Breast self-examination practice and breast cancer risk perception among female university students in Ajman, UAE

Transcription

1 Breast self-examination practice and breast cancer risk perception among female university students in Ajman, UAE Shatha Al-Sharbatti 1*, Rizwana B Shaikh 1, Elsheba Mathew 1, Mawahib A Albiate 2 1 Department of Community Medicine, Gulf Medical University, Ajman, UAE 2 Department of Obstetrics and Gynaecology, Gulf Medical College Hospital and Research Centre, Ajman, UAE *Presenting Author ABSTRACT Objectives: The present study assessed the prevalence of Breast Self-Examination (BSE) practice among female university students and identified the most important reasons for not performing BSE and also assessed their breast cancer risk perception. Materials and Methods: A cross-sectional study was conducted among female students in three universities in Ajman namely, Gulf Medical University [U1], offering health related programs, Ajman University of Science and Technology [U2] offering mostly science and technology programs, and Preston University Ajman [U3] offering science programs. A stratified random sampling procedure was adopted in recruiting the participants. Validated, pilot-tested, self-administered questionnaire was used to collect data related to sociodemography, information whether they practiced BSE, the frequency of BSE, timing of BSE in relation to menstruation, and if they were using any measure to remind themselves about the timing, factors that discouraged them doing BSE, whether they considered themselves to be at-risk of having breast cancer or not, how much the risk they attributed to. Data were entered in to Excel sheets and analyzed using PASW 19. The χ 2 test was used for testing the association. Results: The results shows that the majority of the participants were between years of age (63.5%), from Eastern Mediterranean countries (72.2%), and unmarried (82%). The family history of breast cancer was positive for 9.2% and was more common among second degree relatives (63.9%). None of the students had a personal history of breast cancer. 89 (22.7%) reported ever practiced BSE, only 3.3% were practicing monthly, while 77.3% admitted that they were not practicing BSE. No significant association was noticed between family history of breast cancer and the practice of breast self-examination (P<0.9).No significant associations were noticed between BSE Practice and age, nationality, and university. Married female students had significantly higher frequency of BSE practice. With regard to the risk perception about breast cancer, (25%) thought that they were at risk. Higher frequency of BSE practice was seen among participants who perceived themselves to be at risk of breast cancer, but the difference was not significant. Conclusion: The study showed that the proportion of female university students who ever practiced or practiced BSE monthly was low. The most frequent discouraging factors for BSE were lack of knowledge on how to do BSE and the absence of advice of a doctor to do BSE. About one third of the respondents perceived themselves to be at risk for breast cancer and in about half of those the perceived risk was low. Key words: BSE, university students, perceived risk, UAE INTRODUCTION Breast cancer is the most common cancer among women worldwide 1. Although breast cancer is thought to be a disease of the developed world, a majority (69%) of breast cancer deaths occur in the developing countries 2. The estimated number of new cases is expected to rise from 10 million reported in 2002 to 15 million by 2025, with 60% occurring in the developing countries 3. Breast cancer survival rates vary greatly worldwide, ranging from 80% or over in the developed countries to less than 40% in low-income countries 4. The low survival rates in the less developed countries have been attributed to the lack of early detection programs, resulting in a high proportion of women presenting 72 GMJ, 4 th Annual Scientific Meeting of Gulf Medical University Oral Proceedings 2012

