Breast cancer knowledge perception and breast self examination

							The International Medical Journal                                             Vol. 4 No 2 Dec 2005

Breast cancer knowledge, perception and breast self-examination
practices among Iranian women

Parisa Parsaa and Mirnalini Kandiahb
a
 Department of Community Health, Faculty of Medicine and Health Sciences,
b
 Department of Nutrition Epidemiology. Department of Nutrition and Health Sciences,
Faculty of Medicine and Health Sciences, University Putra Malaysia.

ABSTRACT

A cross sectional study was carried out to determine breast cancer knowledge, perception and
breast self-examination (BSE) practices among Iranian woman living in the city of Hamadan,
Iran. The aim was to detect breast cancer in an early stage. In all 261 women who were referred to
health and medical centers in Hamadan city were interviewed with a structured questionnaire. The
mean age of women was 28/8±7y. Most of them were married (95.4%) and 2.7% of respondents
reported having a family history of breast cancer while 8% had history of other breast related
problems, the most common one being pain (61.9%). Two-thirds of the respondents said that they
had never performed BSE most frequently cited reason was lack of knowledge (48%). Doing BSE
was more frequent in women with history of breast related problem or history of visit to
gynecologist. The chi-square (c2) test detected a significant association between age, occupation,
knowledge and practices (p-value <0.05). The findings show that Iranian women’s knowledge and
perception regarding breast cancer and the practice of BSE is inadequate. Targeted education
measures should be implemented to improve early detection of breast cancer.

Keywords: Iran, breast Cancer, early detection, breast self-examination

INTRODUCTION

The incidence of breast cancer varies markedly between countries highest being in the United States
and Northern South America, and lowest in Asia [3]. However, the incidence of breast cancer has
been increasing in traditionally low-incidence Asian countries as these regions move toward a
Western-type lifestyle and pattern of reproductive behavior4, 5. In Iran a well established cancer
registry does not exist, but hospital statistics indicate a rising trend in the incidence rate of breast
cancer. The crude incidence rate of the disease has been estimated to be about 20 new cases per 100
000 women per year which corresponds to a total number of 6000 new cases of breast cancer
annually6. At the time of presentation with breast cancer Iranian women are relatively younger than
their Western women. Many of them are already in the advanced stages of the disease resulting in
high mortality6, 7. Given that Iran has a population of 30 million females, early detection of breast
cancer would have an immense impact on breast cancer mortality. Early detection of breast cancer
can be achieved by performing periodic breast self examination (BSE), mammography, and clinical
breast examination. While for the woman below the age of 50 y mammography is ineffective and
clinical examination is often infrequent, BSE is highly significant for the younger age group
women8. Results of the Canadian National Breast Screening Study-2 (CNBSS-2), a 13-y
randomized trial in women aged 50 – 59 y suggest that in countries such as Iran where
mammography services are almost non-existent and breast cancer is becoming a public health
problem, women over the age of 50 y could also benefit from annual physical examination and the
teaching of BSE by skilled health professionals9. Mammography screening is often labeled as a
profit-driven technology, compounded by unreliability and possible risks. An annual clinical breast
examination by a trained health professional together with monthly BSE is the safer and more cost
effective route for prevention10. Yet results from large randomized and quasi-randomized trials of
BSE have failed to identify any impact of the technique on breast cancer mortality or on the stage or
size of the cancer when detected11-14. While it can be argued that BSE may not necessarily reduce


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mortality, evidence from the Canadian study suggests that self examination does contribute to a
reduction in mortality from breast cancer if done well10.

Currently there is no population-based mammography-screening program in place in Iran. However,
there are several ongoing health promotion programs to raise awareness of and to assist early
detection and presentation with breast cancer. Such programs include launching of a national breast
cancer help-line, educational programs for employed women, and educational workshops for female
primary care physicians and the distribution of printed informational materials in specialist
centers7.

We investigated breast cancer knowledge, perception and BSE practices in a sample of Iranian
women living in city of Hamadan.

