Breast cancer is the most frequent cancer in women

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1 B 2006 Lippicott Williams & Wilkis, Ic., Philadelphia Esi Çeber, PhD, RN Meral Turk Soyer, PhD, MD Meltem Ciceklioglu, PhD, MD Suduz Cimat, RN Breast Cacer Risk Assessmet ad Risk Perceptio o Nurses ad Midwives i Borova Health District i Turkey K E Y W O R D S Assessmet Breast cacer Calculatio Estimatio Gail model Perceptio Risk Risk perceptio is a sigificat compoet of awareess of breast cacer risks. It ca be helpful to reduce deaths of breast cacer via icreasig awareess risk level. This study aimed to discuss the level of perceived ad calculated breast cacer risk ad to provide data o the practice of breast self-examiatio ad use of mammography amog 215 urses ad midwives workig i the 23 primary healthcare ceters i Turkey. Participats were asked to assess their persoal lifetime breast cacer risk by a 4-item Likert scale ( o risk, usual, moderate, ad strog risk), which determied perceived breast cacer risk. Gail model was used to assess the calculated breast cacer risk, which was calculated by the tool provided by the Natioal Cacer Istitute, versio 7. Perceived ad calculated risk levels were compared. The relatio betwee sociodemographic ad risk factors with perceived risk was examied. I additio, the ifluece of perceived risk o breast cacer screeig practice was also assessed. The level of perceived risk of urses ad midwives was higher tha that of calculated risk. Cosiderig the fact that participats were healthcare professioals, the use of breast self-examiatio ad mammography practices as a prevetive behavior by urses ad midwives was lower tha expected. Implicatios are discussed with regard to breast cacer risk ad prevetive behavior. Breast cacer is the most frequet cacer i wome worldwide. Breast cacer is still a global public health cocer, although mortality rates have bee decliig i some coutries because of improvemets i adjuvat therapy ad screeig for breast cacer. 1 I Turkey, breast cacer is also the most commo form of cacer amog Turkish wome. The primary site of cacer i Turkish wome is breast cacer, which represets 24.1% of all female cacer. 2 From the Izmir Ataturk School of Health, Ege Uiversity, Izmir, Turkey (Dr Çeber); Departmet of Public Health, Faculty of Medicie, Ege Uiversity, Izmir, Turkey (Drs Soyer ad Ciceklioglu); ad Miistry of Health, Izmir, Turkey (Dr Suduz Cimat). Correspodig author: Esi Çeber, PhD, RN, Izmir Ataturk School of Health, Ege Uiversity, Izmir, Turkey ( esi@med.ege.edu.tr, turkista@ borova.ege.edu.tr). Accepted for publicatio November 29, Cacer Nursig TM, Vol. 29, No. 3, 2006 Çeber et al Copyright Lippicott Williams & Wilkis. Uauthorized reproductio of this article is prohibited.

2 The early detectio ad diagosis rate of breast cacer is cosiderably low amog Turkish wome compared with wome i Wester coutries. 3,4 This fact reflects the lack of awareess of breast cacer as well as low cacer detectio ad prevetio activities amog Turkish wome. Although the early detectio of breast cacer ca icrease the survival rate, there has ot bee ay systematic approach to icrease awareess of breast cacer i Turkey. Therefore, may wome miss early detectio ad treatmet opportuities due to lack of iformatio, kowledge, ad awareess of breast cacer, as well as cacer screeig practices. Nurses ad midwives are ideal health professioals to icrease public kowledge of breast cacer ad to ecourage the practice of mothly breast self-examiatio (BSE). 5,6 They are icreasigly ivolved i providig iformatio ad advice to wome who are cocered about their risk for breast cacer. Couselig about breast cacer risk, however, may be complicated by difficulties i uderstadig risk estimates, probabilities, ad the relative importace of breast cacer risk factors. 7 Nurses ca combie their kowledge of the health services to educate wome about breast cacer risk factors ad available breast cacer screeig services ad practices. 