2 with late-stage disease, as well as lack of adequate facilities for diagnosis and treatment 5. Early diagnosis is an important strategy, particularly in low- and middleincome countries where the disease is diagnosed in late stages and resources are limited. There is some evidence that this strategy can produce down staging of the disease to stages that are more amenable to curative treatment 6. There is evidence that breast cancer deaths can be reduced significantly if the tumor is discovered at an early stage 7. The American Cancer Society (ACS) guidelines 8 for the early detection of breast cancer vary depending on the age of women and include mammography and clinical breast examination (CBE). In 2003, the American Cancer Society revised its recommendation for all women to perform monthly breast self examination (BSE) 9. The recommendations, however, encourage all women to become familiar with both the appearance and feel of their breasts so that they can notice any changes and report them promptly to a doctor or nurse. Evidence suggests that BSE is a reliable screening tool when used as an adjunct to clinical breast examination and imaging studies 10,11. In addition, early diagnosis of breast cancer has been related to the frequency of BSE 12. In the UAE, cancer among women is a problem of public health concern 13. The National Cancer Incidence Report 14 showed that the majority of cases (47.9%) had regional lymph node involvement, and distant metastasis was observed in 9% of the cases, which indicated late diagnosis in the majority of cases. The UAE standards for Screening and Diagnosis of Breast Cancer indicated that women between years need to be Breast Aware which means that they should be encouraged and educated on how to conduct breast self-examination to become aware of the feel and shape of their breasts, so that they are familiar with what is normal for them and to report any changes immediately to her healthcare provider 15. To date, breast cancer screening and early detection remain the most important strategy in improving survival and breast cancer outcome 1. In the UAE, the available data showed marked underutilization of the existing public screening services. In 2007, only 12% of the target population of women underwent screening via mammography 16. No information is available about the frequency of this practice among female university students in Ajman, UAE or about their breast cancer risk perception. In the present study authors assessed the prevalence of Breast Self Examination (BSE) practice among female university students and identified the most important reasons for not performing BSE and also assessed their breast cancer risk perception. MATERIALS AND METHODS A cross sectional study was conducted between April 2011 and June The study included female students in three large universities in Ajman namely, Gulf Medical University [referred to as U1], offering health related programs, Ajman University of Science and Technology [referred to as U2] offering mostly science and technology programs, and Preston University Ajman [referred to as U3] offering science programs. A stratified random sampling procedure was adopted in recruiting the participants. Validated, pilot-tested, self-administered questionnaire was used as a tool for data collection. The questionnaire included in addition to demography data, information whether they practiced BSE, and if the response was yes, then the frequency of BSE, timing of BSE in relation to menstruation, and if they were using any measure to remind themselves about the timing. For participants who were not doing BSE, the questionnaire included questions related to factors that discouraged them. Perception of the participants was assessed by a question whether they considered themselves to be at-risk of having breast cancer or not and for those whose reply was yes, how GMJ,4 th Annual Scientific Meeting of Gulf Medical University Oral Proceedings

3 Table 1. Distribution of participants by age, nationality, marital status and university Variables (n=392) Categories No % Age (in years) < Ethnicity Europe South East Asia West Pacific Africa America Eastern Mediterranean Marital status Unmarried Married Separated/ widows University U U U Table 2. Distribution of participants by family history of breast cancer Family history (n=36) No % First degree Second degree Others Table 3. Distribution of participants by Breast Self Examination (BSE) practice Practice of BSE Number % No practice Rarely Sometimes Every Month Total Table 4. Participants responses for factors that might discourage BSE practice Factors that might discourage BSE practice Yes NO Total No. % No. % Do not have time Do not think am at risk Do not know how to do My doctor did not ask me to do BSE is harmful I am afraid to do BSE I feel shy to do BSE GMJ, 4 th Annual Scientific Meeting of Gulf Medical University Oral Proceedings 2012

