Assessment Awareness of Public About Breast Cancer and its Screening Measurements in Asir Region, KSA
verfasst von:
Safar M. Alshahrani, Khalid A. Fayi, Saeed H. Alshahrani, Dhafer S. Alahmari, Khaled M. Al Bejadi, Dhafer M. Alahmari, Talal M. Alshahrani, Motaz N. Alsharif
Breast cancer (BC) has a major impact on women’s health worldwide. The Kingdom of Saudi Arabia is no exception, where it is considered the most common malignancy, embodying the second leading cause of cancer deaths after lung cancer. In today’s world, people are more health conscious and more aware of different medical specialties. Despite the tremendous advancements in education, there seems to be a limited knowledge among the public regarding this issue. Various studies have been conducted in many regions to determine the perception/awareness about breast cancer. The present study is of the first of its type in our region, assessing the awareness of the public about breast cancer and its screening measurements. As per our knowledge, there is no study that estimated the awareness of breast cancer and its screening measurements among the public in the Asir region. Therefore, this study aims to estimate the awareness of breast cancer and its screening measurements among public and assess the knowledge about Breast Self-Examination (BSE) and their opinion about its effectiveness in early diagnosis of breast cancer to detect the relationship between awareness and socioeconomic status. This study is a cross-sectional prospective study, with a sample of 1046 participants aged between 12 and 80 years (male and female) from the Asir region evaluated by questionnaire after attaining consent. The selection of participants was based on the simple random sampling method. The majority of participants were of age 20 to less than 30 years (56.9%). About half of them were males (52.7%). The majority was single (61.2%). Most of them (74.0%) have a high education level (University and more). About one-third of the participants (32.7%) worked in the medical field, and most of them worked in the non-medical field (46.6%). Regarding general knowledge, the score was 60.2%, which represented a relatively good knowledge. The overall knowledge regarding breast cancer as recorded by our population reported that only 18.8% had good knowledge. Participants of this resettlement colony have poor knowledge about breast cancer, be it about risk factors, signs, and symptoms, or early detection procedures, where the overall knowledge score was only 18.8%.
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Introduction
Breast cancer (BC) is a serious disease and a leading cause of deaths among females worldwide [1]. Approximately 1.67 million new cases of breast cancer, representing 25% of all cancers, were diagnosed among women in 2012 [2]. Its incidence is the highest in developed countries, with rates as high as 92 per 100,000 people in North America compared with 27 per 100,000 people in Middle Africa and Eastern Asia [2].
In 2010, breast cancer was the ninth leading cause of death for females in the Kingdom of Saudi Arabia (KSA) [3, 4]. Moreover, 1308 new breast cancer cases were reported in 2009, and about 25% of all new cancer cases were registered among Saudi women [5]. The incidence of breast cancer, it is expected, will increase in the coming decades in KSA due to the population’s growth and aging [6].
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A breast lump, one of the most common presentations of breast lesion, can be detected through breast self-examination (BSE), clinical breast examination (CBE), and mammography. Early detection and prompt treatment offer the greatest chance of long-term survival in breast cancer patients [7, 8]. Mammography, CBE, and BSE are the secondary preventive methods used for screening in the early detection of breast cancer [7]. Cancer-screening tests play a pivotal role in reducing breast cancer-related mortalities [7]. The American Cancer Society (ACS) recommends CBE and mammography for the early detection of breast cancer [9]. According to ACS recommendations, women should know how their breasts normally feel and report any changes promptly to their health care providers. BSE is an option for women starting from the early 20s [7, 9‐11].
Many women miss early detection and treatment opportunities owing to lack of information, knowledge, breast cancer awareness, and cancer-screening practices [12]. A significant number of women have advanced stages of the disease due to lack of information, knowledge, and awareness of early detection measures. Two previous studies showed limited knowledge about breast cancer screening, and few women performed screening for early detection purposes [13‐15].
