Keywords
Breast cancer - breast self-examination - knowledge - screening
Introduction
Breast cancer is a major public health problem and the most commonly diagnosed cancer for women worldwide,[1]
[2]
[3] with >1 million new cases are diagnosed annually.[4] Breast cancer has been reported recently to account for 23% of all new cancer cases and 14% of all cancer deaths. Half of the cases and 60% of deaths happen in economically developing countries.[5]
In India, breast cancer accounts for 19%–34% of all cancer cases and rated as second-most common cancer among females.[6] The incidence of breast cancer is gradually overtaking cancer of the cervix, which is the most common cancer in females in India. However, according to national cancer registries, it is the most common cancer among women in many cities in India including Delhi, Mumbai, and Kolkata.[7] In Sikkim among ethnic Nepali community, it is the most common cancer among females.[8] Usually, it is after the age of 45 years that breast cancer develops; however, current evidence is suggestive of decreasing age of onset.[9]
Most of the patients seek medical advice when the disease is fairly advanced. An estimated 20%–30% of Caucasian women wait for at least 3 months before seeking help for breast cancer symptoms [10] compared with over 70% of Indian women presenting with advanced stages resulting in poor survival and high mortality rates.[7]
A number of studies reported the early detection of breast cancer by screening is an effective way to improve the patients' prognosis.[11]
[12] However, early detection through mammography is not feasible for economically developing countries and therefore, breast self-examination (BSE) and promotion of awareness of early signs and symptoms are recommended for these countries.[5] Some authors argued that BSE is the only realistic approach to early detection of breast cancer in developing countries as it is simple and cost-effective.[13] Furthermore, BSE familiarize woman with both the appearance and the feel of their breasts and help detection of any abnormal changes in breasts as early as possible and raise the awareness about early detection of breast cancer, particularly among women living in rural areas.[9]
Women's choice of not performing BSE is complex, thus more specific information is needed about what kind of knowledge and what specific health perception determines the performance, taking into account the significant demographic factors of this region.
Women's knowledge of breast cancer risk factors, symptoms, and BSE, a practice has been studied in Western countries.[14]
[15]
[16]
[17]
[18] However, no studies have been employed among Sikkimese women to examine their knowledge of risk factors, symptoms associated with breast cancer, their attitudes and practices, and barriers towards BSE.
Methodology
Sikkim, which is located in the Eastern Himalayas, became the 22nd state of the Indian Union. The Central Referral Hospital (CRH) is the teaching hospital of Sikkim Manipal Institute of Medical Sciences, who's Institutional Ethics Committee, approved the study.
This cross-sectional study was conducted from May 1, 2015 to June 30, 2015, with women between 18 and 65 years of age attending the Outpatient Department of CRH.
Women were approached to participate in the interview if they were aged between 18 and 65 years, irrespective of the reason for their visit. Only those who were too ill to answer were excluded from the study. All the participants provided written and informed Consent.
A face-to-face semi-structured questionnaire-based interview was conducted among the participant women with a fixed list of questions in a standard sequence. The questions were both closed and open ended. The interview was conducted in a private atmosphere in their preferred language which lasted for about 10–15 min.
The questionnaire included questions regarding the participants' sociodemographic characteristics, knowledge of Breast cancer-its risk factors and symptoms, BSE, and practice of breast self-examination. Perceived barriers to practice of BSE were also assessed. For assessing the socioeconomic status, Modified Kuppuswamy Scale (Modified June 2012) was employed.
Pretesting of the questionnaire was done among 20 participants women before the actual study commenced and necessary changes were made accordingly.
The collected data were thoroughly checked, then entered in an Excel Spreadsheet (Microsoft, Redmond, WA, USA) for analysis. The method consisted of transcription, preliminary data inspection, and interpretation. Data were analyzed using Graph PadInsat version 3 (GraphPad Software, La Jolla, CA, USA). Descriptive statistics were analyzed by the Chi-square test, with P < 0.05 considered significant. Univariate analysis was also performed, followed by multivariate binary logistic regression analysis.
