|Year : 2016 | Volume
| Issue : 2 | Page : 226-229
Knowledge, attitude and practice about breast cancer and breast self-examination among women seeking out-patient care in a teaching hospital in central India
Rao Siddharth, D Gupta, R Narang, P Singh
Department of Surgery, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra, India
|Date of Web Publication||6-Jan-2017|
Department of Surgery, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Breast cancer (BC) continues to be a major cause of morbidity and mortality throughout the world. Early detection of BC and early treatment increases the chance of survival. According to Breast Health Global Initiative guidelines for low and middle income countries, diagnosing BCs early by promoting breast self-awareness; clinical breast examination (CBE) and resource adapted mammographic screening will reduce BC mortality. There is a paucity of data on the knowledge and awareness of BC and self-breast examination in India. We designed this hospital based cross sectional descriptive study to evaluate the current status of knowledge, awareness and practices related to BC and breast self-examination in the female rural population attending a teaching hospital. Materials and Methods: We did a random sampling to identify and enroll 360 women and their female relatives. We excluded a participant from the study if she had already undergone a screening mammography or had had a BC. The data was collected by a self-administered questionnaire in vernacular language. Results: Our study population included 360 women with a mean age of 45.81 (±10.9) years. Only 5 (1.38%) females had a family history of BC. A whopping 81% of women did not have any knowledge about BC. All the women thought that CBE by doctors was the only way for screening BC. Conclusions: We concluded that with the results of this study, it is imperative to increase awareness about BC and its detection methods in the community through health education campaigns. We should have major policy changes to increase future screening programs and health education programs which would have an overall positive impact on reducing the disease burden.
Keywords: Breast cancer, early detection, self-breast examination
|How to cite this article:|
Siddharth R, Gupta D, Narang R, Singh P. Knowledge, attitude and practice about breast cancer and breast self-examination among women seeking out-patient care in a teaching hospital in central India. Indian J Cancer 2016;53:226-9
|How to cite this URL:|
Siddharth R, Gupta D, Narang R, Singh P. Knowledge, attitude and practice about breast cancer and breast self-examination among women seeking out-patient care in a teaching hospital in central India. Indian J Cancer [serial online] 2016 [cited 2021 Aug 5];53:226-9. Available from: https://www.indianjcancer.com/text.asp?2016/53/2/226/197710
| » Introduction|| |
Breast cancer (BC) continues to be a major cause of morbidity and mortality throughout the world. BC is the most common cancer comprising 18% of all female cancers and with over 1 million newly diagnosed cases annually across the globe. Incidence of BC in India varies from 7.2 to 33.4/100,000 (annual age adjusted rate). BC accounts for about one-fourth of all cancers in Indian women and about half of all cancer-related deaths. Only a lesser than 8% are detected in Stage 1 and 23-58% in Stage 2 and 3. 5 year survival rates are 90% in Stage 1 and only 22% in Stage 4. Early breast cancer constitutes only 30% of the BC cases seen at different cancer centers in India, whereas it constitutes 60-70% of cases in the developed world. It is not surprising that the majority of BC patients in India are treated at locally advanced or metastatic stage. In India the incidence/mortality ratio is 0.48 compared with 0.25 in North America. Late diagnosis is attributed to lack of awareness and non-existent BC screening programs in India.
Early detection of BC and early treatment increases the chance of survival. Breast self-examination (BSE), clinical breast examination (CBE), Mammography are different methods for screening of EBC. Of the three modalities of BC screening – BSE, CBE and mammography – BSE fulfills the first two criteria, but early results of two randomized trials conducted in Russia and China suggest that it would not be effective in reducing mortality from BC. CBE is also relatively simple and inexpensive, but its effectiveness in reducing mortality from BC has not been directly tested in a randomized trial. The American cancer society (ACS) recommends CBE and mammography in early detection of BC. According to ACS recommendations women should start BSE in her early 20's, should know the normal feel of her breasts and promptly report any changes to her health-care providers. But ACS does not advocate BSE as one of the tools, which increase survival rates in BC., According to Breast Health Global Initiative guidelines for low and middle income countries, diagnosing BCs early by promoting breast self-awareness; CBE and resource adapted mammographic screening will reduce BC mortality. In theory 95% of survival rate can be achieved by early detection of BC. It has been observed that women can detect 95% of BCs and 65% of early minimal BCs by themselves. It was estimated that BSE may reduce the mortality by as much as 18% and that this figure may increase with women who are particularly competent. Though theoretically BSE remains the tool for abating mortality with BC in low and middle income countries; in real life its application is low. Studies conducted among different groups of women in United States, showed that monthly BSE rates ranged from 29%-63%.
