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1
CHAPTER ONE
INTRODUCTION
1.1 Background
Cancer is a group of diseases characterized by uncontrolled growth and
spread of abnormal cells. If the spread is not controlled, it can result in
death. Among them is the breast cancer which is the most frequently
diagnosed cancer in women worldwide with an estimated 1.4 million new
cases in 2008. About half of these cases occurred in economically devel-
oping countries (GLOBOCAN, 2008). Globally, breast cancer is the most
common malignant neoplasm among women, with approximately one in
nine women developing the disease in her lifetime. Every year, about
900,000 women are diagnosed with the disease (Ahmed A M. et al,
2010).
It is the most form of malignant diseases found in women. Meanwhile,
early discovery of breast lumps through breast self-examination (BSE) is
important for the prevention and early detection of such disease (Nadia Y.
and Magda A., 2000).
Female breast cancer is by far the leading cancer in the Sudan. The
alarmingly high frequency of women presenting with advanced breast
cancer to the Radiation Isotope Center Khartoum (RICK) and Gezira
2
Institute for Cancer treatment and Molecular Biology (GICMB), which
are the only two oncology centers in the Sudan, has prompted looking for
an investigation that might help in solving this real health problem. The
highest percentages were recorded in 1998 (38.4% of all female cancers),
followed by the years, 1999, 2000 and 2001, which attended 36.03%,
35.2% and 32.4% respectively (Ahmed et al. 2010). Recent studies
carried out on breast cancer percentage in the Gezira state in the National
Cancer Institute in the state in the years 2005, 2006, 2007 and 2008 were
18%, 29%, 25% and 28% respectively compared to all other cancers
(National Cancer Institute of Gezira, 2008).
Apart from the highly increased risk of getting breast cancer related to
rare mutations, for example BRCA1 and BRCA2 (Hofmann 2000; Yang
1999). Other Numerous risk factors are also associated with breast
cancer. One major risk factor is increasing age. Among the factors that
increase the risk of breast cancer the most important ones include either a
personal or a family history of breast cancer and some specific genetic
mutations and hyperplasia that have been confirmed on biopsy. Other
factors that augment the risks of developing breast cancer are: an early
menarche and late menopause, obesity after menopause, use of iatrogenic
hormones (both oral contraceptives and postmenopausal hormone therapy
have been implicated), nulliparity or 'having the first child after the age of
3
30', certain ethnic features, radiation, or intake of alcohol on a daily basis
(Shiyam Kumar et al., 2009).
Effective early detection of breast cancer requires both early diagnoses in
symptomatic and asymptomatic patients at risk. In low-resource settings,
any programme for early detection must be focused and sustainable. In
Sudan, It is implemented early screening programmes for only three
cancers, breast, cervical and oral cancer (Hussein M. A., 2006).
Preventive behavior is essential for reducing cancer mortality.
Knowledge is a necessary predisposing factor for behavioral change.
Knowledge also plays an important role in improvement of health seeking
behavior. Not only that knowledge might dramatically improve the
attitude, disbelieve, and misconception and consequently enhance
screening practice (Soheil Mia, 2007).
This study is to assess the Knowledge, attitudes and practices of women
towards early detection of breast cancer in Wad Madani, Gezira state,
Sudan.
1.2 Problem Statement
Breast cancer is the most common cancer among women in Gezira State
according to the report form National Cancer Institute in Gezira state in
2008 which breast cancer constituted about 28% of all cancers. The
mortality rate can be reduced by early detection of the breast cancer. But
4
the lack of awareness among women about the Knowledge and positive
attitudes towards the early detection of breast cancer lead to the rise of
incidences of the disease mortality among women. In the light of all
above, this study aims at determining the Knowledge, attitude, and
practices of women towards early detection of breast cancer in Wad
Madani, Gezira state, Sudan.
Effort to reduce breast cancer mortality must focus on early detection
primarily through the use of the following screening techniques as
recommended by the American Cancer Society:
a. Monthly breast self-examination (BSE) beginning at age 20;
b. Clinical breast examination (CBE) every three years for women 20
to 39 years of age and annually after 40 years of age;
c. Annual mammography beginning at age 40 years (American
Cancer Society, 2003).
1.3 Justification
Since the prevalence of breast cancer among women in Gezira state is
high compared to other cancers (the last study in NCI, 28% in 2008), it is
important to detect the breast cancer early because Breast cancer is most
treatable when it is found early – when it is small and has not spread.
There is no way to predict who will develop breast cancer and who will
5
not. For these reasons, routine early detection tests (checking for breast
cancer when there are no symptoms present) are recommended.
1.4 Research Questions
The following research questions were examined in this study:
1. What is the women’s knowledge regarding breast cancer (risk
factors, symptoms)?
2. What is the women’s awareness about breast self examination
(BSE)?
3. Is there any association between the level of education and the
knowledge of practice of breast self-examination (BSE)?
1.5 Objectives of the study
1.5.1 General Objective
To determine the Knowledge, attitudes and practices of women towards
early detection of breast cancer.
1.5.2 Specific objectives
To determine the knowledge of the women towards the most
important factors that enhances the development of breast cancer.
To identify the percentage of women who have correct knowledge
about early detection by BSE.
To measure the percentage of women who perform regular BSE.
6
To determine the different types of breast cancer among patients.
To determine the most important factors those enhance the
development of breast cancer.
7
CHAPTER TWO
LITERATURE REVIEW
2.1 Anatomy and physiology of the breast
The breasts lie between the skin and the pectoral fascia to which they are
loosely attached. Apparently the adult female breast overlies the area
from the second to the sixth ribs and from the lateral border of the
sternum to the anterior axillary line.
2.2.0 Components of the breast
The adult female breast has two components:
The epithelial elements- these are responsible for milk secretion and
transport. Each breast consists of 15-20 radially arranged and each is
drained by a lactiferous duct, the ducts converge at the nipple. A lobe is
made up of 20-40 lobules, each of which consists of 10-100 alveoli. The
alveoli and ducts are lined by a single layer of epithelium and the ducts
are surrounded by contractile myoepithelial cells which are stimulated by
oxytocin and move milk towards the nipple.
The supporting tissues- fibrous septa (coopers ligaments) extend from
the pictoral fascial to the skin and are responsible for the division of the
parenchyma into lobes (Galal and Korashi, 2011).