Results
A total of 340 consecutive women were approached of which 302 consented to participate in the survey, with a response rate of 88.8%. Majority of the women interviewed were between 21 and 35 years of age (56%), married (62.6%), Hindu by religion (63.6%), belonged to nuclear family (59.6%), and were from urban area (58.6%). [Table 1] presents the sociodemographic characteristics of the participant women.
Table 1
Sociodemographic characteristics of 302 women of reproductive age from the state of Sikkim, India, who consented to participate in the survey
|
Characteristics
|
n (%)
|
|
Age (years)
|
|
|
<20
|
57 (18.9)
|
|
21-35
|
169 (56.0)
|
|
36-50
|
60 (19.9)
|
|
>50
|
16 (5.3)
|
|
Marital status
|
|
|
Unmarried
|
111 (36.8)
|
|
Married
|
189 (62.6)
|
|
Separated
|
2 (0.6)
|
|
Family type
|
|
|
Nuclear
|
180 (59.6)
|
|
Joint
|
122 (40.4)
|
|
Religion
|
|
|
Hindu
|
192 (63.6)
|
|
Muslim
|
6 (2.0)
|
|
Christian
|
27 (8.9)
|
|
Buddhist
|
76 (25.2)
|
|
Others
|
1 (0.3)
|
|
Residence
|
|
|
Urban
|
177 (58.6)
|
|
Rural
|
125 (41.4)
|
|
Education
|
|
|
Illiterate
|
17 (5.6)
|
|
Primary <5th standard
|
20 (6.6)
|
|
Secondary/postsecondary <12th
|
135 (44.7)
|
|
>12th
|
130 (43.0)
|
|
Occupation
|
|
|
Homemaker
|
128 (42.4)
|
|
Working
|
139 (46.0)
|
|
Student
|
35 (11.6)
|
|
Socioeconomic status
|
|
|
Lower
|
4 (1.3)
|
|
Upper lower
|
14 (4.6)
|
|
Lower middle
|
110 (36.4)
|
|
Upper middle
|
173 (57.3)
|
|
Upper class
|
1 (0.3)
|
Three-fourths (75%) of the participants women were aware of breast cancer and heard about it when described. Eighty percent of the women who had heard about breast cancer were not aware of any risk factors of breast cancer while only 9% (n = 20) identified improper breastfeeding, 4% (n = 10) family history of breast cancer, and only four women identified smoking as probable risk factor of breast cancer [Table 2].
Table 2
Knowledge of breast cancer - its risk factors and symptoms among 302 women from the state of Sikkim
|
n (%)
|
|
*Multiple answers were allowed
|
|
Awareness of breast cancer
|
|
|
Ever heard of breast cancer
|
227 (75.1)
|
|
Never heard of breast cancer
|
75 (24.83)
|
|
Do you know risk factors of breast cancer (n=227)?*
|
|
|
Don’t know
|
183 (80.6)
|
|
Improper breastfeeding
|
20 (8.8)
|
|
Family history of breast cancer
|
10 (4.4)
|
|
Smoking
|
4 (1.8)
|
|
Alcohol
|
3 (1.3)
|
|
Oral pills
|
2 (0.9)
|
|
Older age
|
1 (0.4)
|
|
Large breasts
|
1 (0.4)
|
|
Late menopause
|
1 (0.4)
|
|
Others
|
2 (0.9)
|
|
Do you know symptoms of breast cancer? (n=227)*
|
|
|
Do not know
|
116 (51.1)
|
|
Painless breast lump
|
65 (28.6)
|
|
Change in shape of breast
|
18 (7.9)
|
|
Pain in the breast region
|
11 (4.8)
|
|
Nipple discharge/bleeding
|
6 (2.6)
|
|
Bruising of breast
|
3 (1.3)
|
|
Nipple inversion/puling
|
2 (0.9)
|
|
Others
|
6 (2.6)
|
When enquired about the symptoms of breast cancer, only 28.6% (n = 65) replied painless breast lump, 8% (n = 18) said change in shape of breast, 5% (n = 11) said pain in breast region, six women told nipple discharge/bleeding, and only two women told nipple inversion or pulling as symptoms of breast cancer [Table 2].
