To Determine The Level Of Knowledge Regarding Breast Cancer And To Increase Awareness About Breast Cancer Screening Practices Among A Group Of Women In A Tertiary Care Hospital In Mumbai, India
S Ahuja, N Chakrabarti
breast cancer knowledge, breast cancer screening practices, mumbai
S Ahuja, N Chakrabarti. To Determine The Level Of Knowledge Regarding Breast Cancer And To Increase Awareness About Breast Cancer Screening Practices Among A Group Of Women In A Tertiary Care Hospital In Mumbai, India. The Internet Journal of Public Health. 2009 Volume 1 Number 1.
The most prevalent cancer in the world is that of the breast being responsible for 10.4% of the global burden
Moreover, upon studying the trends of the major prevalent cancers through the years 1982 to 2002 during various population based cancer registries, it was observed that the incidence of breast cancer was steadily increasing among Indian women and continues to be on the rise
These figures appear to be consistent with the economic and social changes occurring in India with increasing number of women marrying late, thus having children at an older age, and low parity in general
Therefore, with the overall risk of an Indian woman’s chances of acquiring breast cancer being increased several fold it is imperative that we come to terms with the reality of a substantive presence of this modern epidemic.
Even though India’s National Cancer Control Programme, established in the year 1975-76, has contributed enormously to the development of various Regional Cancer Control Centers and Oncology wings in medical colleges in many metropolitan cities, there does not as yet exist a standardized and acceptable prevention strategy for breast cancer for the entire nation. Likewise, despite the fact that a range of awareness programmes have been undertaken in some cities, there is lack of a uniform information, education and communication (IEC) policy for cancer prevention in general
Whereas certain types of cancers are contracted as a result of the recipients’ voluntary acts or personal behaviour such as smoking which can cause lung cancer and unprotected sex which is a factor implicated in acquiring cervical cancer, the aetiopathogenesis of breast cancer involves multiple factors, some of which a woman may have absolutely no control over. This makes it an even more traumatic disease for a woman and her family and puts a far greater deal of responsibility in the hands of health care providers to make available appropriate information about breast cancer and its various risk factors, early warning signs and their management among women.
Increasing awareness about breast cancer would go a long way in the cure of this disease, since breast cancer is a progressive disease having a predilection of early dissemination and consequently detection of small tumors are more likely to be early stage disease, which would have a better prognosis and higher probability of getting effectively treated.
Women, in general, and especially those over the age of 35 years are required to be more educated about the many available screening modalities for breast cancer and also need to be encouraged to adopt these measures as efficiently as they can.
Screening for breast cancer includes mammography, clinical breast examination by a physician (CBE), and breast self examination (BSE). Although mammography has been established as an effective technique for early detection of breast pathologies, mammographic screening of an outsized population cannot be supported as a priority in India owing to its high cost.
Breast self examination (BSE) on the other hand is simple, self generated, repeatable at monthly intervals and cost free. BSE involves regular monthly systematic examination of the breasts and axillary area, both visually and by palpation, for any signs of abnormality. It has been observed that how a woman learns about BSE can determine the frequency with which she performs it, and therefore it is important for every woman to adopt the correct method of performing BSE as demonstrated by a nurse or physician.
This technique will enable a woman to familiarize herself with the structure of her own breasts so that she may readily recognize any deviation in the way they look or feel. Nonetheless, conformity to the regular practice of BSE requires constant motivation and the recognition that breast cancer is a potential hazard. It is therefore important for us to first gauge the level of knowledge regarding breast cancer among the women in our study sample and more importantly, to empower them with the correct information and demonstrate the correct method of performing BSE. It is with this intention of gauging the awareness of an average Indian woman regarding breast cancer and the importance gives to its early detection practices (BSE) that this study was designed.
Review of Literature
A lot of research has been carried which aims to explore the knowledge about breast cancer and the attitudes and beliefs regarding its screening practice among women in different parts of the world. To make our review of literature more focused we have documented studies beginning with studies conducted in the western world and then moving on to those carried out in Middle Eastern and South East Asian countries.