8
2.3 Hormonal control
Breast development is under the control of the following hormone:
Oestrogen, Adenocortical steroids and growth hormone
promote development of ducts
Progesterone stimulates the growth of lobules
Prolactin is essential for alveolar formation (Galal and
Korashi, 2011).
2.3.1 Physiological changes
At puberty: the breast remains dormant until puberty. The onset of
cyclical hormonal activity stimulates growth, branching of ducts and
formation of ductules.
Menstrual changes: during the menstrual years the breast
undergoes cyclical changes which can cause heaviness, discomfort
and increasing nodularity during the latter part of menstrual cycle.
During pregnancy: there is marked lobular development.
Lactation: following delivery, reduction of estrogens increases
sensitivity of mammary epithelium to the lactational complex.
9
After menopause: the lobules gradually disappear (Galal and
Korashi, 2011).
Figure (2.1). Anatomy of female breast showing ducts and lobules.
2.4 Cancer overview
The body is made up of trillions of living cells. Normal body cells grow,
divide, and die in an orderly fashion. During the early years of a person's
life, normal cells divide faster to allow the person to grow. After the
person becomes an adult, most cells divide only to replace worn-out or
dying cells or to repair injuries. Cancer begins when cells in a part of the
10
body start to grow out of control. There are many kinds of cancer, but
they all start because of out-of-control growth of abnormal cells.
Cancer cell growth is different from normal cell growth. Instead of dying,
cancer cells continue to grow and form new, abnormal cells. Cancer cells
can also invade (grow into) other tissues, something that normal cells
cannot do. Growing out of control and invading other tissues are what
makes a cell a cancer cell.
In most cases, the cancer cells form a tumor. Some cancers, like
leukemia, rarely form tumors. Instead, these cancer cells involve the
blood and blood-forming organs and circulate through other tissues where
they grow.
Cancer cells often travel to other parts of the body, where they begin to
grow and form new tumors that replace normal tissue. This process is
called metastasis. It happens when the cancer cells get into the
bloodstream or lymph vessels of our body.
Not all tumors are cancerous. Tumors that aren’t cancer are called benign.
Benign tumors can cause problems – they can grow very large and press
on healthy organs and tissues. But they cannot grow into (invade) other
tissues. Because they can’t invade, they also can’t spread to other parts of
the body (metastasize). These tumors are almost never life threatening
(American Cancer Society, 2011).
11
2.5 History of breast cancer
The origin of the word cancer is credited to the Greek physician
Hippocrates (460-370 B.C.), the "Father of Medicine." Hippocrates used
the terms carcinos and carcinoma to describe non-ulcer forming and
ulcer-forming tumors. In Greek these words refer to a crab, most likely
applied to the disease because the finger-like spreading projections from a
cancer called to mind the shape of a crab. Carcinoma is the most common
type of cancer.
Thus breast cancer is a “malignant neoplasm of the breast.” A cancer cell
has characteristics that differentiates it from normal tissue cells with
respect to: the cell outline, shape, structure of nucleus and most
importantly, its ability to metastasize and infiltrate. When this happens in
the breast, it is commonly termed as ‘Breast Cancer. Cancer is confirmed
after a biopsy (surgically extracting a tissue sample) and pathological
evaluation.
During the mid 1800’s, surgeons first began to keep detailed records of
breast cancer. Those statistics indicate that, even those treated by
mastectomy had a high rate of recurrence within eight years—especially
when the glands or lymph nodes were affected. Nevertheless, the
12
common treatment was to remove the breast and the surrounding glands
in an effort to stave off any further tumor development.
In 1949 Raul Leborgne (Uruguay) emphasized breast compression for
identification of calcifications. In 1940s-1950s breast self-examinations
were advocated (Anna H. Israyelyan, 2003).
It is a common cancer in women, a disease in which cancer cells are
found in the tissues of the breast. Each breast has 15 to 20 sections called
lobes. Lobes have many smaller sections called lobules. The lobes and
lobules are connected by thin tubes called ducts. The most common type
of breast cancer is ductal cancer. It is found in the cells of the ducts.
Cancer that begins in the lobes or lobules is called lobular carcinoma.
Lobular carcinoma is found in both breasts more often than other types of
breast cancer. Inflammatory breast cancer is an uncommon type of breast
cancer. In this disease, the breast is warm, red, and swollen. (East African
Breast Cancer, 2009).
2.6 Breast cancer in Sudan
Breast cancer is a public health problem in Sudan; According to the latest
WHO data published in April 2011 Breast Cancer deaths in Sudan
reached 1,968 or 0.53% of total deaths. The age adjusted death rate is
16.31 per 100,000 of population (WHO, 2011).
13
The breast cancer incidence in Gezira state exceeds 260 cases annually
and the number of cases of women younger than 40 years of age reaches
about 67.3% of all cases (National Cancer Institute of Gezira, 2008).
Therefore, it is critical that efforts in prevention and early diagnosis of
breast cancer are implemented everywhere. One of the main problems
concerning breast cancer relates to the lack of patients awareness about
the disease. Limitations in implementing breast self-examination and
mammography screening programs are the other important issues.
Overall survival and mortality due to this disease are influenced strongly
by the stage of the disease at diagnosis.
The optimal chances for surviving breast cancer in woman is by detecting
it early; either by breast self examination (BSE) conducted by a woman
herself, clinical breast examination by health staff or by mammography
(Ahmed HG. et al., 2010).
Knowledge of risk factors, as well as, rising of the awareness is
momentous, particularly in a country like the Sudan, where many patients
present from remote areas with poor health services. For that reason, the
incidence and mortality of breast cancer are high, remarkably constant
and the frequency is increasing particularly amongst younger women.
Exposure to endogenous estrogens increases the risk of breast cancer.
Women who start menstruating before age 12 or begin menopause after
14
age 55 generally have more monthly cycles and therefore a longer
lifetime exposure to estrogen. This tends to increase their risk of breast
cancer. (Hussein G. Ahmed et al., 2010).
The incidence of breast cancer is lowest in women who have given birth
to babies at an early age and have had multiple pregnancies. In
communities where the custom is for women to marry early and have
their first babies whilst still in their teens, the incidence of breast cancer is
low, whilst in Westernized societies where first babies are commonly
born to women over the age of 30 years, the incidence of breast cancer is
higher. There may also be some protection against breast cancer by
prolonged breast feeding as is common in most developing countries,
although the evidence for this is less clear. Women who have never had a
child, such as nuns, have the highest incidence of breast cancer (Stephens
& Aigner, 2009).