[Table 3] presents the unadjusted associations between participants' demographic profile and results of multivariate analysis of selected independent variables and their associations with awareness of breast cancer among the surveyed women. Older women were less aware of breast cancer; however, this finding was not statistically significant (P > 0.05). Factors which significantly determined the awareness of breast cancer were marital status, education, and working urban women with higher economic status (P < 0.0001) [Table 3].
Table 3
Unadjusted associations and results of multivariate modeling/binary logistic regression analysis to determine factors independently associated with awareness of breast cancer among reproductive women in East Sikkim, India (n=302)
|
Demographic characteristics
|
Aware of breast cancer, n (%)
|
Not aware of breast cancer, n (%)
|
P
|
OR
|
95% CI
|
|
BSE - Breast self-examination; OR - Odds ratio; CI - Confidence interval
|
|
Age
|
|
|
|
|
|
|
<20
|
46 (80.7)
|
11 (19.3)
|
>0.05
|
1.90
|
0.82-4.42
|
|
21-35
|
127 (75.1)
|
42 (24.9)
|
|
1.37
|
0.73-2.59
|
|
36-50
|
44 (73.3)
|
20 (33.3)
|
|
1
|
|
|
>50
|
10 (62.5)
|
6 (37.5)
|
|
0.76
|
0.24-2.37
|
|
Marital status
|
|
|
|
|
|
|
Unmarried/separated
|
102 (90.3)
|
11 (9.7)
|
<0.0001
|
0.22
|
0.10-0.43
|
|
Married
|
125 (66.1)
|
64 (33.9)
|
|
|
|
|
Family type
|
|
|
|
|
|
|
Nuclear
|
147 (81.7)
|
33 (18.3)
|
<0.05
|
2.34
|
1.38-3.98
|
|
Joint
|
80 (65.6)
|
42 (34.4)
|
|
|
|
|
Religion
|
|
|
|
|
|
|
Hindu
|
150 (78.1)
|
42 (21.9)
|
>0.05
|
1
|
|
|
Christian
|
22 (81.5)
|
5 (18.5)
|
|
1.23
|
0.44-3.45
|
|
Buddhist
|
51 (67.1)
|
25 (32.9)
|
|
0.57
|
0.32-1.03
|
|
Muslim and others
|
4 (57.1)
|
3 (42.9)
|
|
0.37
|
0.08-1.73
|
|
Residence
|
|
|
|
|
|
|
Urban
|
147 (83.1)
|
30 (16.9)
|
<0.05
|
2.76
|
1.61-4.71
|
|
Rural
|
80 (64.0)
|
45 (36.0)
|
|
|
|
|
Education
|
|
|
|
|
|
|
Illiterate
|
4 (23.5)
|
13 (76.5)
|
<0.0001
|
1
|
|
|
Primary <5th standard
|
4 (20.0)
|
16 (80.0)
|
|
0.81
|
0.17-3.90
|
|
Secondary/postsecondary <12th
|
97 (71.9)
|
37 (27.4)
|
|
8.52
|
2.61-27.81
|
|
>12th
|
122 (93.8)
|
8 (6.2)
|
|
49.56
|
13.11-187.36
|
|
Occupation
|
|
|
|
|
|
|
Homemaker
|
70 (54.7)
|
58 (45.3)
|
<0.0001
|
1
|
|
|
Working
|
125 (89.9)
|
14 (10.1)
|
|
7.40
|
3.9-14.2
|
|
Student
|
32 (91.4)
|
3 (8.6)
|
|
8.84
|
2.6-30.4
|
|
Socioeconomic
|
|
|
|
|
|
|
Lower class
|
73 (57.0)
|
55 (75.3)
|
<0.0001
|
5.88
|
3.28-10.52
|
|
Upper class
|
154 (88.5)
|
20 (11.5)
|
|
|
|
[Table 4] shows the knowledge and practice of BSE among the participants.