8,9 Thus, urses ad midwives firstly should be aware of their risk for breast cacer ad of the advaces i breast cacer screeig. Risk perceptio is a sigificat compoet of awareess of breast cacer risks. Ogoig study of risk perceptios ad the risk factors wome associate with breast cacer is eeded to idetify treds i their uderstadig of breast cacer risk. These results will assist healthcare professioals i respodig more effectively to requests for iformatio about breast cacer ad i providig breast cacer risk iformatio i ways that support the developmet of accurate risk perceptios. 7 The purposes of this study were the followig: 1. To ivestigate the relatio of perceived breast cacer risk of participats to their professio ad sociodemographic characteristics, 2. To explore the relatio of perceived breast cacer risk of participats to prescribed risk factors, 3. To describe the relatioship betwee the perceived risk ad screeig practices for breast cacer, 4. To compare perceived ad calculated breast cacer risk estimates. Methods Subjects ad Settig All of the urses ad midwives (223) workig i 23 primary healthcare ceters of Borova Health District i 2003 were ivited to participate i the study. Exclusio criteria were age less tha 21 ad persoal history of breast cacer. The study icluded a total umber of 215 participats (participatio rate 96.4%), 92 of which were urses ad 123 were midwives. Istrumets ad Procedures A questioaire with 25 questios regardig various fields cocerig breast cacer risk had bee developed. Previously breast cacer risk ad risk perceptioybased published surveys were used to develop the perceived risk questioaire. 9Y15 Geeral breast cacer risk questios were used to assess the calculated risk by Gail model, which was validated i the previous studies. 16 Breast cacer screeig questios, which would reflect the participats frequecy of BSE ad mammography, were added i the questioaire. We also added to the questioaire basic demographic variables, such as age, marital status, graduatio, gyecologic history, ad family history of breast cacer. Iformatio o family history of breast cacer was collected by askig ther respodets whether they had a mother, sister, daughter, gradmother, aut, or other wome relative with a history of breast cacer. Iformatio o persoal gyecologic history was collected for specific coditios by askig date of mearche, first birth, ad meopause. Assessmet of Perceived Breast Cacer Risk ad Calculated Risk Perceived risk was ivestigated o a 4-poit Likert scale ( o risk, usual, moderate, ad strog risk) ad classified ito 3 levels: usual risk ( o risk was combied ito usual ), moderate, ad strog risk. Risk classificatio scheme was based o similar studies. 14,15,17 Actual breast cacer risk (calculated risk) was determied usig the modified Gail model. The risk was calculated by a computer program, a tool provided by Natioal Cacer Istitute, versio Accordig to the model, followig prescribed risk factors were used to calculate breast cacer risk: participat s age, race, age at mearche, age at first live birth, umber of first-degree relatives with breast cacer, umber of previous breast biopsies, ad a history of atypical hyperplasia. 16 Lifetime breast cacer risk of participats was calculated by the researchers by the help of the computer program usig the prescribed risk factors. Numeric evaluatio was doe so as to reflect the extet of usual = cosiderably lower tha the average (G15%), moderate = average (15%Y30%), or strog = cosiderably higher tha the average (930%). Such a categorizatio of Gail model was also used by Quilli et al i previous studies. 14 All participats were asked to provide iformatio about their mothly BSE practices, ad those who were 40 years ad older were also ivestigated if they uderwet mammography. Data Collectio This cross-sectioal study was coducted with a aim to display the relatio amog the risk factors, screeig practices, ad perceived risk of breast cacer as well as to provide compariso of the perceived to the calculated risk. After receivig approval from the admiistrators of the health ceters to coduct the Breast Cacer Risk Assessmet ad Risk Perceptio Cacer Nursig TM, Vol. 29, No. 3, Copyright Lippicott Williams & Wilkis. Uauthorized reproductio of this article is prohibited.