SUBJECTS AND METHODS

In this cross sectional study 261 women who were referred to the health care and medical centers in
Hamadan city, Iran were selected randomly from four central districts of Hamadan bringing women
from different socio-economic sub-groups for this study. Data was collected during a face-to-face
interview with the women using a structured questionnaire which consisted of three sections namely
demographic status, knowledge and perception about breast cancer and BSE practices. Knowledge
and perceptions was measured using the Breast Cancer Perceptions and Knowledge Survey
(BCPKS). The BCPKS is a 10-item instrument that is a modified version of the Breast Cancer
Instrument [15]. The original instrument included 48 items and was based on the five sub scales of
the Health Belief Model (knowledge, susceptibility, severity, barriers, and benefits). The response
format was a five-point Likert scale. Ten of the 48 items focused on breast cancer knowledge. The
10-item breast cancer knowledge sub scale was adapted for use in the current study by changing the
response categories to yes (agree) or no (disagree) and ‘I do not know’ response (Table 2). The
original response format was amended because previous research suggests that people with lower
educational levels have difficulty in distinguishing levels of gradation within a Likert scale16. This
type of information may be more useful for the development of educational strategies. Questions
focused on perceived causes of breast cancer, risk factors, and efficacy of screening and treatment.
To obtain a composite score, one point is added for each correct response and with scores ranging
from 0 to 10. The instrument was pilot tested for comprehension and readability using a sample of
15 women not included in the study sample at the health care center. On average, the participants
were able to complete the BCPKS in less than 5 minutes. The majority reported that the
questionnaire was easy to read and all agreed that the instructions were clear. Price [15] had
reported test-retest reliability of 0.70 for this instrument when used on a sample of low-income
African-American women. For the current study, the Kuder–Richardson reliability was 0.84. Test-
retest reliability was evaluated by administering the BCPKS to the women at baseline and 2 weeks
later. T-test showed no significant difference in their mean knowledge scores between baseline and
after 2-weeks, which supports the stability of the measure (d.f. = 14; t = 0.593; ρ = 0.562).

Data was analyzed using the EPI-INFO computer soft-ware (CDC, Atlanta). Descriptive statistics
were obtained for all the variables studied. Pearson Chi-Square was used to test for association
between categorical variables. The significance level used was p<0.05.

RESULTS

Table 1 describes the socio-demography of the respondents; ages of the women range from 17-60
with a mean of 28.8 ±7.6. Most of the women were married (95.4%). About an equal proportion of
women had primary (38.4%) and secondary level education (36.4%) while 10.4% of women were
illiterate and 15% were university graduates. Only 14% of the women were gainfully employed
while the rest were housewives. Family history of breast cancer was reported by 7 (2.7%) of the
respondents while 21 (8%) had history of breast problems. The most common problem experienced
was pain (61.9%). Among the remaining women, 5 subjects (23.8%) had a lump which had been
diagnosed and 3 women reported having discharge from the nipple.


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                    Table1. Personal characteristics of the respondents (n=261)

                      Characteristics                            n (%)
                      Age group
                      <20                                      41 (15.7)
                      20-30                                    98 (37.6)
                      30-40                                    59 (22.8)
                      40-50                                    52 (19.5)
                      >50                                       12 (4.5)
                       Mean age ± SD                          28.8±7.6 yr
                      Education level
                      Illiterate                                27 (10.3)
                      Primary                                   99 (37.9)
                      Secondary                                 96 (36.8)
                      University                                 39 (15)
                      Marital status
                      Married                                   25 (95.4)
                      Single                                    12 (4.6)
                      History of breast problem
                      Yes                                        21 (8)
                      No                                        241 (92)
                      Family history of breast cancer
                      Yes                                        7 (2.7)
                      No                                       255 (97.3)
                      Job
                      Housewife                                223 (85.5)
                      Employee                                  38 (14.5)

Breast cancer perception and knowledge

Table 2 presents the responses of the study participants on breast cancer perception and knowledge
statements. Slightly more than two-thirds of the women held the misperception that big breasts
increased the likelihood of developing breast cancer (67%) while some believed that painful lumps
are indicative of cancer (59%). Still other women were more informed about the fact that
discharges from the nipple was a possible sign of breast cancer (82%). Majority of the women were
not sure whether a high fat/low fruit and vegetable intake might increase their personal risk of
breast cancer. Only 55% agreed that early detection would not increase a woman’s chances of
survival, while about one forth were not aware about this fact.