There is a dearth of large scale breast screening programs in India. BSE is advocated, but data on what proportion exercised is not available. Nearly all Indian BCs are clinically detected; almost none are detected by screening. There is a paucity of data on the knowledge and awareness of BC and breast self examination (BSE) in India. We designed this hospital based study to evaluate the current status of knowledge, awareness and practices related to BC and BSE in the female rural population attending a teaching hospital. We also wanted to explore if any associations exists between demographic variables, knowledge of BC and the practice of BSE.
| » Materials and Methods|| |
We did this study in the out-patient department (OPD) of a 780-bed teaching hospital located in central India.
We obtained approval from the institutional ethics board for conducting this study. We also took an informed consent form all study patients.
We did a cross-sectional descriptive study among consecutive women and their female relatives attending the OPD of our hospital. All patients, seeking out-patient care in our hospital are electronically registered in the registration OPD and are asked to visit a general OPD, managed by the Community Medicine department. The interns, supervised by faculty triage these patients to the different departments of the hospital, based on their initial history and key physical examination findings. We did a random sampling to identify and enroll 360 women and their female relatives. We took their informed consent for collecting this information and ensured that their privacy, confidentiality and rights are respected. We excluded a participant from the study if she had already undergone a screening mammography or had a BC.
The data was collected by a self-administered questionnaire in vernacular language. The questionnaire was adapted from Champion's Health belief model for BC after due permission. The questionnaire was translated into vernacular language from English and then was back-translated and piloted. The structured questionnaire had three parts: Part one, for demographic information such as age, place of residence, monthly income of the family, academic level, age of menarche, marital status, parity and lactation history, menarche- first child interval, exposure to tobacco and other addiction, family history of BC and; Part two, regarding awareness of BC which includes questions concerning knowledge and attitude – if the participant has heard of BC, source from which they have heard about BC, symptoms of BC, risk factors and methods of detection (SBE and screening mammography). Part three of the questionnaire was regarding BSE which includes questions on the awareness of BSE, whether the participant had ever done BSE, frequency and few questions on how to do BSE. The questionnaire was distributed by study investigator to all the participants. Each correct answer was assigned one mark whereas incorrect answer and non-response was given zero.
We transferred the paper based data into Microsoft excel. We described continuous variables by mean and standard deviation if they are normally distributed and by medians and interquartile range if they are skewed. We used the Students t-test to compare means, Chi-square test to compare proportions and a log rank test to compare medians. We described the precision of estimates by 95% confidence intervals. P < 0.05 was considered statistically significant. Data was analyzed using Stata software (version 11, Stata Corporation, Texas, USA).
| » Observation and Results|| |
Our study population included 360 women with a mean age of 45.81 (±10.9) years. About 31% of women had not received any formal education and another 21% were educated only until primary level. All women were married and their mean ages of menarche were 13.83 (±1.05) years and were in their second decade at the time of birth of their first child (19.29 ± 3.84 years). Most of the women (92%) had breast fed their children and had no addictions (95%). Only 5 (1.38%) females had a family history of BC [Table 1] and [Table 2].
A whopping 81% of women did not have any knowledge about BC. Remaining 68 participants had heard or had some knowledge of BC either from friends and relatives (16.94%) or television and radio (0.56%) or from doctors (0.56%). All the women thought that CBE by doctors was the only way for screening BC. It was seen that the proportion of women who were aware increased as the literacy status increased and this was statistically significant (P > 0.005). Similarly, those who belonged to higher socio-economic status (SES) were more aware about BC as compared to those belonging to a lower SES and this difference was also statistically significant [Table 3].
It was but a surprising revelation that none of the study participants had knowledge about BSE or had previously done BSE.
| » Discussion|| |
From our study, we found that more than three fourths of the study population (81.11%) was unaware about BC. Those who were aware were more educated and belonged to higher socioeconomic strata. None of the study participants had any knowledge about BSE or were performing BSE. All the women in the study thought that BC could only be detected by CBE by doctors. Somdatta and Baridalyne  found that only half of the study population was aware of BC and the awareness increased with increasing literacy and increasing SES. This was comparable to our study. It has been shown that women of low SES have a low incidence of BC compared to women of higher SES, but they experience a higher mortality rate, due to higher late stage diagnosis.
The same study also highlighted that half of their study population also thought that BC can only be detected by clinical examination by doctors. Only 11% women were aware of BSE and only two of them have ever done BSE. However, none of them do it on a regular basis. Barriers identified that contribute to low screening rates for BC among underserved women suggest that there are both personal and health-care factors that influence participation in screening. Personal barriers include lack of awareness or knowledge about cancer screening, embarrassment in participating in actual screening procedures, low trust in prevention and fear of cancer. Additional personal barriers that prevent underserved women from participating in screening include procrastination, social and cultural beliefs and perceptions of discrimination in the health care system.