3 survey, all urses ad midwives were give the questioaire through primary health ceter admiistrators. These admiistrators supervised the admiistratio of the questioaire to their employees. To esure that they were carryig out the survey, periodic cotact was made with the key admiistrators durig the 3-week period of data collectio. Data Aalysis Aalysis was based o 25 questios from the questioaire. Data aalysis was performed by SPSS 11.0 for Widows. Descriptive statistical methods of each questio were carried out accordig to the differet demographic data of the collectio of respodets. Statistical evaluatio was accomplished usig Pearso chi-square test to test the relatioship of sample characteristics ad categorical variables. P value of less tha.05 was regarded sigificat. Results Sample Characteristics Table 1 shows the distributio of perceived breast cacer risk of participats accordig to professio ad sociodemographic characteristics. Nurses ad midwives uder the study had a mea age of 34.1 T 6.0 (mi = 23, max = 54) years ad the mea of their workig experiece was 15.1 T 5.7 years. Participats were maily from the 30 to 34 age group, married, ad graduates of vocatioal high schools of health. No sigificat differece was idetified betwee the perceived risk levels of participats with respect to their professioal ad sociodemographic characteristics. Breast Cacer Risk Factors ad Perceived breast cacer risk of participats was explored with respect to prescribed risk factors (Table 2). All participats disclosed a sigificat relatioship betwee the perceptio of breast cacer ad the presece of family history, history of previous breast disease, ad age. Participats were more likely to rate their risk as moderate ad strog who had risk factors of breast cacer such as previous persoal history of breast disease (# 2 = 22.8, P =.00), presece of family history of breast cacer (# 2 = 20.2, P =.00), ad age over 40 (# 2 = 6.70, P =.03). Screeig Practice ad Distributio of perceived breast cacer risk of participats by breast cacer screeig practices (BSE ad mammography) is show i Table 3. Approximately half of the participats practiced BSE mothly. Relatioship betwee the perceived risk categories ad mothly BSE was ot statistically sigificat for all participats (# 2 = 2.15, P =.34). Perceptio categories ad use of mammography displayed a statistically sigificat relatioship (# 2 = 8.02 P =.01). Compariso of Risk Estimates Table 4 shows the compariso of participats perceived ad calculated breast cacer risk estimates. There were statistically sigificat differeces betwee the perceived ad calculated breast cacer risk categories (# 2 = 25.1, P =.00). Overall, 138 (64.2%) participats reported a baselie perceptio of usual breast cacer risk, whereas 61 (28.4%) reported moderate risk, ad the remaiig 16 (7.4%) strog risk. Table 1 & Distributio of Perceived Breast Cacer Risk of Participats Accordig to Professio ad Demographic Characteristics Usual Moderate Strog Variables No. (138) % No. (61) % No. (!6) % P* Age groups ad youger Y Y ad older Professio.71 Nurse Midwife Graduatio.29 High school Health vocatioal high school Marital status.55 Married Umarried *P value correspods to the Pearso chi-square test. 246 Cacer Nursig TM, Vol. 29, No. 3, 2006 Çeber et al Copyright Lippicott Williams & Wilkis. Uauthorized reproductio of this article is prohibited.

4 Table 2 & Distributio of Perceived Breast Cacer Risk of Participats Accordig to Risk Factors Usual Moderate Strog Risk Factors No. (138) % No. (61) % No. (!6) % P* Early mearche (G12 years).30 Risk preset Risk abset Family history.00 Risk preset Risk abset Age (40 years ad older).03 Risk preset Risk abset No childre.18 Risk preset Risk abset History of previous breast disease.00 Risk preset Risk abset *P value correspods to the Pearso chi-square test. Accordig to Gail model, 213 (99.0%) participats had a risk less tha 15, which poited to usual breast cacer risk, ad oly 2 participats had a risk of 15 ad 30, each idicatig a moderate level (Figure 1). The study fidigs suggested that participats were more likely to rate their perceived risk as moderate ad strog whe compared with their calculated risk by Gail model. Discussio Sigificat differeces were observed betwee participats perceived ad calculated breast cacer risks; it was see that most participats greatly overestimate their risk. I this study, sigificat differeces were ot observed i perceived risk of participats with respect to their professio ad sociodemographic characteristics. However, participats were more likely to rate their perceived risk as moderate ad strog who had sigificat risk factors of breast cacer (such as previous persoal history of breast disease, presece of family history of breast cacer, ad age over 40). Cosiderig the fact that participats were healthcare professioals, use of BSE ad mammography practices by urses ad midwives was lower tha expected, but the sigificat relatioship betwee the perceived risk ad mammography over the age of 40 showed that strog risk perceptio ecouraged the use of mammography. Breast cacer risk perceptio is importat. Several studies have bee coducted o the estimatio of breast cacer related to the Gail model or perceived risk examiatio. 11Y13 There are few studies which evaluated ad compared perceived ad calculated breast cacer risks. 14 I our study, comparig with calculated risk by Gail model, urses ad midwives rated their perceived risk more likely as moderate ad strog. Similarly, Davids et al, 10 Smith et al, 13 Buxto et al 7 reported that wome overestimated persoal breast Table 3 & Distributio of Perceived Breast Cacer Risk of Participats Accordig to Breast Cacer Screeig Practices (BSE ad Mammography) Usual Moderate Strog Breast Cacer Screeig Practices No. (138) % No. (61) % No. (!6) % P Mothly BSE practice.34 Yes No Mammography practice (40 years ad older)*.01 Yes No BSE idicates breast self-examiatio. * = 43 (40 years ad older). Breast Cacer Risk Assessmet ad Risk Perceptio Cacer Nursig TM, Vol. 29, No. 3, Copyright Lippicott Williams & Wilkis. Uauthorized reproductio of this article is prohibited.