The average score of the respondents was 5 out of a total of 10 (range 2- 10) on the BCPKS. Overall
only 45.6% of the subjects were able to provide correct answers.

BSE practice

Thirty-five (13.4%) of the respondents stated that they performed BSE regularly, 56(21.5%)
occasionally and 170(65.1%) had never done it. The commonest reason given for not doing BSE
was a lack of knowledge on how to do it (48%). Other reasons included: forgetfulness (20%), fear
of finding a mass (17%), not necessary (9%), and lack of time (4%). BSE was more frequent in
women with history of a breast problem or history of a consultation with a gynecologist (58%).

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There was a statistically significant association between age, occupation, knowledge and BSE
practices (p value <0.05) (Table 3).

     Table 2: Participant responses to breast cancer perception and knowledge survey (n=261)

               Statement                    Agree          Disagree      % I do not know (n)
                                             n%             n (%)
  1. Breast cancer is more common
                                           175 (67)         50 (19)              36 (14)
  in women with big breasts
  2. Lumps in the breast that are
                                           154 (59)         42 (16)              65 (25)
  cancer are usually painful
  3. Changes found in the breast
  during BSE are usually beast             146 (56)         70 (27)              44 (17)
  cancer
  4. A change in the color or
  discharge of a women's nipple            214 (82)          13 (5)              34 (13)
  could be a sign of breast cancer
  5. If a woman's mother or sister had
  breast cancer, she is more likely to     133(51)           52(20)              76(29)
  get breast cancer
  6. One of the best ways to find
                                           167 (64)         31 (12)              63 (24)
  breast cancer is monthly BSE
  7. A woman who eats foods high in
  fat and little fruit and vegetable
                                            34(13)           68(26)             159 (61)
  may be more likely to get breast
  cancer
  8. The best time to check for lumps
  in the breast is just after the period   144 (55)         52 (20)              65 (25)
  ends
  9. Doctor and nurses are the only
  ones who could find a lump in the        31 (12)          209 (80)             21 (8)
  breast
  10. A women's chance of surviving
  breast cancer is very low, even if it    144 (55)         31 (12)              33 (13)
  is found early


DISCUSSION

Knowledge and Perception

Results of this study showed that the respondents have moderate knowledge about breast cancer.
Findings of another study that was conducted in 414 female teachers in the city of Khorramabad, in
Iran revealed that 89.2% of female teachers had poor knowledge, 13.8% had moderate knowledge
and no one had a good knowledge about BSE. Regarding attitude, 10.4% of them had poor attitude,
10.1% had moderate attitude and 79.5 % had a good attitude towards breast cancer screening [17].
Similarly in a study conducted on 122 working woman in Egypt, only 10.6% and 11.5% of the
total sample had satisfactory knowledge about breast cancer and BSE respectively [18]. A study by
Powe [19] among 179 African-American women identified higher knowledge on breast cancer than
the subjects in our study. Similarly in a study by Chong [20] among 447 nurses in Singapore, 58% of
them had moderate score for knowledge.




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          Table 3: Association of socio-demography with women’s BSE practice (n=261)