4 Table 5. Distribution of participants by family history of breast cancer and the practice of Breast Self Examination Family History of breast cancer Practice of Breast Self Examination Total (100%) No (%) Yes (%) No 275 (77.2) 81 (22.8) 356 Yes 28 (77.8) 8 (22.2) 36 Total 303 (77.3) 89 (22.7) 392 Table 6. Distribution of participants by age, nationality, marital status, university and BSE Practice Variables (n=392) Age (in years) Ethinicity Marital status University BSE Categories No (100%) NO Yes No. (%) No. (%) < (73.7) 15(26.3) (83.5) 22(16.5) (73.3) 31(26.7) (75.0) 12(25.0) (76.3) 9(23.7) Others (76.1) 26(22.3) Eastern Mediterranean (77.7) 63(23.9) Unmarried (80.2) 69(19.8) Married / Separated/ 43 23(53.5) 20(46.5) widows U (74.6) 36(25.4) U (75.9) 33(24.1) U (82.2) 20(17.7) P > 0.05 > 0.05 <0.001 >0.05 Table 7. Distribution of participants by breast cancer risk perception and the BSE practice Risk perception for breast cancer Practice of Breast Self Examination Total (100%) No (%) Yes (%) No 228(77.6) 66(22.4) 294 Yes 75(76.5) 23(23.5) 98 Total much the risk they attributed to. The tool also included a question about their willingness to participate in education programs for breast cancer and to encourage female relatives and friends to undergo screening. Data were entered in to excel sheets and analyzed using PASW 19. The χ 2 test was used for testing the association. RESULTS The study included 392 participants. Their distribution by age, nationality, marital status and university are given in Table 1, which shows that the majority of the participants were between years of age (63.5%), from Eastern Mediterranean countries (72.2%), and unmarried (82%). Table 2 shows the family history of breast cancer which was positive for GMJ,4 th Annual Scientific Meeting of Gulf Medical University Oral Proceedings

5 9.2% (n=36) of the participants, and the disease was more common among second degree relatives (63.9%, n= 23). None of the students had a personal history of breast cancer. Table 3 shows distribution of participants by Breast Self Examination (BSE) practice. Although 89 participants (22.7%) reported ever practiced BSE, only 3.3% (n=13) were practicing monthly, while 77.3% (n=303) admitted that they were not practicing BSE. Among participants who practiced BSE, 34.8% of them (n=31) practiced at the correct timing in relation to menstruation and 16.9% of them (n=15) marked the next date for BSE on the calendar. Among participants who practiced BSE, 34.8% (n=31) practiced at the correct timing in relation to menstruation and 16.9% (n=15) marked the date for the next BSE on the calendar. Participants responses for factors that might discourage BSE practice are shown in Table 4. The most frequent discouraging factors were: lack of knowledge regarding how to do BSE (about 60%), and lack of previous advice by doctor for doing BSE (about 52%). Distribution of participants by family history of breast cancer and the practice of Breast Self Examination is shown in table 5. No significant association was noticed between family history of breast cancer and the practice of breast self examination (P=0.9). No significant associations were noticed between BSE Practice and age, nationality, and university. Married female students had significantly higher frequency of BSE practice (Table 6) With regard to the risk perception about breast cancer, 98 participants (25%) thought that they were at risk. Higher frequency of BSE practice was seen among participants who perceived themselves to be at risk of breast cancer, but the difference was not significant (Table 7). As regards opinion on the perceived risk, out of the 93 respondents, the perceived risk was low in 43 (46.2%), moderate in 39 (41.9%) and high in 11(11.8%). Comparing the frequency of breast cancer to other cancers, out of the total 274 respondents, 207 (75.5%) correctly identified breast cancer as the most frequent cancer among women, only 12 (4%) incorrectly reported breast cancer to be the least frequent cancer among women and 51 respondents(19%) did not know about the magnitude of this problem. Among the 392 participants 259 (66.1%) were willing to participate in education programs for breast cancer and 336 (85.7%) willing to encourage female relatives and friends to undergo screening. DISCUSSION Breast cancer is the most common cancer among females in the UAE, accounted for 37.3% and 38.6% in 2004 and 2005 respectively 17. Early detection plays the leading role in reducing mortality rates and improving the patients prognosis 18. Ministry of Health, UAE 2008 report showed that 28% of deaths attributed to breast cancer occurred in women less than 45 years of age 19. Breast cancer is generally more aggressive in young women and results in lower survival rates, making early detection even more important 19. Although evidence exists that breast self-examination does not reduce breast cancer mortality 20,21, findings support that BSE makes women more breast aware, which in turn may lead to an earlier diagnosis of breast cancer 22. Moreover, the practice of BSE has been seen to empower women, taking responsibility for their own health 1. In this study 22.7% of the participants practiced BSE but only 3% of them practiced BSE monthly. This is lower than that reported in a study among female university students in Malaysia 22, where 36.7% practiced BSE and 10% practiced monthly and that (54.8%) reported from Nigeria 23. In Turkey 24, 6.7% of the high school students performed BSE monthly and 20.3% performed BSE irregularly. In 76 GMJ, 4 th Annual Scientific Meeting of Gulf Medical University Oral Proceedings 2012

