KNOWLEDGE ON BREAST CANCER AND PRACTICE OF BREAST

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1 Open Access Research Journal Medical and Health Science Journal, MHSJ ISSN: (Print) (Online) Volume 7, 2011, pp. -56 KNOWLEDGE ON BREAST CANCER AND PRACTICE OF BREAST SELF EXAMINATION AMONG SELECTED FEMALE UNIVERSITY STUDENTS IN MALAYSIA Breast cancer is the most common cancer affecting women in most parts of the world including Malaysia. Even though breast self examination (BSE) is not seen as a relevant cancer screening tool anymore, it still plays an important role in the breast health awareness programme. Aim of the study to determine the knowledge of respondents on breast cancer regarding the risk factors, symptoms, and to determine respondents practice of breast self-examination. A cross sectional study was carried out in University Putra Malaysia, data were collected using validated questionnaire developed for this study. Among respondents 197(83.1%) were single, 100 were Malay (42.3%) and (20.7%) of the respondents reported having a family history of breast cancer. eighty-seven respondents (36.7%) claimed they had practice BSE. There were statistically significant differences between those who practice and did not practice BSE in term of knowledge regarding risk factors, symptoms of breast cancer, total knowledge of breast cancer and knowledge score of BSE (p-value <0.05). The findings showed that knowledge of breast cancer and the practice of BSE is inadequate among young Malaysian female. MEHRNOOSH AKHTARI-ZAVARE 1, MUHAMAD HANAFIAH JUNI 1, ROSLIZA ABDUL MANAF 2, IRMI ZARINA ISMAIL 2, SALMIAH MD. SAID 1 1 Department of Community Health, Faculty of Medicine and Health Science, University Putra Malaysia 2 Department of Family Medicine, Faculty of Medicine and Health Science, University Putra Malaysia Keywords: Breast cancer, breast awareness, breast self-examination, Malaysia. UDC: Introduction Breast cancer appears to be a major global health problem of both the developing and developed countries (World Health Organization, 2009). Similarly, in Malaysia breast cancer was reported as the most common cancer among female and also the most important cancer among population regardless of sex in Peninsular Malaysia by the National Cancer Registry (NCR, 2006). There was 3525 female breast cancer cases registered in the NCR for 2006, accounted for 16.5% of all cancer cases registered (National Cancer Registry, 2006). In Malaysia, 50-60% of women s with breast cancer presenting at Stage 3 or Stage 4 with little or no benefit to be derived from any form of therapy (Hisham and Yip, 2004). Also, among the younger women breast cancer tend to be larger, at a more advanced stage and more aggressive than those affecting older women (Brennan, 2005). Young women (aged years) with breast cancer have a 72.4 per cent mortality rate (National Breast Cancer Centre, 2004). The social and cultural perceptions of breast cancer in Malaysia are the most important contributors to the advanced stage of presentation. Women in Malaysia may seek alternative and traditional medicine in a desperate effort to combat the disease (Hashim and Yip, 2003). Breast cancer not only threatens the life of a woman but also affects her gender identity and body image (Parsa, Kandiah, Mohd Zulkefli, Abdul Rahman, 2008). There are reliable evidences in the literature which support the effectiveness of CBE and mammography in reducing mortality due to early detection and treatment of breast cancer (Larkin, 2001). On the other hand, the effectiveness of BSE in mortality reduction is contentious which, some scholars argue that practicing BSE make women more breast aware (Larkin, 2001). However, in developing countries like Malaysia where national - -