    BSE practice         Regularly       Occasionally     Never            Total       p value
    Factors              performed        performed     performed          n (%)
                           n (%)            n (%)         n (%)
     Knowledge
     Poor                  7 (3.1)          24 (9.2)    111(42.5)        142 (54.4)
     Sufficient           28 (10.3)        32 (12.3)     59 (22.6)       119 (45.6)    <0.001*
     Total                35 (13.4)        56 (21.5)    170 (65.1)       261 (100)
     Education
     Illiterate            2 (0.7)          3 (1.1)       22 (8.7)       27 (10.3)
     Primary               9 (3.5)          11 (4.2)     79 (30.2)       99 (37.9)     <0.001*
     Secondary             15 (5.7)        28 (10.7)     53 (20.7)       96 (36.8)
     University            9 (3.5)          14 (5.6)      15 (5.8)        39 (15)
     Total                35 (13.4)        56 (21.5)    170 (65.4)       26 1(100)
     Job
     House wife            26 (9.9)        44 (16.9)    153 (58.6)       223 (85.5)
     Employee              9 (3.5)          12 (4.6)     17 (6.5)         38 (14.5)     0.007*
     Total                35 (13.4)        56 (21.5)    170 (65.1)        261(100)
     Age
      <20                     -             3 (1.1)      38(14.6)        41 (15.7)
     20-29                10 (3.8)          22 (8.5)     66(25.3)        98 (37.6)
     30-39                12(4.6)           14 (5.6)     33 (12.7)       59 (22.8)     <0.001*
     40-49                11 (4.3)          12 (4.4)     28 (10.7)       51 (19.5)
     50>                   2 (0.7)          5 (1.9)       5 (1.9)         12 (4.5)
     Total                35(13.4)         56 (21.5)    170 (65.1)       261 (100)


  *p <0.05 significant using Pearson Chi square test

The majority of nurses had correct answers for most questions except for those on whether BSE
decreases mortality (1.4%) and on the incidence of breast cancer (16%). Previous studies performed
in Turkey indicated that the level of cancer knowledge was inadequate, the rate of performing BSE
was very low and most of the women did not know how to examine their breast correctly 21. The
findings of these studies indicate that women need not only correct information on breast cancer and
BSE but also opportunities for supervised practice which will increase their confidence in their
ability to perform BSE correctly. The majority of our respondents believed that having large breasts
is a risk factor for breast cancer; in contrast to the observation made by Powe where 86% of the
women were sure that larg breasts is not a risk factor19. Although a change in the breast size or
breast enlargement is a symptom of breast cancer the normal size of the breasts is not a risk factor.
Powe’s subjects were well informed and this could be due to the fact that the African American
women had a higher educational level. The majority of the women in Powe’s and our study were
similarly aware that abnormal discharge from the nipple is a possible sign of breast cancer. A diet
low in fat and high in fiber, fruits and vegetable is recommended as a preventive measure against
breast cancer. However many of our respondents were relatively unaware of this information.
Despite the higher educational, the women in Powe’s study, were also unsure of the importance of a
healthy diet in breast cancer prevention. Our results indicate that Iranian women need more
exposure to correct information on breast cancer prevention.

BSE practices

The American Cancer Society1 and other leading cancer agencies8, 9, 10 recommend monthly BSE to
women. In our study BSE was performed regularly only by 13.4% of respondents. These findings
are different from a previous study among 264 women aged 20 years and over in Ilam, Iran which



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found that 57.3% of women had low knowledge, 64% had positive attitude and 35% performed
BSE of whom slightly more than half (56%) did it inaccurately23. Another study that was carried
out on 382 health-care professional women in Iran aged 20 to 64 years showed the majority had
good knowledge and attitudes, but had poor practices regarding breast cancer early detection. In this
study, the women’s practices varied according to their educational level, marital status, occupation
and age24. In another study that was conducted in female teachers in Iran only 6% of women
reported that they perform BSE regularly 7. In a study in Singapore 62.7% nurses examined their
breasts every month20. In a study that was conducted among 57 South Asian women living in the
United Kingdom aged above 40 years it was found that 12% of participants practiced BSE
monthly, 49% had undergone at least one clinical breast examination and the majority (54%) said
they did not have enough knowledge about breast cancer25. In a study among 124 Chinese women
in Hong Kong, less than half of the sample practiced BSE but only 16% reported that they
performed BSE every month26. All these studies show that Asian women have low to moderate
knowledge with poor to moderate breast cancer screening practices. In Italy and in Russia, the
figures reported for monthly BSE were about 23% and 31%, respectively27,28. Among 194 Asian
Indian women living in the United States, 40.7% reported having performed a BSE in the previous
month29. In contrast, a study from Sweden reported that about 70% of women between the ages of
25-80 years examined their breasts regularly30. BSE practices appear to be correlated to the level of
education and good health care services in these countriescompared to developing countries.