2.7 Breast cancer early detection
Breast cancers that are found because they are causing symptoms tend to
be larger and are more likely to have already spread beyond the breast. In
contrast, breast cancers found during screening exams are more likely to
be smaller and still confined to the breast. The size of a breast cancer and
how far it has spread are some of the most important factors in predicting
the prognosis (outlook) of a woman with this disease. Most doctors feel
15
that early detection of breast cancer save thousands of lives each year,
and that many more lives could be saved if even more women and their
health care providers took advantage of these tests. Following the
American Cancer Society's guidelines for the early detection of breast
cancer improves the chances that breast cancer can be diagnosed at an
early stage and treated successfully (American Cancer Society, 2010).
2.7.1 Breast-Self Examination
Breast self-examination is one of the vital screening techniques for early
detection of breast lumps, most especially cancer of the breast. The
procedure, though simple, non-invasive, requiring little time, can only be
practiced with the right attitude to sustain it and achieve the desired goal
(Kayode F. O. et al., 2005).
Breast self examination consists of two basic steps: tactile and visual
examination:
2.7.1.1 Tactile examination
An effective breast self examination is one that is conducted at the same
time each month, uses the techniques properly and covers the whole area
of each breast, including the lymph nodes, underarms, and upper chest,
from the collarbone to below the breasts and from the armpits to the
breast bone. The breast self examination can be done using vertical strip,
wedge section and concentric circle detection methods. The breasts
16
should not be compressed between fingers as it may cause the woman to
feel a lump that does not really exist.
2.7.1.2 Visual examination
The visual examination of the breast is another tool in identifying
possible breast disease. In preparing for the visual examination, the
woman should stand in front of a mirror. When looking into the mirror,
the woman must look for any changes in the contour or placement of the
breasts, changes in the color and shape, discharge from nipples and
discoloration of the skin (Khatib, 2006).
The recent fall of death from breast cancer in western nations is
particularly explained by earlier diagnosis as a result of early
presentation. In most of the developing countries patient comes for
treatment in an advance stage when little or no benefit can be derived
from any sorts of therapy. Early diagnosis can be successfully achieved
by mass screening either by Mammography, Clinical Breast Examination
(CBE) and Breast self examination (BSE) or by the combination of three.
Though it is well documented that mammography is the best choice for
screening, breast self examination is also equally important and beneficial
for mass awareness especially in country with limited recourses (Soheil
Mia., 2007).
17
If cancer awareness among the general public is limited then people are
ill equipped to make informed decisions about their health, which may
consequently lead to delayed presentation and poorer survival (Ramirez
et al, 1999; Richards et al, 1999; Coleman et al, 2003; MacDonald et al,
2006).
2.7.2 Clinical Breast Examination:
Clinical Breast Examination (CBE) is a standardized procedure whereby
a health care provider examines a women’s breast, chest wall, and axillae.
The examination consist of 1) Visual inspection of the breast while the
women in upright position and her arms relaxes and then raised above her
head. 2) Palpation of the axillae and supraclavicular fossae when the
women in the upright position and 3) palpation of the breasts while the
women both in upright and supine positions. The examiner inspects the
breast visually for symmetry, skin of the breast, areola, and nipple for
oedema, erythema, puckering, dimpling, or ulceration, all of which can be
evidence of underlying masses. The provider palpates the regional
axillary nodes. Enlarged hard, matted or fixed nodes can indicate cancer
(Benjamin O. Anderson et al., 2003).
2.7.3 Mammography
A mammogram is a special X-ray of the breast that may show the
presence of cysts, dense fibrous tissue, or a cancer in the less-dense fatty
18
tissue of the breast. Small amounts of X-rays only are needed so this
examination is safe if not used excessively. Although mammograms
produce some false negatives and some false positives they are
nevertheless very useful, safe and inexpensive in screening for breast
cancer. However, even the small doses of X-rays needed for
mammography are better avoided in women who may be pregnant or
wish to have further pregnancies as even this exposure to irradiation can
cause genetic mutation of fetal cells or of actively functioning ovarian
tissue. This usually means that mammography is not routinely
recommended in women younger than 40 (Stephens & Aigner, 2009).
2.8 Risk factors of breast cancer
Although the causes and natural history of breast cancer remain unclear,
epidemiological research has uncovered genetic, biological,
environmental, and lifestyle risk factors for the disease.
A risk factor is anything that affects your chance of getting a disease,
such as cancer. Different cancers have different risk factors. Having a risk
factor, or even several, does not mean that you will get the disease. Most
women who have one or more breast cancer risk factors never develop
the disease, while many women with breast cancer have no apparent risk
factors (other than being a woman and growing older). Even when a
19
woman with risk factors develops breast cancer, it is hard to know just
how much these factors may have contributed to her cancer.
There are different kinds of risk factors. Some factors, like a person's age
or race, can't be changed. Some are related to personal behaviors such as
smoking, drinking, and diet.
2.8.1 Gender
Simply being a woman is the main risk factor for developing breast
cancer. Although women have many more breast cells than men, the main
reason they develop more breast cancer is because their breast cells are
constantly exposed to the growth-promoting effects of the female
hormones estrogen and progesterone. Men can develop breast cancer, but
this disease is about 100 times more common among women than men.
2.8.2 Aging
The risk of developing breast cancer increases as the women gets older.
About 1 out of 8 invasive breast cancers are found in women younger
than 45, while about 2 of 3 invasive breast cancers are found in women
age 55 or older(American Cancer Society, 2010).
2.8.3 Genetic risk factors
About 5% to 10% of breast cancer cases are thought to be hereditary,
resulting directly from gene defects (called mutations) inherited from a
parent.
20
BRCA1 and BRCA2: (which are abbreviated BR from breast and CA
from cancer) the most common cause of hereditary breast cancer is an
inherited mutation in the BRCA1 and BRCA2 genes. In normal cells,
these genes help prevent cancer by making proteins that help keep the
cells from growing abnormally. If a woman has inherited a mutated copy
of either gene from a parent, she will have a high risk of developing
breast cancer during your lifetime (Trunbull C. & Rahman N., 2008).