6 Iran 25, 37% of the respondents practiced BSE and 17% of women practiced regular BSE. In the present study, 9% of the participants reported family history of breast cancer, a percentage is similar to that reported in another study (9.8%) among female high school and college students in Saudi Arabia 26. The 2009 Lebanese National Mammography Campaign showed that 8.9% of participants had a family history of breast cancer 27. In Pakistan 28, among the one thousand women interviewed, 13.4% reported family history of breast cancer among which 18% had their first degree relatives affected. No significant association was noticed between family history of breast cancer and BSE practice, which is in agreement with another study reported from Iran 25. A study to investigate the knowledge and practice of breast self-examination (BSE) among Saudi female nursing college students showed no significant association between family history of breast cancer and BSE practice 29. There is evidence that having a family history is the strongest predictor of lifetime risk. Moreover, a perception of personal risk, which is important for appropriate prevention efforts, is found to be exaggerated among individuals with family history 30. A recent study showed that family history of cancer significantly influenced the practice of the BSE among Malaysian women 31. In the present study no significant association was observed between age and BSE, similar to a study among women in rural area of Turkey 32. But this finding disagrees with those of studies from Iran 25,33. Marital status was significantly associated with BSE practice, which is in agreement with studies from Iran 25,33. The most frequently reported barrier to BSE in the present study group was the lack of knowledge about BSE (60%), a finding consistent with reports from Nigeria 34 (stated as 87.5%), and Turkey 24 ( 98.5%). The perception that young women do not consider themselves at risk for developing breast cancer can discourage them from doing BSE and this was stated by about one third of the participants studied. In Turkey 24, a similar perception was reported by 45.6% of respondents. In a study from Saudi Arabia 34, the reported frequencies for the previous two barriers were 65% and 55% respectively. Identification of barriers regarding BSE is essential and can be used to design appropriate educational interventions which promote early identification of any pathology in the breast. Information on perceived barriers has been reported by researchers from Iran 35 who have used it as a predictor of BSE behaviour. In this study, a high frequency of BSE practice was observed among participants who perceived themselves to be at risk of breast cancer, which emphasizes the Health Belief Model which stipulates that health-related behaviour is influenced by a person s perception of the threat posed by a health problem and by the value associated with his or her action to reduce that threat 32. Regarding the participants perception of the magnitude of the problem of breast cancer, most of the respondents (75.5%) correctly reported breast cancer as the most frequent cancer among women. This is in agreement with a study among Myanmar women 36. In a study from Germany, only one-third of the respondents correctly estimated the incidence of breast cancer 37, and the authors felt that such knowledge could influence the efficacy of program for early detection of breast cancer. The current data show that participants who perceived themselves to have a risk of breast cancer had higher median knowledge scores. The results show an association between perceived risk and undergoing screening measures like mammography or genetic testing 38. Positive attitudes toward breast cancer education and screening were noticed among the majority of the study participants. Evidence exists that education regarding BSE, CBE, GMJ,4 th Annual Scientific Meeting of Gulf Medical University Oral Proceedings