2 mammography screening program for early detection of breast cancer is unavailable due to limited resources, BSE become a palatable option in increasing breast health awareness (Yip, Mohd Taib, Ibraham, 2006; Ministry of Health Malaysia, 2002). BSE is considered to be a simple, inexpensive, noninvasive, and non-hazardous intervention, which is not only acceptable, cost-effective and appropriate (Norman and Brain, 2005). Practicing BSE could provide an opportunity for women to know how their breasts normally feel and notice any changes in their breast tissue (American Cancer Society, 2005b). There were also data suggesting that factors related to women's knowledge about breast cancer and its management may contribute significantly to medical help-seeking behaviors (Odusanya and Tayo, 2001). Understanding the factors that influence patients delay in seeking breast cancer treatment is therefore necessary to improve its treatment outcomes. In Malaysia, breast cancer awareness studies among young women were not well documented (Hadi et al., 2010). For instance, in the study by Parsa et al. (2008) conducted among 425 female secondary school teachers. The general perception is that young women do not consider themselves at risk for developing breast cancer as they believe that it is a problem that affects old(er) women (Johnsona and Dickson-Swifta, 2008). The aim of this study to investigated the knowledge of breast cancer and BSE practices in a sample of undergraduate female students at University Putra Malaysia (UPM), Malaysia. Methodology Study design and population A cross sectional study was conducted from September 2010 to October 2010 among undergraduate female student at University Putra Malaysia (UPM), Malaysia. Respondents were identified and selected using systematic random sampling from the list of students who registered. This list was used as sample frame. A total of 262 female undergraduate students were selected as a sample. Data collection Data were collected using self administered questionnaire which was developed and validated for this study. The questionnaire contained 37 items which were related to sociodemographic status of respondents, knowledge of breast cancer which includes risk factors, signs and symptoms of breast cancer and BSE practices. Ethical consideration Ethical approval to conduct the study was obtained from Medical Research Ethics Committee of the Faculty of Medicine and Health Sciences, University Putra Malaysia. Then approval was obtained from the Vice Chancellor of UPM as well as the dean of selected faculties in UPM. A written consent was taken from each respondent before conducting the survey. Data analysis Data was analyzed by using PASW Statistics 18.0 program. Normality tests were done and all of the quantitative data were found to be normally distributed. Descriptive statistical analysis, which included frequency, mean, standard deviation (SD) and percentages, was used to characterize the data. Parametric test such as independent sample t-test were employed to determine differences between the BSE practice category and the knowledge score of risk factors, symptoms of breast cancer, BSE and total knowledge of breast cancer. The level of statistical significance was set at α <

3 Result Medical and Health Science Journal / MHSJ / ISSN: (Print) (Online) A total of 262 respondents were selected as the sample for this study. However, 10 respondents (3.81%) refused to participate, and 15 respondents (5.72%) did not complete the questionnaire. Hence, 237 female students participated in this study. The response rate in this study was 90.45%. Socio-demographic characteristics Table 1 shows the distribution of respondents according marital status, race and religion and year of study, family history of breast cancer, age and family monthly income. Overall, the majority of respondents were single 197(83.1%), Malay 100(42.2%), Muslim 112(47.3%), and (20.7%) of respondents reported having a family history of breast cancer. The mean age of respondent was 22(SD=2.3) and ranged between 18 to 30 years old. The mean family monthly income was RM 5347 (SD= RM 2740) and ranged between RM 950 to RM TABLE 1. SOCIO-DEMOGRAPHIC DATA OF RESPONDENTS (N=237) Characteristics Frequency Percentage (%) MARITAL STATUS Married Divorced and Widowed Single RACE Malay Chinese Indian Others RELIGION Islam Buddhism Hinduism Christian Others YEAR OF STUDY First year Second year Third year Fourth year Fifth year FAMILY HISTORY OF BREAST CANCER Yes No AGE (YEAR) Mean (SD) 22(2.3) Range FAMILY MONTHLY INCOME (RM)* Mean (SD) 5347(2740) Rang Note: *(USD 1=RM 3.0) The percentage of participants who performed BSE was 36.7% while the percentage of female who not performed BSE was 63.3% (Table 2). Among those who practice BSE, most of them practice BSE occasionally (50, 57.5%). Also, there were not statistically significant relationship between those practicing BSE and those who did not practice BSE with Family history of breast cancer of respondents (x 2 =0.114, df=1, p=0.736, n=237)

4 TABLE 2. BREAST SELF-EXAMINATION PRACTICES OF RESPONDENTS (N=237) Characteristics Category Frequency Percentage (%) Performing BSE yes no Frequency of BSE (overall) at least once a month once a 2-3 months occasionally none Frequency of BSE (among those practice BSE) at least once a month once a 2-3 months occasionally TABLE 3. KNOWLEDGE ON BREAST CANCER FACTS (N=237) Correct answer Knowledge on breast cancer facts RISK FACTORS OF BC Age Having family history of BC Late age at first child birth Use of HRT Use of OCP Drinking Alcohol Early menarche Diet and lifestyle Obesity or overweight after menopause Performing BSE Not performing BSE Overall Freq. % Freq. % Freq. % SYMPTOMS OF BC Lump Nipple that turns in Nipple itches Swelling of all or part of the breast Bloody nipple discharge CLINICAL BREAST EXAMINATION (CBE) AND MAMMOGRAPHY The optimal time for doing a clinical breast examination Appropriate age to initiate CBE Mammography is a useful method to diagnose breast cancer BREAST SELF-EXAMINATION (BSE) Appropriate age to initiate BSE The optimal time for doing a BSE before menopause Name of different position for doing a BSE The optimal time for doing a BSE after menopause