2.8.4 Family history of breast cancer
Women whose close blood relatives have breast cancer have a higher risk
for this disease. Having a first-degree relative (mother, sister, or
daughter) with breast cancer almost doubles a woman's risk. Having 2
first-degree relatives increases her risk about 3-fold. Although the exact
risk is not known, women with a family history of breast cancer in a
father or brother also have an increased risk of breast cancer.
2.8.5 Lifestyle-related factors
2.8.5.1 Parity
Women who have not had children or who had their first child after age
30 have a slightly higher breast cancer risk. Having many pregnancies
and becoming pregnant at an early age reduces breast cancer risk. The
higher parities and earlier age at first pregnancy of women in many
21
developing countries might account for lower incidence of breast cancer
in relation to developed countries.
2.8.5.2 Oral contraceptives
Studies have found that women using oral contraceptives (birth control
pills) have a slightly greater risk of breast cancer than women who have
never used them (American Cancer Society, 2010).
2.8.5.3 Breast-feeding
Some studies suggest that, breast-feeding may slightly lower breast
cancer risk, especially if it is continued for 1½ to 2 years. For example,
the US Cancer and Steroid Hormone Study found that breast feeding for a
total of 25 months or more reduced the risk of cancer by 33% in over
4500 women studied. (Sherif O. Jarques et al., 2010).
2.8.5.4 Alcohol
Consumption of alcohol is clearly linked to an increased risk of
developing breast cancer. The risk increases with the amount of alcohol
consumed. Compared with non-drinkers, women who consume 1
alcoholic drink a day have a very small increase in risk. Those who have
2 to 5 drinks daily have about 1½ times the risk of women who drink no
alcohol. (American Cancer Society, 2010).
22
2.9 warning signs of breast cancer
Early breast cancer is usually symptom less. But there are some
symptoms develop as the cancer advances. Breast lump or breast mass is
the main symptoms of the breast cancer. Lump is usually painless, firm to
hard and usually with irregular borders. Every lump is not cancerous,
sometimes some lumps or swelling in the breast tissue may be due to
hormonal changes or benign (not harmful) in nature. Beside these some
others symptoms are important, like:
Lump or mass in the armpit
A change in the size or shape of the breast
Abnormal nipple discharge
- Usually bloody or clear-to-yellow or green fluid
- May look like pus (purulent)
Change in the color or feel of the skin of the breast, nipple, or
areola
- Dimpled, puckered, or scaly
- Retraction, "orange peel" appearance
- Redness
- Accentuated veins on breast surface
Change in appearance or sensation of the nipple
- Pulled in (retraction), enlargement, or itching
23
Breast pain, enlargement, or discomfort on one side only
Any breast lump, pain, tenderness, or other change in a man
Symptoms of advanced disease are bone pain, weight loss, swelling
of one arm, and skin ulceration (Medline plus Encyclopedia, 2011).
2.10 Stages of breast cancer and survival rates
The staging systems currently in use for breast cancer are based on the
clinical size and extent of invasion of the primary tumor (T), the clinical
absence or presence of palpable axillary lymph nodes and evidence of
their local invasion (N), together with the clinical and imaging evidence
of distant metastases (M). This is then translated into the TNM
classification which has been subdivided into Stage 0 called carcinoma in
situ (lobular carcinoma in situ (LCIS) and ductal carcinoma in situ
(DCIS) and four broad categories by the Union Internationale Centre
Cancer (UICC), which are the following.
Stage 0 :( Carcinoma in Situ) Carcinoma in situ is very early breast
cancer. In this stage cancer has not invaded into the normal breast tissue
and is contained in either the breast duct (ductal carcinoma in situ) or the
breast lobule (lobular carcinoma in situ). By definition, this type of
cancer is not invasive and is not able to travel to the lymph nodes or other
parts of the body.
24
Stage I – early stage breast cancer where the tumor is less than 2 cm
across and hasn't spread beyond the breast.
Stage II – early stage breast cancer where the tumor is either less than 2
cm across and has spread to the lymph nodes under the arm; or the tumor
is between 2 and 5 cm (with or without spread to the lymph nodes under
the arm); or the tumor is greater than 5 cm and hasn't spread outside the
breast.
Stage III – locally advanced breast cancer where the tumor is greater than
5 cm across and has spread to the lymph nodes under the arm; or the
cancer is extensive in the underarm lymph nodes; or the cancer has spread
to lymph nodes near the breastbone or to other tissues near the breast.
Stage IV – metastatic breast cancer where the cancer has spread outside
the breast to other organs in the body. (Anna H. Israyelyan, 2003).
The five-year survival rate from breast cancer among women age 15 and
older is 89% in the United States, 82% in Switzerland, and 80% in Spain.
Breast cancer survival rates in developing countries are generally lower
than in Europe and North America, with rates as low as 38.8% in Algeria
, 36.6% in Brazil, and only 12% in Gambia. The stage at diagnosis is the
most important prognostic variable. For instance, the overall five-year
relative survival among US women diagnosed with breast cancer at early
stage is 98%, compared to 84% and 23% when the disease is spread to
25
regional lymph nodes or distant organs, respectively (GLOBOCAN,
2008).
5-years Relative Survival Rate
Table (2.1). 5-years Relative Survival Rate
Stage Survival rate%
Stage 0 100%
Stage I 100%
Stage IIA 92%
Stage IIB 81%
Stage IIIA 67%
Stage IIIB 54%
Stage IV 20%
(American Cancer Society, 2005).
2.11 Previous studies
A number of articles have been found on breast cancer knowledge,
attitude and Practice.
Samira H. AbdElrahman and Magda A. Ahmed conducted a
longitudinal interventional study in 2003 in the University of Gezira; the
study was the role of medical students in the Faculty of Medicine about
self examination of the breast for early detection of breast cancer. The
study was done in three phases.
26
Phase one: training of students, phase two: students intervention and
phase three: evaluation of students intervention.
Pre-test assessment and post-test assessment was done, it comprised 200
students and 340 women. In the pre-test assessment 66.5% of students
have heard about BSE, 8.0% rated BSE as very important and only 7.2%
used to practice it. After the intervention the last figures rose to 100% and
73.9% successively. Prior to study, only 12.0% of the women have heard
about BSE. By the end of student’s intervention 60.5% of the women
adhered to regular monthly BSE. No lump was detected by a student.