Table 4
Knowledge and practice of breast self-examination among the participants (n=302)
|
Items
|
n (%)
|
|
*Multiple answer allowed as depicted in legend. **Multiple answers were allowed. BSE - Breast self-examination
|
|
Are you aware BSE? (n=302)
|
|
|
Yes
|
138 (45.69)
|
|
No
|
164 (54.3)
|
|
Source of knowledge (n=138)*
|
|
|
Doctor, nurse
|
38 (27.5)
|
|
Friends
|
36 (26.1)
|
|
Newspaper
|
16 (11.6)
|
|
Medical text book
|
8 (5.8)
|
|
Television
|
7 (5.1)
|
|
Others
|
33 (23.9)
|
|
Practice of BSE (n=138)
|
|
|
Ever practiced BSE? (n=138)
|
|
|
Yes
|
57 (41.3)
|
|
No
|
81 (58.7)
|
|
Starting age of BSE (n=57)
|
|
|
<20 years
|
22 (38.6)
|
|
21-45 years
|
31 (54.4)
|
|
After 45 years
|
4 (7.0)
|
|
Frequency of BSE (n=57)
|
|
|
Once a month
|
19 (33.3)
|
|
Once in 3 months
|
7 (12.3)
|
|
Once in 6months
|
10 (17.5)
|
|
Once a year
|
21 (36.8)
|
|
Barriers to BSE (n=81)*
|
|
|
Did not feel necessary
|
49 (60.5)
|
|
Lack of knowledge/awareness
|
17 (21.0)
|
|
Never told by a doctor
|
4 (4.9)
|
|
Fear of detecting cancer
|
3 (3.7)
|
|
Feel discomfort
|
3 (3.7)
|
|
Others
|
4 (4.9)
|
When the question of whether they were aware of BSE was asked to the participants, 46% (n = 138) replied that they were aware of it. Most common source of knowledge were from health professionals (doctors and nurses 27.5%, n = 38), friends and relatives 26.1% (n = 36). Twelve percentage women heard about BSE from print media while eight women heard about from medical books and only 5% women heard about it from electronic media (TV, radio).
Of the 138 women (46%) who were aware of BSE, 41.3% (n = 57) ever practiced BSE. Majority (54.4%, n = 31) had started BSE between 21 and 45 years of age while 38.6% (n = 22) started before the age of 20 and only four women (7%) started BSE after the age of 45. Thirty-seven percent had BSE once in a year and one-third practiced BSE every quarter of a year.
[Table 5] depicts the relationship of practice of BSE between participants' demographic profile, and results of multivariate analysis of selected independent variables and their associations with BSE among the participated women. Women's marital status, level of education, occupation, and socioeconomic status were found to be a significant predictor of practice of BSE. Working women and students were found to be twice more likely to practice BSE compared to homemakers. Similarly, women belonged to lower socioeconomic status were 70% less likely to practice BSE than women of affluent class [Table 5].