Knowledge and awareness of early detection measures of BC such as BSE is nonexistent., It is established and recommended that screening by mammography substantially reduces mortality from BC, especially in women over the age of 50 years. However, this technique is expensive and is not available easily and hence is difficult to implement in India where resources are constraint. A cohort study in Finland and a case-control study in Canada  suggested BSE to be beneficial (reduction in BC mortality) at all ages. Recently, there is a debate on the role of regular self-examination of the breast in preventing BC mortality. However, the teaching of BSE can help women to be alert to any abnormal changes in their breasts and seek medical advice immediately. Positive health-care behavior can go a long way in increasing health awareness amongst the population and also health seeking behavior.,,
We acknowledge certain limitations of this study. We do not have information about women who refused to participate in the study or who were not available at the time of study. If the women who were not included in the study were different from those who were interviewed in some characteristics like age, the results of the study may have been different.
| » Conclusion|| |
This study has shown that among women attending our hospital the knowledge about BC, its signs and symptoms or detection procedures is very poor. BC is one of the leading causes of death globally. BSE helps detect BC at an early stage and decreases both morbidity and mortality. The data on awareness and practice of BSE in India is sparse. It is imperative to increase the awareness about BC and its detection methods in the community through health education campaigns. Educating health-care workers and nurses to impart training about BSE is also crucially important in this regard. We should have major policy changes to increase future screening programs and health education programs, which would have an overall positive impact on reducing the disease burden.
| » References|| |
Stuckey A. Breast cancer: epidemiology and risk factors. Clin Obstet Gynecol 2011;54:96-102.
Leong SP, Shen ZZ, Liu TJ, Agarwal G, Tajima T, Paik NS, et al
. Is breast cancer the same disease in Asian and Western countries? World J Surg 2010;34:2308-24.
Somdatta P, Baridalyne N. Awareness of breast cancer in women of an urban resettlement colony. Indian J Cancer 2008;45:149-53.
Sadler GR, Dhanjal SK, Shah NB, Shah RB, Ko C, Anghel M, et al
. Asian Indian women: Knowledge, attitudes and behaviors toward breast cancer early detection. Public Health Nurs 2001;18:357-63.
Mittra I, Baum M, Thornton H, Houghton J. Is clinical breast examination an acceptable alternative to mammographic screening? BMJ 2000;321:1071-3.
Tang TS, Solomon LJ, McCracken LM. Cultural barriers to mammography, clinical breast exam, and breast self-exam among Chinese-American women 60 and older. Prev Med 2000;31:575-83.
Smith RA, Saslow D, Sawyer KA, Burke W, Costanza ME, Evans WP 3rd
, et al
. American Cancer Society guidelines for breast cancer screening: Update 2003. CA Cancer J Clin 2003;53:141-69.
Lee EH. Breast self-examination performance among Korean nurses. J Nurses Staff Dev 2003;19:81-7.
Anderson BO. The breast health global initiative: why it matters to all of us. Oncology (Williston Park) 2010;24:1230-4.
Tavafian SS, Hasani L, Aghamolaei T, Zare S, Gregory D. Prediction of breast self-examination in a sample of Iranian women: An application of the Health Belief Model. BMC Womens Health 2009;9:37.
Mittra I. Breast screening: the case for physical examination without mammography. Lancet 1994;343:342-4.
Champion VL. Revised susceptibility, benefits, and barriers scale for mammography screening. Res Nurs Health 1999;22:341-8.
Palmer RC, Samson R, Batra A, Triantis M, Mullan ID. Breast cancer screening practices of safety net clinics: Results of a needs assessment study. BMC Womens Health 2011;11:9.
Parkin DM. Global cancer statistics in the year 2000. Lancet Oncol 2001;2:533-43.
Singh MM, Devi R, Walia I, Kumar R. Breast self examination for early detection of breast cancer. Indian J Med Sci 1999;53:120-6.
Nelson HD, Tyne K, Naik A, Bougatsos C, Chan BK, Humphrey L, et al
. Screening for breast cancer: An update for the U.S. Preventive Services Task Force. Ann Intern Med 2009;151:727-37, W237.
Schwartz GF, Hughes KS, Lynch HT, Fabian CJ, Fentiman IS, Robson ME, et al
. Proceedings of the international consensus conference on breast cancer risk, genetics, and risk management, April, 2007. Cancer 2008;113:2627-37.
Takiar R, Vijay CR. An alternative approach to study the changes in the cancer pattern of women in India (1988-2005). Asian Pac J Cancer Prev 2010;11:1253-6.
Galukande M, Kiguli-Malwadde E. Rethinking breast cancer screening strategies in resource-limited settings. Afr Health Sci 2010;10:89-92.
Agarwal G, Ramakant P. Breast Cancer Care in India: The Current Scenario and the Challenges for the Future. Breast Care (Basel) 2008;3:21-7.
[Table 1], [Table 2], [Table 3]
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|[Pubmed] | [DOI]|