the risk factors for developing prostate cancer are being over the age of 50. 69.4% compared to 65.9% [44] of the respondents correctly identifed age >50 years.
Te major sources of information about the urinary diseases were physicians, the Internet and television, compared to reference [44]. where the major sources of information about the PSA test were physicians, television/  Journal of Environmental and Public Health newspapers, and family. Men who had received information from a physician were more likely to know about and take up a PSA test [44]. For example, Carrasco-Garrido et al. [49] found that men who had received information from healthcare workers had a higher probability to know about and to receive a PSA test. Also, in another study conducted in the United States of America, the most frequent sources of information were physicians (86%) and mass media (62%). By contrast, in reference [48], only 12.3% of respondents reported that physicians informed them about screening for prostate cancer.
If we look at the descriptive statistics in relation to information about school education and the way from where they got some information, we can see the highest score is noticed with those who fnished primary school, those who do not visit doctors, and those who get information about disease on TV. Te conducted study based on specially prepared questionnaires indicates that there is no excessive diference in the awareness of sportsmen in the Republic of Serbia in relation to the population in the world.
Also, a shortcoming was seen in terms of the lack of studies that examined the awareness of athletes about prostate cancer. As shown, the athletes were mentioned only through the media, in the form of various newspaper articles and in associations in the framework of the fght against prostate cancer, as well as in personal stories.
With regard to this research and its fndings, as well as other mentioned studies, which were done with the aim of discovering the level of awareness, a campaign to promote urological diseases in the Republic of Serbia is suggested. Te aim of the campaign would be to raise awareness of urological diseases and to improve the general health of the target population in the Republic of Serbia by using eHealth services, e.g. mobile and web apps. Te campaign goal is to decrease the number of urological diseases in the country, and its impact is refected in the greater understanding of the importance of urological diseases and prostate cancer prevention. It is of paramount importance to state that the campaign should be at the national level. As a result, the campaign would get full media coverage and would become one of the most important strategies. In Serbia, there are the Nation Youth Strategy, the National Cervical Cancer Prevention Program, the National Breast Cancer Early Detection Program, as well as the recently adopted National Program for Safeguarding and Improving Sexual and Reproductive Health. Starting a campaign might contribute to people's being better and more efciently informed about urinary diseases.
More specifcally, by reviewing the literature and talking to athletes, it was seen that athletes and their popularity among the public could be of crucial importance for raising awareness about urogenital diseases, especially with an emphasis on prostate cancer. As we have already mentioned, sportsmen in the Republic of Serbia have not shown an enviable level of information and awareness about prostate cancer. Terefore, we propose the following steps to improve the current situation: (1) Post hashtags on social media (as they are one of the best ways to draw attention to important issues: Facebook, Twitter, Instagram, Snapchat, YouTube, TikTok, etc.) (2) Spread awareness in the workplace (print and distribute guides throughout the place of work to provide colleagues with information on prostate cancer) (3) Attend events (many events are going virtual; a man may also be able to fnd one that he can join online from the comfort of his own home) (4) Sportsmen can wear shirts with messages that mention prostate cancer (5) Get a prostate cancer screening (one of the best ways men can show support in September-and beyond. It is a great way to take care of your own health while also inspiring other people with prostate problems to do the same.) (6) Te takeaway (Raising awareness for prostate cancer is one of the best ways to help people learn about signs, symptoms, and preventive screening. It also helps build communities and foster connections.).
Also, the month of September is the month of fghting and raising awareness about prostate cancer. Te very importance of timely prevention and the problem it creates (number of new cases, mortality, reduced awareness) can be concluded by looking at the announcement of the White House on August 31, 2022, "A Proclamation on National Prostate Cancer Awareness Month, 2022".
Te limitations of the study, in this case, are the relatively small number of respondents, which is further reduced when the number is divided within that division into age subgroups and subgroups with regard to educational status. Te results obtained in this way represent the beginning of future studies and open the door to research, and on the other hand, the results indicate a lack of knowledge and awareness about prostate cancer. Certainly, in this particular case, they cannot be generalized to the entire adult, urban population since they do not include the other regions of adult population (all big cities, villages, and other country regions); so, a large national study should be done. Also, one of the limitations of the study is the absence of some other factors that could afect the level of information about the considered diseases, e.g., property status, the presence of these diseases in the respondents themselves or their relatives, etc.

Conclusion
Despite advances in care and the main health priority of stopping cancer, prostate cancer is the most commonly diagnosed cancer in over 50% of countries (112/185), with more than 1.4 million new cases and 375,000 deaths in 2020 alone. Te study conducted, as well as public material available through scientifc publications, indicates that there is a clear need to improve the basic concepts and general knowledge of both athletes and the general public about the practice of prostate cancer screening. Te prostate cancer screening program in the Republic of Serbia does not exist and therefore does not represent an obligation; patients voluntarily go for examinations, which, with this level of general information and awareness, turned out to be very Journal of Environmental and Public Health bad. Also, an acceptable level of recognition of risk factors for prostate cancer was indicated, but their recognition of symptoms was below the acceptable limit. Te study showed that increasing the awareness of the population, athletes in our case and men globally, is crucial and in this case, is connected with a higher level of education. In accordance with the abovementioned statements, the key next steps in the continuation of surveillance would imply the necessity for doctors to engage more and talk more with their patients in order to provide them with as detailed and accurate information as possible and then refer them to specifc examinations and problem-solving. Considering the shortcoming of the study in the number of respondents, in order to confrm the above data, it is necessary to conduct a larger study at the national level. It can also be concluded that the participants used social media the most as a source of information about prostate cancer, and the evidence showed that social media is a powerful tool for increasing community awareness about cancer prevention, screening, and treatment in real life and time. As a unifed result of the study, it can be said that it is necessary to conduct more campaigns to raise awareness in the community by including public fgures with an apostrophe to professional athletes, role models of the nation, but also famous doctors (urologists), who will indicate problems, symptoms, and methods of diagnosis and treatment. Tis connection should be established through guest appearances on television shows, followed by the distribution of information leafets aimed at men and women in certain settings, such as waiting rooms in health centers and urology clinics in hospitals.

Data Availability
Te data used to support the fndings of this study are included within the article.

Conflicts of Interest
Te authors declare that they have no conficts of interest.