This study aims to assess breast cancer knowledge, beliefs, and practices among Saudi women and men related to (i) disease-associated risk factors, (ii) causes (including myths and folklore), (iii) early detection, and (iv) existing and preferred sources of information. The ultimate goal of the work is to inform the development of effective breast cancer educational resources for Saudi women aimed at removing barriers to evidence-based prevention and early detection interventions. Hence, we undertook this study with an aim to ascertain awareness among the public about breast cancer.
Materials and Methods
This study is a cross-sectional prospective study, with a sample of 1046 participants aged between 12 and 80 years (male and female) from the Asir region evaluated by a questionnaire after taking their consent. The participants were selected based on the simple random sampling method. The consent form was given to participants after the purpose and method of the study was explained to each one of them. Participants who refused were excluded. We invited them to participate in a 31-question survey to assess their attitude, knowledge, perception, and understanding of breast cancer and its screening measurements. The information sought in the questionnaire also included demographics of the participants. The personal information about the students was kept confidential. The study was performed from Nov. 2018 to Mar. 2019. The study protocol was approved by the Ethics Committee of King Khalid University, and this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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Statistical Analysis
The collected data was revised, coded, and fed to the statistical software IBM SPSS version 20. The given graphs were constructed using Microsoft Excel. All statistical analysis was done using two-tailed tests and with an alpha error of 0.05. A p value less than or equal to 0.05 was considered to be statistically significant. For knowledge domains, each correct answer was given one point score, and the total domain score was assessed by summing the discrete scores for each item. The score was then transferred into score percent of maximum by dividing over the total score and multiplying it by 100. The score percentage was then categorized into poor level if it was less than 60% of the maximum score and good if more. Chi-square/Mont Carlo exact test and Fisher’s exact test were used to test for the association between different patients’ factors and knowledge level. Exact tests were used if there were small frequencies where chi-square was invalid. Multiple logistic regression models were used to estimate the adjusted effect of different participants’ data on their knowledge level.
Results
Table 1 shows the distribution of 1046 participants according to some of their socio-demographic characteristics. The majority of them were of age 20 to less than 30 years (56.9%). About half of them were males (52.7%). The majority was single (61.2%). Most of them (74.0%) have a high education level (University and more). About one-third (32.7%) worked in the medical field, and most of them worked in non-medical fields (46.6%). Approximately, all of them were from Saudi (98.6%), and one-half belonged to intermediate monthly income families of 5000–15,000 Saudi Riyals (51.9%). Almost all of them have no breast cancer history (98.1%). Breast cancer in their family history was reported by 13.4% of the participants.
Table 1
Personal and family data of general population participants from the Asir region, Saudi Arabia, 2018
Personal data
No.
%
Age in years
< 20 years
124
11.9
20−
595
56.9
30−
168
16.1
40+
159
15.2
Gender
Male
551
52.7
Female
495
47.3
Marital status
Single
639
61.1
Married
391
37.4
Divorced/widow
16
1.5
Educational level
Below university
272
26.0
University/more
774
74.0
Work field
Not working
217
20.7
Non-medical field
487
46.6
Medical field
342
32.7
Nationality
Saudi
1031
98.6
Non-Saudi
15
1.4
Monthly income
Less than 5000 S.R
199
19.0
5000–15,000 S.R
543
51.9
15,000–30,000 S.R
243
23.2
More than 30,000 S.R
61
5.8
History of breast cancer
Yes
11
1.1
No
1035
98.9
Family history of breast cancer
Yes
140
13.4
No
906
86.6
Table 2 shows the distribution of participants according to knowledge and BSE issues of breast cancer. Regarding general knowledge, the score was 60.2%, representing a relatively good knowledge. With regard to knowledge of signs and symptoms, risk factors, and BSE. The scores were 51.4%, 31.8%, and 49.8% respectively, reflecting poor knowledge.