Table 5
Associations of sociodemographic characteristics’ and practice of breast self-examination among reproductive women in Sikkim (n=302)
|
Characteristics
|
Ever practiced BSE, n (%)
|
Never practiced BSE, n (%)
|
P
|
OR
|
95% CI
|
|
BSE - Breast self-examination; OR - Odds ratio; CI - Confidence interval
|
|
Age
|
|
|
|
|
|
|
<20
|
11 (19.3)
|
46 (80.7)
|
>0.05
|
1
|
|
|
21-35
|
34 (20.1)
|
135 (79.9)
|
|
10.64
|
5.25-21.58
|
|
36-50 and above
|
12 (15.8)
|
64 (84.2)
|
|
7.93
|
3.36-18.71
|
|
Marital status
|
|
|
|
|
|
|
Unmarried and separated
|
27 (23.9)
|
86 (76.1)
|
<0.05
|
1.66
|
0.93-2.98
|
|
Married
|
30 (15.9)
|
159 (84.1)
|
|
|
|
|
Family type
|
|
|
|
|
|
|
Nuclear
|
40 (22.2)
|
140 (77.8)
|
>0.05
|
1.77
|
0.95-3.29
|
|
Joint
|
17 (13.9)
|
105 (86.1)
|
|
|
|
|
Religion
|
|
|
|
|
|
|
Hindu
|
31 (16.1)
|
161 (83.9)
|
>0.05
|
1
|
|
|
Christian
|
10 (37.0)
|
17 (63.0)
|
|
3.05
|
1.28-7.29
|
|
Buddhist
|
15 (19.7)
|
61 (80.3)
|
|
1.28
|
0.64-2.53
|
|
Muslim and others
|
1 (14.3)
|
6 (85.7)
|
|
0.86
|
0.10-7.42
|
|
Residence
|
|
|
|
|
|
|
Urban
|
38 (21.5)
|
139 (78.5)
|
<0.05
|
1.53
|
0.83-2.80
|
|
Rural
|
19 (15.2)
|
106 (84.8)
|
|
|
|
|
Education
|
|
|
|
|
|
|
<12th standard
|
16 (9.3)
|
156 (90.7)
|
<0.0001
|
0.22
|
0.12-0.42
|
|
>12th standard
|
41 (31.5)
|
89 (68.5)
|
|
|
|
|
Occupation
|
|
|
|
|
|
|
Homemaker
|
14 (10.9)
|
114 (89.1)
|
<0.05
|
1
|
|
|
Working
|
34 (24.5)
|
105 (75.5)
|
|
2.64
|
1.34-5.19
|
|
Student
|
9 (25.7)
|
26 (74.3)
|
|
2.82
|
1.10-7.21
|
|
Socioeconomic
|
|
|
|
|
|
|
Lower class
|
12 (9.4)
|
116 (90.6)
|
<0.05
|
0.30
|
0.15-0.59
|
|
Upper class
|
45 (25.9)
|
129 (74.1)
|
|
|
|
Of the women who were aware of BSE, majority (58.7%, n = 81) had never practiced BSE. Most common reason offered for not doing so were that they did not feel it necessary (60.5%, n = 49) said. Twenty percent (n = 17) admitted that they did not have knowledge of BSE. For women (4.9%) blamed their family physician for not telling to do so, while 3.7% (n = 3) women feared of detecting cancer and equal number of women offered discomfort as the reason for not doing BSE [Table 4].
Discussion
The findings of the present study suggests poor level of knowledge among Sikkimese women and abysmal level of ignorance about risk factors and common symptoms of breast cancer among the representative sample women of East Sikkim which are mostly inhabited by urban and educated people. The poor level of knowledge found in this survey is similar to reports from other Indian states.[19]
[20]
[21]
[22] In their study, Sharma et al.
[22] found Knowledge about breast cancer was present in less than half (43.67%) of the participants. Their knowledge about the symptoms of breast cancer was poor. Very few participants (21.37%) knew that breast cancer presents commonly as a painless breast lump. Although three-fourths of the surveyed women claimed to be aware of breast cancer, 80% of them were not aware of any risk factors of breast cancer while only 28.6% could identify that painless breast lump may be a warning symptom of breast cancer. Very few of the surveyed women were able to identify nonlump presenting symptoms of breast cancer. Similar level of poor awareness was reported from other low-income countries.[23] In their study, Uche [23] from Nigeria reported only 32% of the women having knowledge of breast lump as a warning sign for breast cancer, 58.5% being unaware of most warning signs, and only 9.8% knowing methods of detecting breast cancer.