Olumuyiwa O,Odusanya and Olufemi O.Tayo conducted a cross
sectional survey in 2001 among nurses in general hospital in Lagos,
Nigeria. 204 nurses were included in the study. Knowledge about
symptoms methods of diagnosis, and Self breast Examination was above
60%. In response to question on 5 risk factors more than 50% identified
positive family history and that bruising the breast is a potential risk
factor for developing breast cancer. The nurses were well informed about
frequency of Breast Self Examination (BSE). More than one third
(39.7%) of the respondents knew that, BSE should be done monthly
interval. Majority (78.4%) of the respondents agreed that breast cancer is
a curable disease if diagnosed and treated early. Majority (90%)
27
considered that, the disease is serious and would see a doctor within one
month. BSE was most frequently done (89%).
Among them 39 % conducted the procedure at monthly interval. Use of
all 3 methods of screening was more common among those who had a
greater knowledge about breast cancer. Perceived cancer risk assessment
was done, 61% claimed not at risk.
Another cross-sectional study was conducted among one thousand
community-dwelling women from a semi-urban neighborhood in Nigeria
by Michael N Okobia and et al conducted a study in 2006 to elicit
knowledge, attitude and practices towards breast cancer. The Study result
showed poor knowledge on breast cancer. Mean knowledge score was
42.3% and only 214 participants (21.4%) knew that breast cancer present
commonly as a painless breast lump. In response to questions about
etiology of breast cancer, 40% believed that evil spirit causes breast
cancer and 259 (25.9%) indicated that breast cancer result from an
infection. In terms of methods of diagnosis 432(43.2%) were able to
answer correctly identified that BSE is a method of diagnosis. There was
an indication of positive health seeking behavior as a majority of the
participants mentioned that visiting the doctors was the best approach for
breast cancer treatment. In terms of practices, 34.9% participants practice
BSE. Only 91participants (9.1%) had clinical breast examination (CBE)
28
in the past year and no one had the history of mammography
examination. Majority of the respondents did not take part in BSE or
clinical breast examination due to having no breast problem.
Grunfeld E A et al conducted a survey in 2002 on 1830 general female
population of UK to elicit knowledge and believe about breast cancer. In
the study it was found that, women had limited knowledge on risk factors
and breast cancer related symptoms. Only 23% correctly indicated that 1
in 10 have a chance to developed breast cancer. Less than one third
recognized the role of advancing age as a potential risk factor. More than
70 % of the sample identified that painless breast lump, lump under
armpit, nipple discharge are potential symptoms.
Bener A et al conducted a cross sectional community base line survey in
2001 to explore the knowledge, attitude and practice related to breast
cancer screening among women of United Arab Emirates. They found
that only 30% of the women agreed that family history was a risk factor,
and 45 % incorrectly stated that most of the breast lump would become
cancerous. One third (33%) of the women knew that early breast cancer
was painful. Most of the women (79%) agreed to have breast examination
by a doctor but only 14% had experienced a clinical breast examination.
Only 13% performed breast self examination regularly on monthly basis.
29
Pinar Erbay et al in their study of “The knowledge and attitude of breast
self examination and mammography in a group of women in a rural area
in western Turkey” found that majority (76.6%) had heard about breast
cancer but only 56.1% of them had sufficient knowledge about breast
cancer. TV and radio programs were identified as the main source
(39.3%) for information. Most of the respondents (72.1%) had knowledge
about Breast self Examination but only 40.9% of the women had
practiced BSE in the previous 12 months.
Pöhls U G et al conducted a study in 2004 on “Awareness of breast
cancer incidence and risk factors among healthy women” in Düsseldorf,
Germany found that78.8% were well aware of breast cancer in general
terms. Most of the women (94.9%) considered that former history of
breast cancer is a risk factor Interestingly 37.1% considered breast
feeding 32.0% considered age at menopause and 23.7% considered
childlessness as a potential risk factors. Two -third of the participant
estimated their personal risk of developing breast cancer was low to
average. Gynecologists were the main source of information (59.9%) on
breast cancer.
Jebbin NJ and Adotey JM conducted a study in 2004 on “Attitude,
knowledge and practice of breast self-examination (BSE) in port
Harcourt, Nigeria” and found that 85.5% of the respondent had heard of
30
Breast self examination but 39.0% practiced BSE only occasionally. The
news media nurses and physicians were the commonest sources of
information on BSE.
WA Milaat conducted a cross sectional study in 2000 on 6380 female
secondary-school student in Jeddah to identify their knowledge of breast
cancer and attitude towards breast self-examination (BSE). Knowledge of
risk factors was very low. Over 80% of students failed to answer 50% of
the questions correctly. Only 47.1% of students reported that they had
heard of or read some scientific information about breast cancer in
various media and 39.1% reported that lump in the breast is the warning
sign of breast cancer. Only15.2% agreed that use of contraceptive pill is a
potential risk factor. Few (16.2%) knew that breast cancer could appear
as a change of or bleeding from the nipple.
Ahmed HG et al; Conducted a case control study in the Sudan in 2010,
risk factors for breast cancer were evaluated among 150 women with
breast cancer (ascertained as cases) and 100 apparently health women
(ascertained as controls); their ages ranging from 20 to 65 years with a
mean age of 40 years old. The majority of patients were at the age range
36 - 45 years constituting 60(40%); hence the distribution was similar in
respect to the upper and lower limits from the mean. Results showed Out
of the 150 patients with breast cancer (cases), and 100 apparently healthy
31
individuals (controls); 38 (25.3%) and 38(38%) were identified as having
a previous history of oral contraceptives usage, respectively. Information
concerning the type of oral contraceptives were available for only 35
patients, of whom 28 (80%) were using progesterone only pill and the
remaining seven (20%) were using combined pill.
Out of the 150 cases and 100 controls, 22 (14.7%) and 14(14%) were
found with a family history of breast cancer (First degree mother side), as
well as, 20 (13.3%) were detected as having a previous history of breast
cancer, respectively. Furthermore, 11(7.3%) of the cases and 27 (27%) of
the controls have claimed other cancers in their families.
32
CHAPTER THREE
MATERIALS AND METHODS
Figure (3.1) Map showing Gezira State and Wad Madani, the capital city
3.1 Study Area
Sudan is a country in North Africa that is often considered to be part of
the Middle East as well. It is bordered by Egypt to the north, the Red
Sea to the northeast, Eritrea and Ethiopia to the east, South Sudan to the
south, the Central African Republic to the southwest, Chad to the west,
and Libya to the northwest.