Table 2
Breast cancer knowledge domains as recorded by the general population in the Asir region, Saudi Arabia, 2018
Knowledge domain
Poor
Good
Score (%)
No.
%
No.
%
General knowledge
592
56.6%
454
43.4
60.2
Knowledge about signs and symptoms
539
51.5%
507
48.5
51.4
Knowledge about risk factors
944
90.2%
102
9.8
31.8
Knowledge about BSE
688
65.8%
358
34.2
49.8
Poor: score % < 60%.
Good: score % 60–100%.
BSE breast self-examination.
Fig. 1 illustrates the overall knowledge regarding breast cancer as recorded by our population; as reported, only 18.8% had good knowledge.
Fig. 1
Overall knowledge regarding breast cancer as recorded by the general population in the Asir region, Saudi Arabia, 2018
×
The associations between socio-demographic characteristics and BC knowledge scores are illustrated in Table 3. Knowledge of BC was significantly associated with age, gender, educational level, the field of work, and monthly income (p value = 0.001, 0.002, 0.002, 0.001, and 0.018 respectively). The good knowledge scores were lowest among participants whose age was less than 20 years (8.1%), male gender (15.2%), participants with below university educational level (12.5%), non-medical field workers (12.5%), and participants whose income was less than 5000 SR (13.6%). Conversely, the good knowledge scores were highest among participants of age 20 to less than 30 years (27.4%), female gender (22.8%), participants with university or more educational level (21.1%), medical field workers (28.9%), and participants whose income was more than 30,000 SR (27.9%).
Table 3
Distribution of breast cancer knowledge of the general population by their personal and family data, Asir region, Saudi Arabia, 2018
Factors
Overall knowledge
p
Poor
Good
No.
%
No.
%
Age in years
< 20 years
114
91.9
10
8.1
.001*
20−
448
75.3
147
24.7
30−
147
87.5
21
12.5
40+
140
88.1
19
11.9
Gender
Male
467
84.8
84
15.2
.002*
Female
382
77.2
113
22.8
Marital status
Single
508
79.5
131
20.5
.208
Married
327
83.6
64
16.4
Divorced/widow
14
87.5
2
12.5
Educational level
Below university
238
87.5
34
12.5
.002*
University/more
611
78.9
163
21.1
Work field
Not working
180
82.9
37
17.1
.001*
Non-medical field
426
87.5
61
12.5
Medical field
243
71.1
99
28.9
Monthly income
less than 5000 S.R
172
86.4
27
13.6
.018*
5000-15,000 S.R
446
82.1
97
17.9
15,000–30,000 S.R
187
77.0
56
23.0
More than 30,000 S.R
44
72.1
17
27.9
History of breast cancer
Yes
8
72.7
3
27.3
FEP = .472
No
841
81.3
194
18.7
Family history of breast cancer
Yes
106
75.7
34
24.3
.076
No
743
82.0
163
18.0
P Pearson χ2 test, FEP Fisher exact probability
*p < 0.05 (significant)
Table 4 shows the logistic regression analysis of breast cancer knowledge among participants with some independent variables. After adjusting for all possible confounders, the significant predictors to breast cancer were found to be positive females (p = 0.000), high education (p = 0.040), medical field workers (p = 0.000), income (p = 0.017), and lower PMS of barrier domain (p = 0.046).
Table 4
Multiple logistic regression model for predictors of breast cancer knowledge among the general population in the Asir region, Saudi Arabia, 2018
Factor
B
SE
P
AOR
95% C.I. for OR
Lower
Upper
Age in years
− .267
.144
.064
.766
.58
1.02
Female
1.013
.185
.000
2.76
1.92
3.96
Married
.111
.254
.661
1.12
.68
1.8
High education
.089
.043
.040
1.09
1.01
1.19
Medical field work
.666
.141
.000
1.95
1.48
2.56
Income
.249
.104
.017
1.28
1.05
1.57
History of BC
.785
.727
.281
2.17
0.52
9.09
Family history of BC
.389
.228
.088
2.33
0.94
2.42
Constant
− 2.696
1.536
.079
.068
Model pseudo R2; significance
12.3%; .003*
Model fit
81.5%
SE standard error, AOR adjusted odds ratio, CI confidence interval
Regarding sources of BC knowledge among our population, more than half of them received their knowledge from mass media, 18.4% from relatives, 17.1% from conferences, 7.2% from books, and 1.3% from physicians (Fig. 2).