Friedman, Nelson et al
Mc Donald, Thorne and co workers
With education programs being developed to promote adherence to recommended breast cancer screening guidelines in the United States, Sadler GR et al
In another study on breast cancer detection practices of 57 South Asian women aged 40 years and over, residing in Toronto, Canada, Chaudhury and Srivasatava
European studies revealed a relatively different picture. Stephanie Kung et al
In another study of breast self examination attitudes and practices, Wardle et al
A research article by Pinar Erbay
Another Turkish study led by Yaren, Ozkilinic et al
In Puerto Rico’s first national study of breast cancer knowledge, beliefs, and early detection practices among elderly women (65 and above) Sanchez, Suarez et al
Bener, Alvash, Miller and Denic
In the July 2002 issue of the Saudi Medical Journal, Alam AA
Jahan, Al Saigul and Abelgadir
Later in July 2002 Jarvandi S and coworkers
At the Iranian Centre for Breast Cancer, Tehran another cross sectional study was conducted, this time by Haji Mahmoodi
Yavari et al
In the August 2002 issue of the Cancer Nursing Journal, Madanat H and Merrill RM
In another Jordanian cross sectional descriptive study Petro Nustus and Mikhail BI
Shepherd JH and McInerney PA
With breast cancer being the most common cancer among women in Nigeria, even more common than cancer of the cervix, O Abimbola and Oladimeji Oladepo
Therefore many studies have been conducted the world over which are centered around the understanding of breast cancer awareness levels and the adherence to recommended screening methods for its early detection in different groups of women and we have attempted at highlighting a few such studies that we felt were comparable with ours.
Aims and Objectives
To determine the level of awareness regarding breast cancer in the study population.
To assess the level of awareness about BSE (breast self examination) and its performance among women included in the study.
To demonstrate individually to each woman included in the study, the correct method of performing BSE.
Materials and Methods
This cross sectional study was conducted over a period of two months from 1st August to 30th September 2009 at the K.J.Somaiya Medical College and Research Centre, Ayurvihar, Sion, Mumbai. The total study population consisted of 80 women between the ages of 40 and 65 years (mean age 48.3 years) who visited the K.J.Somaiya hospital’s surgical outpatient department (but not necessarily with a breast complaint). Since advancement in age is a definite risk factor for breast cancer, women younger than 40 years were excluded from this study. All 80 women were married and 79 of them had children. 60% of all women were housewives and 38.8% were illiterate. Only 25% of women had total family earnings amounting to over Rs.30,000/- per month.
Data were collected by means of a structured questionnaire devised by the authors themselves. Besides English, the questionnaire was also available in Hindi and Marathi. Willingness to participate in the study was obtained by means of a written informed consent (in the participants mother tongue) after being explained the objectives of the study. The participants were requested to fill out the questionnaire whilst face to face with the authors of the study so as to clarify any doubts that they may have. The questionnaire sought demographic information, including participants’ age, marital status, parental status, education, occupation and monthly family income. We also enquired into their age at menarche, age at menopause (if applicable), whether they had breast fed their child/children or not and whether they visited their family physician or gyneacologist on a regular basis. The last question was aimed at assessing participants’ health seeking behaviour. The questionnaire was subdivided (so as not to make it a lengthy and repetitive one) and was to be answered in yes or no format. The questionnaire aimed to measure the knowledge about breast cancer in general, its risk and protective factors and its symptoms. In addition participants were asked whether they knew about Breast Self Examination (BSE) and the frequency with which they performed it. Reasons for non performance were enquired into as well. In order to measure the attitude towards BSE, 4 statements were used (read results) which were designed by the investigators in accordance to the needs of this study. The knowledge score was computed by totaling the number of correct answers for all questions. Upon completion of the questionnaire an interactive session followed where the investigators of the study demonstrated the correct method of BSE performance in both upright and supine positions. Additionally a figurative hand out was distributed to each woman with the intention to reinforce what had been taught. This education was provided to each woman in the privacy of the side room of the surgical OPD, with a nurse standing by.
The main hypothesis was that level of awareness about breast cancer differs by age, literacy level, income and occupation. We also hypothesized that BSE knowledge and performance in this group of women would be inadequate.
The data were analyzed by descriptive studies, chi square test and analysis of variance in order to find out the P value and appropriate conclusions were drawn based on the above analysis.
Observations and Results
80 women (between the ages of 40 and 65 years) were interviewed by means of a questionnaire. Their average age was found to be 48.3125 years.
All 80 women were married and all except one had children ranging between 0 to 7 in number. This was a group of women of high parity with average number of children being 3.5. Out of 79 women that had children, 77 of them (96.3%) had breast fed them.
Socio-demographic and other data relevant to this study is presented in the form of various charts and graphs as under.