33
3.1.1 Location
Gezira state is one of the 15 states of Sudan. It is located in the middle of
Sudan, bordered in the north by Khartoum State, in the south by Sinnar
state, in the west by White Nile State and in the east by Gedarif State.
The State has an overall population of 3,575,280 people. The region has
benefited from the Gezira Scheme, a program to foster cotton farming
begun in 1925. At that time the Sennar Dam and numerous irrigation
canals were built. Gezira became the Sudan's major agricultural region
with more than 2.5 million acres (10,000 km²) under cultivation.
Wad Madani is the area of current study which is the capital city of the state;
it has a population of 345,290 people according to the last national census in
2008. It is located on the west bank of the Blue Nile River, agriculture is the
central economic activity, like wheat, peanuts, barely and livestock. It is the
home of Gezira University, Wad Madani Ahlia college and other
institutions.
3.2 Study Design
Type of study: this analytical Case control hospital based study
conducted at Madani teaching hospital and National Cancer institute for
cancer treatment (NCI).
Study period: The study was conducted from November, 2011-
February, 2012.
34
Study population: the population under study was women residing in
Wad madani town from 20 years of age who attended to Madani
Teaching Hospital and National Cancer Institute (NCI).
3.3 Inclusion Criteria:
In this study women in Wad Madani Town were included to evaluate
their knowledge attitudes and practices towards early detection of breast
cancer. The reason why women of 20 years of age included the study is
that screening methods especially the breast self examination is
recommended after 20 years of age.
The control women in the survey were female patients and co-patients
who visit to Wad Madani Teaching Hospital, those patients were non
breast cancer patients.
The cases in the study were breast cancer female patients who attended in
the National Cancer institute for cancer treatment in Gezira state in the
period of January 2011 to December 2011.
3.4 Sample technique
The overall women that are 20 years of age and above are about 71,000
women projected from 2008 Population and Housing Census.
35
And the annual breast cancer treated estimated in the NCI was 934 with
an incidence rate of 34%.
At 95% confidence level and 5 %( 0.05) margin error. So the sample size
was calculated using the formula below:
N0 = Z² P Q / d²
When:
N0: sample size
Z²: value of selected α level of 0.25 in each tail (1.96)
P: anticipated population proportion
Q: 1 – p (anticipated population proportion)
D: absolute population required on either side of the population
(incidence point) (Lewanga K. & Lemeshow S., 1991).
n0 =
n0 = 345
So the finite population correction proportion can be calculated:
n = = = 252
36
Patients’ sample: The cases were incident, diagnosed with breast cancer
patients and they were entered in the study because they had a confirmed
pathological breast cancer and admitted to National Cancer Institute
(NCI).
The initial unit in this study was woman with breast cancer treated at
National Cancer Institute by using the statistical formula of a sample size
and a simple random sampling. The sample size calculated was 345.
The patients of breast cancer treated at (NCI) in the year is 934. These
were the new cases treated each year. After the correction formula used
the final overall sample size n= 252. So the recorded data needed to
survey in the patients sample is half of the overall sample which is 126
medical records.
Control Sample: The control women needed to recruit the study of
Knowledge, attitudes and practices of early detection of breast cancer was
randomly selected among women without any history of breast cancer
residing in Wad Madani Town and attended to Madani Teaching
Hospital.
They were also asked whether they have some risk factors of breast
cancer.
37
The control sample equal to the remaining half of the sample which is
126 samples from women attending to Madani Teaching Hospital.
3.5 Data collection and analysis
Data collection was accomplished using interviewer-administered
questionnaires manuscript in Arabic language. The questionnaire was
developed by the researcher using information on breast cancer from the
literature and from questionnaire conducted in the other studies.
The questionnaire used was in three parts. The first part was to elicit
socio-demographic data on age, occupation, and marital status of each
study participant. The second part was about the knowledge of breast
cancer and the risk factors that enhance the development of breast cancer.
Participants’ awareness of breast cancer and early detection methods
were assessed in the third section. The attitudes and practice of BSE,
CBE and Mammography among participants were also assessed in the
last section.
In the case section of the study medical recorded data was collected from
the National Cancer Institute of breast cancer patients attended to the
institute for treatment in the year 2011, the data was collected in a master
sheet.
Obtained data is arranged and finally data analyzed by using SPSS 16.0
software (SPSS Inc., 2008). Demographic characteristics will be simply
38
present in frequency and chi-square test is be used to compare Cases with
Control about the risk factors that enhance the development of breast
cancer.
39
CHAPTER FOUR
RESULTS AND DISCUSSION
4.1 RESULTS
4.1.1 CONTROL
Table (4.1) Distribution of the respondents According to their Age
Table (4.1). Shows the respondents’ frequency and their percentage with
age group (20-29) being the most age group participated the survey of
about 47.6%.
Age Frequency and Percent
Valid 20-29 60 (47.6%)
30-39 24 (19.0%)
40-49 19 (15.1%)
50+ 20 (15.9%)
Total 123 (97.6%)
Missing System 3 (2.4%)
Total 126 (100.0%)
40
Table (4.2) Distribution of Respondents according to their marital
status
Marital Status
Frequency and Percent
Valid Single 36(28.6%)
Married 80(63.5%)
Widowed 6(4.8%)
Divorced 3(2.4%)
Total 125(99.2%)
Missing System 1(.8%)
Total 126(100.0%)
Table (4.2). shows that most married were about 80 (63.5%) and single
were the second 36(28.6%).
41
Table (4.3). Distribution of respondents according to their occupation
Occupation Frequency and Percent
Valid Housewife 80(63.5%)
Employed 16(12.7%)
Student 25(19.8%)
Retired 3(2.4%)
Total 124(98.4%)
Missing System 2(1.6%)
Total 126(100%)
In this table (4.3) results show that most respondents were housewife 80
(63.5%), followed by students of 25 (19.8%).
42
Table (4.4). Association between Education level to the heard of
Breast cancer
In table (4.4). Results show that most participants heard of breast cancer
101(80.1%) of them have heard the breast cancer whereas 25(19.8%) of
them didn’t hear of breast cancer.
Graduates were the most participants heard the breast cancer 39 (30.9%)
followed by the secondary school participants of 23 (18.2%) participants.