Fig. 2
Sources of breast cancer knowledge among the general population in the Asir region, Saudi Arabia, 2018
×
Table 5 shows the BSE practice recorded among our population. About half of the participants (52.5%) had previously undergone BSE. Regarding the frequency of BSE among participants who had undergone it, only 4.2% had undergone it weekly, and 17.3% monthly; the remaining were varied nearly equally between rarely and sometimes (39.6% and 38.8% respectively). Among those who had undergone BSE, 14.2% found changes in their breast.
Table 5
Breast self-examination practice recorded among the general population in the Asir region, Saudi Arabia, 2018
Practice regarding BSE
No.
%
Previously undergone BSE
Yes
260
52.5
No
235
47.5
If yes, frequency (n = 260)
Rarely
103
39.6
Sometimes
101
38.8
Weekly
11
4.2
Monthly
45
17.3
Did you find breast changes (n = 260)
Yes
37
14.2
No
223
85.8
BSE breast self-examination
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Regarding risk factor awareness among our population, the following factors were thought to have risk for occurrence of BC: advancing age (56.1%), exposure to radiation (39.3%), avoiding breastfeeding (57.6%), previous precancerous lesion on breast (49.4%), old primipara (above age of 30 years) (60.0%), breast injuries (40.5%), late menopause (42.4%), obesity (47.2%), smoking (34.3%), wearing of tight brassiere (50.2%), inactivity and sedentary lifestyle (39.7%), and underweight (47.4%) (Table 6).
Table 6
Risk factor awareness among the general population in the Asir region, Saudi Arabia, 2018
Yes
No
Do not know
Count
Row N %
Count
Row N %
Count
Row N %
Positive family history
139
13.3
331
31.6
576
55.1
Advancing age
587
56.1
257
24.6
202
19.3
Race/ethnicity
310
29.6
417
39.9
319
30.5
Exposure to radiation
411
39.3
294
28.1
341
32.6
Avoiding breast feeding
603
57.6
158
15.1
285
27.2
Previous precancerous lesion on breast
517
49.4
223
21.3
306
29.3
Old primipara (above age of 30 years)
628
60.0
100
9.6
318
30.4
Multiparity and gravidity
203
19.4
342
32.7
501
47.9
Null parity
118
11.3
534
51.1
394
37.7
Early menarche (below age of 11 years)
174
16.6
430
41.1
442
42.3
Recurrent oral contraceptives use
158
15.1
375
35.9
513
49.0
Breast injuries
424
40.5
164
15.7
458
43.8
Late menopause
443
42.4
196
18.7
407
38.9
Hormonal replacement therapy
228
21.8
319
30.5
499
47.7
Obesity
494
47.2
128
12.2
424
40.5
Smoking
359
34.3
239
22.8
448
42.8
Wearing of tight brassiere
525
50.2
189
18.1
332
31.7
Inactivity and sedentary lifestyle
415
39.7
238
22.8
393
37.6
Witchcraft
281
26.9
304
29.1
461
44.1
Underweight
496
47.4
247
23.6
303
29.0
Table 7 illustrates the level of general knowledge among our population. Almost all of them (95.8%) had heard of breast cancer. Most of them (59.8%) thought that breast cancer was somewhat prevalent and 12.0% thought breast cancer for once prevent subsequent cancer.
Table 7
General knowledge among the general population in the Asir region, Saudi Arabia, 2018
Count
Column N %
Have you heard of breast cancer?