Only a third of all women knew of the association of genetics with breast cancer. Most women agreed that age (i.e. older women) was a significant risk factor in breast cancer. We asked women whether they felt that trauma, infection, or stress could lead to breast cancer in order to become aware of any lay beliefs that they may have. Whilst almost all women did not believe that trauma or infection causes breast cancer, a very large proportion of women (over 83%) believed that stress could possibly lead to breast cancer. This was in fact, a response we received from a large proportion of educated women belonging to high income groups.
A} It is important for me to examine my breasts regularly
B} Every woman should perform BSE monthly
C} Discovering lumps early would increase my chances of survival if I had Breast cancer
D} I think that doctors should advise their patients to perform BSE.
73 out of 80 women agreed with all of the above statements.
We have divided participants into three groups as having low, moderate or high level of awareness on the basis of how many points they scored out of 29.
Overall awareness was found to be 52%.
= Summation fx/ N
= 1208/ 80
Therefore Total Awareness = 15.1/29*100
Limited data exists which serves to identify awareness levels among the average Indian woman as regards breast cancer.
Although 95% of the women included in this study reported having heard about breast cancer, our study revealed that on an average, awareness levels among these women was 52% (table 11). We further went on to categorize women into groups as having low, moderate and high level of awareness. Even though overall awareness was found to be moderate our study reported that a substantial proportion of women (38.5%) had relatively high level of awareness. This was something we had hypothesized at the very start, considering our study was based in a private charitable hospital in an urban city.
Since most women included in our study, i.e.60% were under educated housewives (table 1), it was not unusual to find their most important source of information (about breast cancer) to be family and friends (table 4). TV and radio is also a facility which is readily available to them, which ranked as the second most important source of information (table 4). This finding clearly indicates the advocacy of mass media in spreading awareness. An unanticipated finding however was that doctors were a relatively poor source of information accounting for only 12% of the group (table 4). This is a significant finding since being an urban city where health care facility is available readily and widely, doctors in Mumbai are falling short of providing basic timely information to their patients about breast cancer and its screening, especially to those women who need it the most, since it is a well known fact that urban women have a much higher likelihood of acquiring this disease as opposed to women hailing from a rural background.
As shown clearly in our results, not very many women (only about a third) knew of the association of genetics with breast cancer (table 5). Most women that did know of this association were educated, working women. It is critical that all women recognize this association so that screening decisions can be individualized in them taking into account the potential benefits and limitations of each screening modality in context of their health condition. As expected, most women did not believe that trauma and infection could cause breast cancer (table5). It was noteworthy however that a sizeable proportion of women, including educated women from higher socio-economic background felt that stress was a definite risk factor for breast cancer (table 5). This was a unanimous response we received even from teachers. Another interesting finding in our study was that almost three quarters of all women felt that smoking was a risk factor for breast cancer (table 6). This probably means that they linked the carcinogenic effects of smoking to multiple types of cancer and could not differentiate all risk factors specific to breast cancer. We also noted that not enough women knew that radiation (in terms of radiotherapy for treatment of cancer as well as that used for diagnostic procedures) was a significant risk factor for breast cancer (table 6). This information needs to be disseminated widely so that the general public may become aware of the ill effects of radiation.
It was interesting for us to note that 85% of all women could recognize that regular BSE( breast self examination) was a protective factor against breast cancer(table 7), since our study was designed not only to assess the awareness levels amongst this group of women, but in addition, also to advocate BSE as an effective screening method. On the other hand not as many women (64%) acknowledged the beneficial effects of a mammography as an early detection method (table 7). This could be due in part to the fact that this screening modality was beyond the reach of a lot of the women since a significant amount of them were economically disadvantaged. Only one woman knew that early menarche and late menopause were risk factors for breast cancer (table 8). A Turkish study too initiated by Yaren et al (
Our study found that younger women had greater awareness about breast cancer in general as compared to older women (table 12). Older women were probably of the opinion that having led a disease free life so far, they were unlikely to get the disease now, and were therefore complacent and perhaps disinterested in acquiring information about breast cancer. This could also be due to inadequate perception in this group of women. This finding was similarly seen in two Jordanian studies, one conducted by Petro-Nustus et al (
In our study, women belonging of higher income group were more aware than those who were economically deprived (table 13). They scored a total of 20 points out of 29 whereas women of low income group had a total score of only 11.9. A Puerto Rican study too conducted by Sanchez Ayender et al (
Well educated women were evidently more aware than those who were less educated and illiterate. Graduates and Post Graduates scored over 19 points while illiterate women scored only 10.26 and primary school educated women scored 14.43 points in our study (table 14). Alam AA (
In our study business women, teachers and women working in the service sector seemed to be more empowered with knowledge about breast cancer in general as compared to home makers and those working as domestic help (table 17). Farmers who comprised 10% of women in the study group, were found to be least aware. Women working outside their homes were more exposed to information and more receptive to knowing about screening procedures. Madanat H et al (
Women who regularly visited a family physician or a gynaecologist were subsequently found to be more aware than those that did not (table 15). This obviously shows that women who considered health a priority were more aware about breast cancer and probably more receptive therefore to its screening methods. Enlightened women, especially in urban areas should therefore be given the right knowledge so that they may spread it to others in their community and should be motivated to practice BSE.