5 Table 4 & Compariso of Participats Perceived ad Calculated Breast Cacer Risk Estimates Risk Estimates No. (138) % No. (61) % No. (!6) % P* Calculated risk.00 Usual Moderate Total *P value correspods to the Pearso chi-square test. Usual Moderate Strog cacer risks. These fidigs suggest that the urses ad midwives have a lack of kowledge about breast cacer risk factors or that they have a serious fear of breast cacer. Participats with a family history of breast cacer or a history of previous breast disease were more likely to overestimate their risk tha wome without these risk factors. This fidig is i accord with results of several other studies. 10,13,19,20 The result suggests that havig a persoal or family history of previous breast pathology may icrease the perceived risk by way of makig wome more sesitive about the topic. The study revealed that approximately half of the participats had a mothly practice of BSE, whereas their use of mammography was lower tha expected despite the fact that they were all healthcare professioals. 3 There is theoretical cocer that lowerig of breast cacer risk perceptios may discourage breast cacer screeig. Although data are limited, optimistic bias might actually be positively associated with adherece to mammography screeig guidelies. 21 Furthermore, there is suggestio that worry about breast cacer is prompted by high perceived susceptibility, ad this might be a barrier to mammography screeig. 22 The study suggests that the urses ad midwives, although they are health professioals, they eed be kowledgeable about breast cacer to be aware of their accurate breast cacer risk ad to covice the wome they cousel. Limitatios Oe of the limitatios of the preset study is that o gold stadard exists for measurig risk perceptios. The perceived risk scale so far developed eeds to be validated by further studies also i Turkey. The secod limitatio is that Gail model is still devoid of a stadard adaptatio i Turkey, although it was previously used i several studies. I Turkey, urses ad midwives have a importat role i cacer prevetio ad health educatio. For breast cacer, primary prevetio icludes educatig wome o breast cacer risk factors ad ifluecig behavior chage, whereas secodary prevetio icludes screeig for ad early detectio of the disease. Previous studies have show that kowledge is directly associated with prevetive efforts, ad a positive correlatio exists betwee breast cacer perceptio ad screeig practices amog differet groups. 9,23 I this study, similar fidigs were foud betwee perceived risk ad use of mammography. The results of the study provide importat baselie iformatio about perceptio of breast cacer i health professios. I Turkey, such iformatio may be used to develop breast cacer awareess ad educatio programs, icrease primary ad secodary prevetive efforts, ad evaluate the effectiveess of prevetio programs. Future Research Future studies may focus o wome i geeral ad other healthcare professioals, such as physicias. I additio, emphasis should also be placed o the relatio betwee breast cacer perceptio ad screeig practices. This relatio would help to clarify whether educatig Turkish wome would actually improve their screeig practices. Coclusio Despite more frequet healthcare utilizatio i recet years, the rate of participatio i breast cacer screeig is still too low. This rate depeds o a balace betwee iformatio demads, fear of cacer, awareess of risk factors, ad persoal risk perceptio. A high level of lifetime breast cacer Implicatios Figure 1 Proportio of participats accordig to perceived ad calculated breast cacer risks. 248 Cacer Nursig TM, Vol. 29, No. 3, 2006 Çeber et al Copyright Lippicott Williams & Wilkis. Uauthorized reproductio of this article is prohibited.