There is a significance according to Chi-square test between the
Educational level and hearing of Breast cancer with P-value = 0.000.
Did you hear about breast cancer
Total Education Level Yes % No %
Education Khalwa 13(10.3%) 4(3.1%) 17(13.4%)
Primary school 17(13.5%) 5(3.9%) 22(17.4%)
Secondary school 23(18.2%) 2(1.6%) 25(19.8%)
Graduate 39(30.9%) 1(0.8%) 40(31.7%)
Illitrate
9(7.1%)
13(10.3%)
22(17.4%)
Total 101(80.1%) 25(19.8%) 126(100%)
43
Table (4.5). Association between Level of Education and heard of breast
self examination BSE.
Did you hear of breast self
examination- BSE?
Total Yes No
Education Khalwa 8(7%) 7(6.1%) 15(13.1%)
Primary school 10(8.8%) 9(7.8%) 19(16.6%)
Secondary school 10(8.8%) 14(12.2%) 24(21%)
Graduate 36(31.5%) 4(3.5%) 40(35%)
Illitrate 4(3.5%) 12(10.5%) 16(14%)
Total 68(59.6%) 46(40.4%) 114(100%)
In table(4.5). Results show that more than half of the participants heard of
breast self examination 68(59.6%) respondents heard of BSE.
Graduates were the highest group to hear about BSE 36(31.5%)
participants, followed by secondary and primary of 10(8.8%) respondents
each. We can also see here in this table a significance between the level
of education and hearing of BSE according to Chi-square test with p-
value= 0.000.
44
Table (4.6). Association between the level of education and the knowledge
of method of breast self examination BSE.
In table (4.6) results show that 40(42.2%) knew the method of breast self
examination whereas 54(57.4%) do not know the breast self examination.
The graduate respondents have the highest knowledge of breast self
examination of 28(29.7%) knew the method of BSE. There was a
significance relationship between the two variables with a p-value of
0.000.
Did you know the method of breast
self examination
Total Level of Education Yes % No %
Education Khalwa 4(4.2%) 7(7.4%) 11(11.6%)
Primary school 2(2.1%) 13(13.8%)) 15(15.9%)
Secondary school 4(4.2%) 12(12.7%) 16(16.9%)
Graduate 28(29.7%) 11(11.7%) 39(41.4%)
Illitrate 2(2.1%) 11(11.7%) 13(13.8%)
Total 40(42.2%) 54(57.4%) 94(100%)
45
Table (4.7) Distribution of respondents according to their practice of
BSE
Do you practice breast self examination
BSE?
Frequency and Percent%
Once a month 11 (8.7%)
Sometimes 19 (15%)
Knew but never practice 10 (7.9%)
Don’t know how to practice 86 (68.2%)
Total 126 (100%)
The table (4.7) shows that the practice of BSE is very low among
respondents only 11 (8.7%) practice monthly regular breast self
examination while 19 (15%) practice it only sometimes but the most
respondents don’t know how to practice it 86 (68.2%).
46
Table (4.8). Association of level of education with the knowledge of early
warning signs of breast cancer
In table (4.8). Results showed that painless lamp is the most known sign
among respondents of 31(32.6%) participants.
Graduates have the highest awareness of early warning signs of breast
cancer of 33 out of 95 participants knew at least one early warning sign.
There was a significance p-value 0.009.
What are the early warning signs of breast cancer
Level of
Education
Painless
lump Swelling
skin
changes
nipple
retraction
I don’t
know Total
Khalwa 2 4 2 0 3 11
Primary school 6 1 1 0 9 17
Secondary
school 7 5 2 0 5 19
Graduate 16 5 2 1 9 33
Illitrate 0 1 0 0 14 15
Total 31 16 7 1 40 95
47
4.2 Cases
Table (4.9). Distribution of medical recorded cases of breast cancer
according to their age
Age Frequency and Percent
Valid 20 – 29
30 - 39
2(1.58%)
28(22.22%)
40 - 49 38(30.15%)
50+ 58(46.03%)
Total 126(100.0%)
In this table (4.9) results show that in Cases the most recorded age group
was (50+) age group with 46.03%.
48
Table (4.10) Distribution of medical recorded cases of breast cancer
according to their marital status
Frequency and Percent
Valid Married 96(76.2%)
Single 14(11.1%)
Widowed 9(7.1%)
Divorced 7(5.6%)
Total 126(5.6%)
The table (4.10) shows that the most recorded patients were married
76.2% followed by single patients with 11.1%.
49
Table (4.11) Association of age with the type of breast cancer
Age * type of Breast Crosstabulation
Type of Breast Cancer
Total Age DCIS IDC LCIS ILC Others
Age 20-29 2 0 0 0 0 2
30-39 11 14 0 1 2 28
40-49 18 16 3 0 1 38
50+ 26 26 1 1 4 58
Total 57(45.2%) 56(44.4%) 4(3%) 2(1.58%) 7(5.55%) 126(100%)
In table (4.11) results show that age crosstabulated with type of breast
cancer without any significance, the most type of breast cancer in the
patients was ductal carcinoma in Situ DCIS of 57 patients(45.2%), followed
by Invasive ductal carcinoma IDC of 56 patients (44.4%), and lobular
carcinoma in situ LCIS, invasive lobular carcinoma ILC represent 6 patients
only (4.58%) an lastly other rare types of breast cancer which constitute
7(5.55%).