5 Knowledge on breast cancer facts and screening Table 3 shows that 82.7% of students knew that there is an association between family history and breast cancer. Regarding other risk factors, only 16%, 16.9% of respondents knew about the relationship between uses of oral contraceptive pills, early menarche with breast cancer, respectively. With regards to symptoms of breast cancer, 64.1% knew that Nipple that turns in is not normal, while only 23.2% knew that there is an association between nipple itches and breast cancer. Regarding the screening methods 74.3% of respondents answered correctly to the question on mammography as a useful method to diagnose breast cancer, while 36.3% and 35.4% of students knew about the optimal time for doing a clinical breast examination and appropriate age to initiate CBE, respectively. Majority of respondents (84%) knew the name of different position for doing a BSE and fifty-five percentages (55.7%) of respondents know about the appropriate age to initiate BSE. Regarding the optimal time for doing a BSE before menopause only 32.1% of respondents know about it. Comparison of the mean knowledge of breast cancer and breast self-examination for those who practice BSE and those who did not practice BSE Table 4 shows the comparisons of mean knowledge score of breast cancer and mean knowledge score of BSE between those practicing BSE and those who did not practice BSE. The results show that there were statistically significant differences between those practicing BSE and those who did not practice BSE with Risk factor BC (t= , p= 0.033), symptoms of BC (t= , p= 0.026), CBEand mammography (t= , p= 0.006), total knowledge of BC, (t= , p= 0.004) and knowledge score of BSE (t= , p= 0.002) at (p value<0.05). Knowledge of Breast cancer Risk factor breast cancer Symptoms of breast cancer CBEand mammography Total knowledge score of breast cancer TABLE 4. COMPARISON OF THE MEAN KNOWLEDGE OF BC, BSE SCORE FOR THOSE HAVING BSE AND THOSE DID NOT (N=237) Performing BSE (N=87) Mean (SD) 15.4(2.1) 7.6(1.7) 5.4(1.1) Not performing BSE (N=150) Mean (SD) 16.1(2.1) 8.1(1.9) 5.9(1.3) T- value p-value * 0.026* 0.006* 28.5(4.0) 30.1(4.1) * Knowledge score of BSE 14.5(2.5) 15.7(3.0) * Note: * P-value<0. Discussion Breast cancer presents a very formidable health threat to all world populations. Informing youth about this serious disease is both a challenge and important investment in the health of future generations of women (Gürsoy, Yiğitbaş, Yılmaz, Erdöl, Bulut, and Mumcu, 2009). We need to inform young people about BSE to develop behaviors and practices which can encourage them to become proactive in taking responsibility for their health issues, in this case, breast health (Gürsoy et al., 2009). In the qualitative study conducted