We also noted that women who had more than 4 children (who also happened to be poorer and less educated) were less aware than women who had fewer than 3 children (table 16). Women who had more number of children and who were poorer in general obviously had limited time for themselves and were more consumed with their day to day family life and therefore tended to neglect their own health. Owing to the larger size of their family too, they were probably unable to find privacy for themselves to be able to perform a self- examination. It is important for us to recognize these practical problems that they may face in their everyday lives so that when we advocate BSE to them we can take them into account and yet find a way to convince them of its importance. Parity was not a demographic variable studied as a deciding factor for awareness by any other study reviewed by us.
A personal history of breast cancer was a factor studied by many researchers in various studies all over the world. However, we did not enquire into a personal history of breast cancer among women included in our study. Madanat H (
75% of all women were able to recognize at least 3 symptoms of breast cancer correctly (table 9).The symptom which was least commonly recognized was discharge of blood from the nipple. This was an important element of our study since recognition of symptoms would decide whether a woman would seek timely medical help. Also in our study we had set out to (additionally) disseminate information about BSE, the success of which requires the recognition that breast cancer is a potential hazard.
Whereas Freidman, Nelson et al (
Our study reported the most frequently endorsed reason for non- performance as not knowing how to perform BSE. Women lacked confidence in their ability to perform BSE and therefore we felt that it was important for us to obviate their fears by demonstrating the correct method of BSE performance by means of a personal instruction .Jarvandi S of Tehran, (
A large proportion of women,(over 90%) had a positive attitude towards BSE and were convinced of its value for early diagnosis of breast cancer. This was a gratifying response since our objective was to disseminate information about BSE and their positive attitude reflects their receptiveness towards learning.
Breast cancer awareness was found to be moderate in our study (52%) which substantiates the fact that it is imperative to educate the middle aged average Indian woman about this disease. Knowing facts about breast cancer will help us move together to reach the common goal- prevention. Knowledge must be spread via mass media since this avenue is available to a large number of people and was stated as an important source of information by women included in our study. The role of physicians and gyneacologists were mentioned as a source of information by only 12% of women, which highlights the inadequacy of doctors in providing appropriate, timely information to patients. This study has allowed us to understand which risk and protective factors women were able to identify easily and those that were missed. BSE knowledge was found to be inadequate (62%) and its regular performance low (15%).Most commonly stated reason for non performance was found to be not knowing its correct method. The study group presented with a positive attitude towards BSE. Therefore this group of women should be taught the correct method of performance of BSE and their awareness about breast cancer should be increased.
Breast cancer is a highly feared disease. Not only is it a major cause of cancer death among women in India, but it often strikes women in their prime years long before a disease of such severity is expected. A critical element in the fight against breast cancer is education. Spreading awareness and the knowledge of screening heralds a welcome shift from reactive medicine to a more proactive approach to health care, in which information about risk factors would help the patient take measures to reduce those risks. Of the three established means of screening namely, Clinical Breast Examination by a physician (CBE), Mammography and Breast Self Examination (BSE), BSE seems to be more practicable in an Indian setting. Whereas mammography has been clearly established as an effective method for early detection, mammographic screening of a large population would prove too expensive and cannot be supported as a priority in India. BSE on the other hand would only impose a small cost for a formal education training initially and no cost thereafter. We therefore strongly recommend BSE as an effective and appropriate screening measure. Women who regularly perform BSE may be more likely to comply with other breast cancer screening guidelines. BSE has been strongly advocated by breast cancer experts such as Haagensen who stated that, “From the point of view of the greatest possible gain in early diagnosis, teaching women how to examine their own breasts is more important than teaching the technique of breast examination to a physician”.
Since maximum women included in our study gave ‘not knowing the correct method of performing’ as a reason for non performance, it is important that we provide this education to them. It is well known that women are more likely to adhere to regular BSE performance if they receive personal instruction from a nurse or physician, therefore this education needs to be disseminated effectively to the general public by means of enhanced programs.