In the present study the most common reason for not doing BSE was lack of knowledge.
Performing BSE was more frequent in women with history of breast problems or history of a
consultation with a gynecologist. Besides, there was statistically significant correlation between
age, occupation, knowledge and women’s practices. Similarly, other investigators have shown that
the most common reasons for not doing BSE and not going for clinical examination were lack of
knowledge (34%) and not to believe in its necessity (36%)7. In a study from Egypt, age was found
to be a significant predictor of BSE18. Younger women tended to practice BSE than the older
women. In yet another study in Iran the most frequent barrier for breast self examination was
forgetfulness (52%) and having ‘no problem in the breasts’ for not going to a physician for
consultation (40%) 24. The practice of BSE was more frequent in married women than in singles
(p<0.001) and in women with positive family history of breast cancer (p<0.039). Beliefs about and
practice of BSE were better in women with history of a breast problem or history of a visit to the
gynecologist. In general, intention to do BSE was associated with self efficacy, knowledge of breast
cancer issues, concern about getting breast cancer and employment status. In this study, pain was
the most common breast problem identified. Majority of the women had a misperception, that pain
is the first sign of cancer. Other studies in Iran and in the United States have reported similar
observations19,23,31. Pain is usually a late sign of breast cancerand this misperception could serve as
a barrier to participation in early diagnostic testing or treatment as the women may not associate the
presence of a lump as a possibile cancer if it were painless.

It is advocated that an ideal screening for breast cancer test should be simple, inexpensive, and
effective. BSE fulfills the first two criteria while mammography may not be the appropriate
technology for screening in developing countries. The value of BSE in the developing countries can
be explained by the fact that using Western ‘high-tech’ medicine in public health diverts scarce
resources from simpler interventions that might provide a far greater net benefit to society32, 33.

The impact of BSE on mortality continues to remain controversial. While this is the case, the more
important issue is that a significant number of women find masses while they are bathing or
dressing, and hence BSE once a month may make woman aware of what is normal for her on other
days34.

There were some limitations in our research. Firstly, the findings cannot be generalized beyond the
study sample because the study was undertaken in one city and the results may not be applicable to
other cities. Secondly, all data was self-reported with no objective measures to evaluate the
subjects. The results o however does provide some understanding on the topic and provide evidence
that the majority of Iranian women need more education on breast cancer and BSE. It is possible, by



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knowing how to do a more thorough BSE women will be able to detect breast cancers at the initial
stages and in turn may lead to improved prognosis and thereby contribute to a reduction in the
number of premature breast cancer deaths in developing countries.

CONCLUSION

The results indicate that most women in our study were not well informed on pertinent issues
surrounding breast cancer and have poor BSE practices. These data imply that Iranian women need
more education on breast cancer early detection particularly on BSE. It is possible, that by knowing
how to do thorough BSE, women in general will be able to identify breast cancer at the initial
stages. This in turn may help to eventually decrease the number of premature breast cancer deaths in
developing countries such as Iran.

Breast cancer afflicts premenopausal women in Iran unlike in the western societies where it is
problem in menopausal women. A health education program targeted at younger women is
necessary to improve breast cancer prevention in Iranian women. They need to remove fear and
misperceptions about BSE. Young women might need help to develop confidence in their BSE
technique as well as accurate information to reduce their fears. Less educated women may need
firstly, information to reduce unwanted fears before being taught the techniques. In addition, an
effective public screening need to be initiated in primary health care settings making it easily
available to all women. Findings from this study may make clinicians become sensitive to some of
the beliefs about breast cancer among their patients.

Acknowledgments

We would like to take this opportunity to express our appreciation to the subjects who participated,
staff physicians and nurses of the Health Care and Medical Centers of Selected Centers in Hamadan
City, Iran.

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Corresponding author
Ms. Parisa Parsa
Department of Nutrition and Health Sciences, Faculty of Medicine and Health Sciences
University Putra Malaysia, 43400 UPM, Serdang, Selangor, Malaysia




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