Yes
1002
95.8
No
44
4.2
What do you think about breast cancer?
Rare
52
5.0
Somewhat prevalent
625
59.8
Highly prevalent
369
35.3
Breast cancer for once prevent subsequent cancer
Yes
125
12.0
No
447
42.7
Do not know
474
45.3
Discussion
According to this study, 95.9% of its participants had heard about breast cancer. This is higher than the percentage observed in a group of Ghana [16], Malaysian [17], and Iranian [18] women: 95%, 81.2%, and 64% respectively. It is, however, much lower than the 100% among the female medical students in Harar, Ethiopia [19], and the 98.7% among the female students in the University of Ibadan, Nigeria [20].
Knowledge and awareness of early detection measures of breast cancer, such as the BSE, is also considerable. About half of the participants, as shown by the findings, knew about BSE as an early detection measure, but very few participants practiced it. This results differed from Somdatta et al. [21], results which reported that knowledge and awareness of BSE are low and only a few women practiced it.
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Our findings reveal poor understanding and misperceptions of the risk factors for breast cancer. More than half of the respondents identified advancing age, avoiding breastfeeding, old primipara (above age of 30 years), and wearing tight brassier as potential risk factors, while more than one-third identified exposure to radiation, previous precancerous lesion on breast, breast injuries, late menopause, obesity, smoking, inactivity, sedentary lifestyle, and underweight as potential risk factors for breast cancer. Only less than one-third of them identified positive family history, race/ethnicity, multiparity and gravidity, null parity, early menarche (below the age of 11 years), recurrent oral contraceptives use, hormonal replacement therapy, and witchcraft as potential risk factors of breast cancer. These results could be compared with those of Sama et al. [22], which revealed a poor understanding and misperceptions of the risk factors, signs/symptoms, prevention, and treatment. More than two-thirds of the respondents did not identify gender, increasing age, race/ethnicity and positive family history, first child at a late age, early menarche, late menopause, positive personal history, and nulliparity as potential risk factors. Knowledge gaps about risk factors have also been reported elsewhere among the general population [17, 23]: university students in Angola [24], female medical students in Saudi Arabia [25], nurses in Pakistan [26], and female teachers in Malaysia [27] and Kuwait [28].
With regard to misperceptions, 26.9% of participants cited witchcraft as a risk factor of breast cancer. This is in line with a community survey in semi-urban Cameroon [29], studies on rural women [30] and market women [31] in Ibadan, Nigeria, and female medical students in Ethiopia [19], suggesting that women still attribute the occurrence of breast cancer to a mystical origin. Among others, they considered it “a spiritual attack”, “God’s curse”, and “attack from the enemy”. This observation was not that different from reports in a more developed setting: female teachers in Saudi Arabia attributed breast cancer to God and a belief in the evil eye [32], while 96.8% of Arab-speaking women in Qatar attributed its occurrence to fate/destiny, and less than one-fifth to Gods’ punishment and bad luck [33].
The major contribution of media in educating the public regarding breast cancer observed in this study has also been reported by other researchers from Saudi Arabia [32], Lebanon [34], Nigeria [35], and Iran [18]. This demonstrates the need to pay greater attention to this source of information to ensure that the correct information reaches the target population.
Conclusion
In conclusion, this study has shown that participants of this resettlement colony have poor knowledge about breast cancer, be it about risk factors, signs, and symptoms, or early detection procedures, where the overall knowledge score was only 18.8%. Therefore, it is important to create awareness, educate the community, and remove the misconceptions associated with ignorance through community-based educational/awareness campaigns. Educating health care workers is also a very important aspect. We also have to keep in mind that media exclusively will not be enough; information needs to be disseminated in a form which is appealing to the community.
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Compliance with Ethical Standards
Ethical Considerations
The official ethical clearance was obtained from the King Khalid University Ethical Committee; the private information of the students was used for research only.
Administrative Considerations
The researchers fulfilled all the required official approvals.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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