Majority of the participants in the present study were not aware of BSE as a screening tool for detecting breast cancer. In their study by Sharma et al.,[22] among South Indian women, only 43.2% women were aware of BSE. Even professional health workers such as nurses were reported to have low knowledge scores and awareness about BSE as reported by Odusanya and Tayo [24] from Nigeria.
This poor level of knowledge reported in the present study and other low-income countries contradicts other international reports from high-income countries. Grunfeld et al.
[25] from the United Kingdom reported that 90%, 70%, and 60% of women, respectively, were able to quantify the relative risk of breast cancer associated with family history, previous history of breast cancer, and smoking, respectively. They also found that over 70% of the surveyed women were able to identify painless breast lump, lump under the armpit, and nipple discharge/bleeding as symptoms of breast cancer. In the our survey, a dismal 4.4% and 1.8% of women, respectively could identify family history of breast cancer and smoking as risk factor for breast cancer.
Our study revealed knowledge of symptoms was poorer among older women and this is quite worrying as risk of breast cancer increases with advancing age. Similar observations were made by Grunfeld et al.,[25] who found that older British women demonstrated poorer knowledge of risk factors for breast cancer. Older women may less likely to perceive nipple eczema, changes in the shape or size of the breast, and nipple retraction as symptoms of breast cancer. It is possible that older women may attribute such symptoms to the aging process, as has been reported previously for other symptoms. Furthermore, older women may have a number of symptoms of other illnesses, may not seek help for symptoms that are not causing them pain. That's why older women, in particular, should be provided with further educational information regarding the potential seriousness of breast changes; BSE and recommendation for action if they identify any warning symptoms.
Our survey indicated that education, marital status, occupation, and socioeconomic status significantly influenced knowledge of breast cancer. Education was the most significant predictor (P < 0.0001) of awareness of breast cancer. Other demographic variables including age and religion were not significantly related to knowledge. Similar observations were made by Grunfeld et al.
[25] in high-income countries and Sharma et al.
[22] in South Indian women.
Screening practice was very low in our study. Only 41.3% women ever practiced BSE. This is similar with observations with other researchers. A high level of practice of BSE had been observed in developed nations. In a survey of practice of BSE among black women in the US, Jacob et al.
[26] reported that 89% of respondents indicated practicing BSE during the past year, with 74% indicating having done so during the past 6 months.
Research has shown that regular practice of BSE increases the probability of detecting breast cancer at an early stage.[27] Routine breast cancer screening is currently not being practiced in Sikkim and India.[8]
[22] In addition, some other cultural factors may operate against routine breast cancer screening. Given the nonavailability of mammography in Sikkim and also lack of adequate data to justify mammography screening and the high cost and skilled expertise required for the procedure, current efforts at breast cancer screening in Sikkim and India must rely on a combination of BSE and CBE. Women should be taught the techniques of monthly BSE and nurses, midwives, and other healthcare providers should be urgently be trained and involved to assist physicians in counseling and teaching about BSE to women and also in performing clinical breast examinations.
Conclusions
Knowledge of breast cancer and screening practices are poor among indexed Sikkimese reproductive women attending tertiary hospital of Sikkim. This poor level of knowledge could potentially contribute to delay in seeking medical help. This is especially true for older women, who have a poor awareness both of the risk factors and the symptoms associated with the breast cancer. This poor level of knowledge is of particular concern; given the increased risk of developing breast cancer with advancing age, and may partly explain the increased delay behavior observed among women. Further research is needed, however, to explain the reasons for delay in seeking help and low level of screening practices in India and other low-income countries.
There is an urgent need for information on the airwaves and in print and for education at health centers and local health posts on warning symptoms of breast cancer and various methods of screening for breast cancer including BSE. Targeted government programs in India and other low-income countries on early detection methods of breast cancer should urgently be implemented at health centers and health posts, which would definitely reduce morbidity and mortality from breast cancer.