6 by Johnsona et al. (2008) showed that all women need to be educated about breast cancer and to learn early intervention techniques such as breast self examination at an early age. Lack of knowledge about breast cancer and breast cancer risk may lead to inaccurate perceptions of the disease and a lack of utilization of early detection techniques. Low levels of knowledge and a lack of perceived risk coupled with the inundation of breast cancer information that focuses on older women reinforces the belief that young women are not at risk and do not need to be aware of breast cancer (Johnsona et al., 2008). In the present survey, most respondents were not knowledge of BSE. The reason may be that participants do not attach importance to BSE personally or poor attitudes of respondents to breast self examination. This showed that many respondents still assumed that breast cancer is a rare disease and that they can never be affected by it. In Malaysia, the Ministry of Health promotes annual CBE by medical or paramedical personnel and the practice of monthly BSE for women above the age of 20 years, (Narimah, Rugayah, Tahir, and Maimunah, 1999). Also, breast self examination is taught to women attending women s wellness clinics and maternal and child-health clinics by the public health nurses (Yip et al., 2006). The result of this study showed only 36.7% of students practice BSE. This result is similar to the findings by another Malaysian study, in which only 24.4% of women practiced BSE once a month (Chee, Rashidah, Shamsuddin Intan, 2003). Also, the finding of the other study conducted by Parsa et al. (2008) among female teachers in Selangor, Malaysia showed that only 19% of female teachers practice BSE. In this study there were significant differences between knowledge of breast cancer and knowledge of BSE between those who practice BSE and those who did not practice BSE. The mean knowledge score for those who did not practice BSE is higher than those practices BSE. This may be explained by the fact the awareness of breast cancer among the respondents could be attributed to the level of education of the respondents. The most common reason that women cited for not performing BSE is that they "forgot", and did not know the optimal time for doing a BSE (32%). This finding is similar to the study conducted by Gwarzo, Sabitu and Idris (2009) among 221 female students at Ahmadu Bello University Zaria in Nigeria found that despite nearly three quarter of the respondents (87.7%) had knowledge of BSE, only 19.0% of them were performing this examination monthly. Also, in a two series study carried out in Đzmir by Aydemir et al., they first found out that the level of knowledge of BSE was 24.5% while the level of practice was found to be 1.5%. In their second study, the percentage of women who knew BSE was 53.7% while 39.0% were performing it. This finding also contrasts with the results of a study conducted in Korea revealed that women who were taught to perform BSE had better level of knowledge about breast cancer (Hyun, 2003). In the study conducted by Parsa et al. (2008), she found that women with higher levels of knowledge in relation to symptoms and screening demonstrated higher performance rates of BSE. Similarly, in a study conducted in Western Turkey, it was found that presence of knowledge about breast cancer had a positive effect on performing BSE (Dundar, Ozmen, Ozturk, 2006). About the risk factors of breast cancer, very low percentage of respondent (16%) knew about the relationship between uses of oral contraceptive pills with breast cancer. This may be explained by the marital status of respondents, because majority of respondents not married, they had the low level of knowledge on OCP as a risk factor for breast cancer. This demonstrated the need for health education programmes on breast cancer in the study population. On the other hand, the most widely known risk factors by the students were family history of breast cancer (82.7%) and age (64.6%). This increased awareness in the role of age and

7 family history of breast cancer in breast cancer, which can be attributed to extensive coverage of this risk factor in Malaysia media. Limitation This study was designed as a cross-sectional survey and did not include monitoring of the participants. Data were collected by self-reporting and this might be affected by memory bias. Recommendation Although this study provided valuable information about BSE frequencies and breast cancer knowledge levels for young females, it does not provide in-depth information about the cultural issue. A recommendation for future studies is conducting research via using qualitative methodology about cultural issue and BSE practice and why women those have knowledge on breast self-examination and breast cancer don t do BSE practice. Conclusion This descriptive study provides valuable information that could be utilized by both researchers and those involved in public health program. The results indicate that the awareness of breast cancer and the practice of BSE are inadequate among the respondents. Thus, it is important to develop breast cancer and breast health awareness campaign among young women to encourage them to report any unusual changes in their breasts to the healthcare providers. Acknowledgements This study was supported by the University Putra Malaysia, through the Graduate Research Fellowship. Researchers would like to thank all the students who took part in the study and gratefully acknowledge the management officer and staff of Faculty of Medicine and Health Science, University Putra Malaysia that involved in this study. References American Cancer Society, How is breast cancer found, Available at: Sitearea =CRI andview mode=printand acts, Accessed at January, 2011 Brennan, M, Breast cancer in young women, Australian Family Physician, Vol.34 (10), pp Chee, H., Rashidah, S., Shamsuddin Intan, O., Factors related to the practice of breast self examination (BSE) and Pap smear screening among Malaysian women workers in selected electronics factories, BMC Women s Health, Vol. 3, p.3 Ministry of Health Malaysia, Clinical practice guideline for management of breast cancer Dundar, P., Ozmen, D., Ozturk, B. et al., The knowledge and attitudes of breast self examination and mammography in a group of women in a rural area in Western turkey, BMC Cancer, Vol.6, pp.43-8 Gürsoy, A., Yiğitbaş C., Yılmaz, F., Erdöl, H., Bulut, H., Mumcu, H., The effect of peer education on university students knowledge of breast self-examination and health beliefs, The Journal of Breast Health, Vol.5(3), pp Gwarzo, U.M.D., Sabitu, K., Idris, S., Knowledge and practice of breast-self examination among female undergraduate students of Ahmadu Bello University, Annals of African Medicine, Vol.8 (1), pp

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