6 risk perceptio amog urses ad midwifes workig i primary health ceters costitutes a cosiderable miscoceptio. To reduce fear ad icrease the participatio rate i early breast cacer detectio program, there is a urget eed to offer more iformatio regardig risk factors i geeral ad give guidace regardig persoal risk. Nurses ad midwives, as healthcare providers, have crucial roles to play i early breast cacer detectio program. They should recogize these miscoceptios ad be aware of their ow risk; hece, may wome may have effective risk couselig. Nurses ad midwives should recogize their resposibility i cacer prevetio through couselig wome about breast cacer risks. Refereces 1. Brewster A, Helzlsouer K. Breast cacer epidemiology, prevetio, ad early detectio. Curr Opi Ocol. 2001;13(6):420Y T.R. Miistry of Health. Cacer Cotrol Programme ad Cacer Statistical i Turkey (1995Y1999). Publish No:618; Zicir H. Malatya Il Merkezide 40 Yas$ Üzeri KadNlarN Meme Kaseri ve Koruma Kousuda Bilgi Tutum ve DavraNs$larN, Yüksek Lisas Tezi, T.C. Iöü Üiversitesi SağlNk Bilimleri Estitüsü Halk SağlNğN Aabilim DalN, Malatya; Rosvold EO. Breast self-examiatio ad cervical cacer testig amog Norwegia female physicias. Soc Sci Med. 2001;52(2):249Y Perallo NP, Fox PG, Alba ML. Acculturatio ad breast self-examiatio amog immigrat Latia wome i the USA. It Nurs Rev. 2000; 47:38Y Cretai KG. Motivatioal factors i breast self-examiatio implicatio for urses. Cacer Nurs. 1989;12(4):250Y Buxto JA, Bottorff JL, Baleaves LG, et al. Wome s perceptios of breast cacer risk: are they accurate? Ca J Public Health. 2003;94(6): 422Y Leslie NS. Role of the urse practitioer i breast ad cervical cacer prevetio. Cacer Nurs. 1995;18(4):251Y Madaat H, Merrill R. Breast cacer risk-factor ad screeig awareess amog wome urses ad teachers i Amma, Jorda. Cacer Nurs. 2002;24(4):276Y Davids SL, Schapira MM, McAuliffe TT, Nattiger AB. Predictors of pessimistic breast cacer risk perceptios i a primary care populatio. J Ge Iter Med. 2004;19:310Y Boyle P, Mezzetti M, Vecchia CL, Fraceschi S, Decarli A, Robertso C. Cotributio of three compoets to idividual cacer risk predictig breast cacer risk i Italy. Eur J Cacer Prev. 2004;3(3):183Y Daly MB, Lerma CL, Ross E, Schwartz MD, Sads CB, Masy A. Gail model breast cacer risk compoets are poor predictors of risk perceptio ad screeig behavior. Breast Cacer Res Treat. 1996;41(1):59Y Smith BL, Gadd MA, Lawler C, et al. Perceptio of breast cacer risk amog wome i breast ceter ad primary care settigs: correlatio with age ad family history of breast cacer. Surgery. 1996;120(2):9297Y Quilli JM, Fries E, McClish D, Paredes E, Bodurtha J. Gail model risk assessmet ad risk perceptios. J Behav Med. 2004;27(2):205Y Schapira Mm, Davids SL, Auliffe TL, Nattiger AB. Agreemet betwee scales i the measuremet of breast cacer risk perceptios. Risk Aal. 2004;24(3):665Y Gail MH, Brito LA, Byar DP, et al. Projectig idividualized probabilities of developig breast cacer for white females who are beig examied aually. J Natl Cacer Ist. 1989;81(24):1879Y PPhls UG, Reer SP, Faschig PA, Lux MD, et al. Awareess of breast cacer icidece ad risk factors amog healthy wome. Eur J Cacer Prev. 2004;13(4):249Y Natioal Cacer Istitute, Software versio 7, July Natioal Cacer Istitute, Baltimore, MD. Available at: brc/; Accessed July 20, Poledak AP, Lae DS, Burg MA. Risk perceptio, family history, use of breast cacer screeig tests. Cacer Detect Prev. 1991;15(4):257Y VaAspere CJ, Joker MA, Jacobi CE, et al. Risk estimatio for healthy wome from breast cacer families: ew isights ad ew strategies. Cacer Epidemiol Biomarkers Prev. 2004;13(1):87Y Facioe NC. Perceived risk of breast cacer: Ifluece of heuristic thikig. Cacer Pract. 2002;10(5):256Y Lerma C, Daly M, Sads C, et al. Mammography adherece ad psychological distress amog wome at risk for breast cacer. J Natl. Cacer Ist. 1993;85(13):1074Y Lee CY, Kim HS, Ham O. Kowledge, practice ad risk of breast cacer amog rural wome i Korea. Nursig ad Health Sciece. 2000;2: 225Y230. Breast Cacer Risk Assessmet ad Risk Perceptio Cacer Nursig TM, Vol. 29, No. 3, Copyright Lippicott Williams & Wilkis. Uauthorized reproductio of this article is prohibited.