7 and mammography, especially among females with family history of breast cancer, results in awareness and positive attitudes towards the benefits of early breast cancer screening 23. A study among nursing students in Nigeria 39 showed that most of the respondents (98.5%) thought BSE was necessary. Another study among female undergraduates in Nigeria 40 showed that while 42.8% of the respondents believed that it was necessary to perform breast self examination, only 18.3% of the respondents actually sought the knowledge about breast selfexamination. CONCLUSION The study showed that the proportion of female university students who ever practiced or practiced BSE monthly was low. The most frequent discouraging factors for BSE were lack of knowledge on how to do BSE and the absence of advice of a doctor to do BSE. About one third of the respondents perceived themselves to be at risk for breast cancer and in about half of those the perceived risk was low. RECOMMENDATION It is recommended that female university students in Ajman should be included in education programs on breast cancer including those on the skills needed for BSE. REFERENCES 1. WHO Report: Breast cancer: prevention and control. [online]. Available from: URL: breastcancer/en/index1.html. [Accessed on 2010,February 21] 2. WHO Report:. The global burden of disease: 2004 update. WHO (2008) [online]. Available from: URL: healthinfo/global_burden_disease/gbd_ report_2004update_full.pdf. [Accessed on 2010,February 21] 3. World Health Organization (WHO). Guidelines for the early detection and screening of breast cancer. EMRO Technical Publications Series No 30, Available from: URL: [Accessed on 2010,February 21] 4. Coleman MP, Quaresma M, Berrino F, et al. Cancer survival in five continents: a worldwide population-based study (CONCORD). Lancet Oncol 2008;9(8): WHO report. Breast cancer: prevention and control. [online]. Available from: URL: breastcancer/en/index.html. [Accessed on 2012,February 29]. 6. Yip CH, Smith RA, Anderson BO, et al. Guideline implementation for breast healthcare in low- and middle-income countries: early detection resource allocation. Breast Health Global Initiative Early Detection Panel. Cancer 2008;113(8): Luquis RR and Villanueva IC. Knowledge, attitudes, and perceptions about breast cancer and breast cancer screening among hispanic women residing in South Central Pennsylvania. J Community Health 2006;31(1): Breast cancer facts & figures Atlanta, American Cancer Society Inc. [online]. Available from: URL: org/acs/groups/content/@nho/documents/ document/caff2005brfacspdf2005pdf.pdf. [Accessed on 2010,February 21]. 9. Smith RA, Saslow D, Sawyer KA, et al. American Cancer Society guidelines for breast cancer screening: update CA Cancer J Clin 2003 May-Jun;53(3): Chong PN, Krishnan M, Hong CY, et al. Knowledge and practice of breast cancer screening amongst public health nurses in Singapore. Singapore Med J 2002;43: Loescher L. Nursing roles in cancer prevention position statements. Semin Oncol Nurs 2004;20: Abdel-Fattah M, Zaki A, Bassili A, et al. Breast self-examination practice and its impact on breast cancer diagnosis in Alexandria, Egypt. Eastern Mediterranean Health Journal 2000;6: Al-Hosani H. Health for all in the United Arab Emirates. Eastern Mediterranean Health Journal 2000; 6: Al Khatib F. Cancer Incidence Report st Ed. UAE: United Arab Emirates Ministry Of Health Preventive Medicine 2002: Health Authority-Abu Dhabi. HAAD Standard for the Screening and Diagnosis of Breast Cancer December [online]. Available from: URL : LinkClick.aspx?fileticket=RbGqiUnqiSk%3D &tabid=819.[accessed on 2012,March 21]. 16. Global Initiative for Breast Cancer Awareness Team. Health Authority Abu Dhabi (HAAD) Public Health & Policy Department. Community Profile Summary of Findings March July. 17. Ministry of health. Annual Report. Preventive medicine sector. UAE GMJ, 4 th Annual Scientific Meeting of Gulf Medical University Oral Proceedings 2012

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