50
4.3 Case control section
Table (4.12) Association of Cases and Controls regarding breast
cancer risk factors
Parameter Cases(n=126)
Number %
Controls (n= 126)
Number % P-value
Age groups (years)
0.000
20-29 2(1.58%)
60 (47.6%)
30-39 28(22.22%) 24 (19.0%)
40-49 38(30.15%) 19 (15.1%)
50+ 58(46.03%) 20 (15.9%)
Missing system 0(0%) 3(2.4%)
Marital status
0.42
Single 14(11.1%) 36(28.6%)
Married 96(76.2%) 80(63.5%)
Widowed 9(7.1%) 6(4.8%)
51
Parameter Cases(n=126)
Number %
Controls (n= 126)
Number % P-value
Divorced 7(5.6%) 3(2.4%)
Missing system 0(0%) 1(0.7%)
Family history of breast cancer
0.12
No 105 (83.3%) 108 (85.7%)
Yes 21 (16.6%) 9 (7.1%)
Don’t know 0(0%) 9(7.1%)
Onset of Menarche
0.000
14 and below 35 (27.7%) 40 (31.7%)
15 and above 21 (16.6%) 73 (57.9%)
Do not remember 70 (55.6%) 13 (10.3)
Parity
0.62
Parous 81 (64.2%) 72 (57.1%)
52
Parameter Cases(n=126)
Number %
Controls (n= 126)
Number % P-value
Nulliparous 45 (35.7%) 54 (42.9%)
Age at First Birth
0.000
<20 13 (10.3%) 28 (22.2%)
20-29 33 (26.1%) 35 (27.7%)
30-39 9 (7.1%) 5 (4%)
Nulliparous 45 (35.7%) 51 (40.4%)
Don’t remember 26 (20.6%) 7 (5.5%)
Smoking
0.50
Yes 1 (0.8%) 3 (2.3%)
No 125 (99.2) 123 (97.7%)
Hypertension
0.14
Yes 18 (14.3%) 6 (4.7%)
53
Parameter Cases(n=126)
Number %
Controls (n= 126)
Number % P-value
No 108 (85.7%) 120 (95.2%)
54
4.4 Discussion
The study carried out determines the knowledge attitude and practices of
women about the early detection of breast cancer and also the risk factors
that enhance the development of the disease, the study was done in
Madani Teaching Hospital and National Cancer Institute for cancer
treatment during the study period of November 2011 to February 2012.
The study revealed that most control participants were married about 80
(63.5%) See table (4.2) and also in Cases the most recorded patients were
also married 96 (76.2%) as explained in table (4.9). The study showed
that the majority of control respondents were housewives 80 (63.5%),
followed by students of 25 (19.8%) as shown in table (4.3). It is obvious
that knowledge and awareness about the breast cancer can have an impact
directly upon behavior leading to modify breast cancer risk. It also plays
an important role in an improvement of health seeking behavior. (Soheil
mia, 2007).
The current study showed that majority of participants heard about breast
cancer 101(80.1%).The percentage of those heard about breast cancer
was more among graduates of about 39(30.9%) as shown in table (4.4).
There is a significance according to Chi-square test between the
Educational level and awareness of Breast cancer with (P-value = 0.000).
55
Here we can realize that the education plays a great role to the awareness
of health related issues.
The current study also revealed that most participants heard of breast self
examination 68 (59.6%) respondents heard of BSE.
Graduates were also among the highest group of awareness about BSE
36(31.5%) followed by secondary and primary of 10(8.8%) respondents
each. We can also see here a significance between the level of education
and hearing of BSE according to Chi-square test with (P-value= 0.000).
The study also showed that 40(42.2%) knew the BSE whereas 54(57.4%)
do not know the breast self examination. Also here the graduates were
among the highest group of knowledge about BSE and the chi-square test
showed significance (P-value 0.00). The practice of BSE was very low
among respondents about 11(8.7%) only practice it monthly regular BSE
while 19(15%) practice it sometimes whereas most respondents 86 (68.2)
don’t know how to practice BSE. So we can say that the practice of BSE
was poor among respondents due to lack of knowledge about the method
of practicing it.
Also in the study respondents were asked whether they know about the
early warning signs of breast cancer, 31 (32.6%) said they know that
painless lump is a warning sign of breast cancer, followed by swelling of
the breast as the second most known sign with 16 (16.8%) respondents
56
whereas 40 (42.6) said they do not know any sign. This shows that about
one third of the respondents do not know any sign of breast cancer
thereby making difficult to go for screening or doing clinical breast
examination.
The results also revealed that age crosstabulated with type of breast
cancer has no any significance p-value=0.6, the most type of breast
cancer in the patients studied was ductal carcinoma in Situ (DCIS) of 57
patients(45.2%), followed by Invasive ductal carcinoma (IDC) of 56
patients (44.4%) as shown in table (4.10). In a study conducted in central
Sudan on breast cancer stages, on 1255 women results showed that
infiltrating ductal carcinoma IDC constituted the majority of breast
cancer diagnosed about 82% of the patients whereas other types of breast
cancer, such as infiltrating lobular carcinoma, ductal carcinoma in situ
and infiltrating medullary carcinoma represented a small fraction of the
diagnosed breast cancer (Elgaili et al., 2010).
In the section of case control study regarding to breast cancer risk factors
126 records of breast cancer patients in NCI were ascertained as cases
whereas 126 others are ascertained as controls, the controls were patients
and co-patients attended to Madani teaching hospital but not with breast
cancer patients, many risk factors for breast cancer development have
been described and some of them including age, family history of breast
57
cancer and reproductive factors are well established ( Henderson IC,
1993).
The results of current study aimed to compare the risk factors that are
present in controls with those of patients recorded, results showed that
about half of the recorded cases were fifty years and above of age that is
58 (46.03%) of breast cancer patients, whereas in controls about half of
them 60 (47.6%) belong to the age group (20-29) as summarized in table
(13) with (P-value= 0.000), this showed a statistically significant
differences between the two groups, being the advanced age as a risk
factor for the development of the breast cancer. Also the age of Onset of
menarche was different among cases and controls and showed
statistically significant difference only 21 (16.6%) of cases their onset of
menarche was between the ages 15-17 years of age and 35 (27.7%) their
ages of menarche were between 11-14 years, but the remaining patients
were uncertain of their age at onset of menarche, on the other hand about
two third of controls' age of onset of menarche was 15-17 years. The age
of first birth also showed significant difference among cases and controls,
only 13 (10.3%) had their first babies before the age of twenty in patients
of breast cancer whereas about double of that percentage 28(22.2%) of
controls had their first child before the age of twenty. So according to this
study giving birth at an early age gives some kind of prevention against
58
the breast cancer. There was no significant difference among cases and
controls with regard to marital status, parity, smoking and hypertension
and hence have no any influence on the risk. A university hospital based
study conducted in turkey in 2009 about the breast cancer risk factors
among Turkish women for the study period from 200-2006. It was found
that increasing age >50 was a risk among the patients, also age at first
birth >34 and positive family history were among the risks found (Vahit
O. et al., 2009).
59
CHAPTER FIVE
CONCLUSION AND RECOMMENDATION
5.1 CONCLUSION
The results of the study indicated that most participants have heard
of breast cancer but with different knowledge among them, also
they have heard about breast self examination but only small
portion knew the method of breast self-examination and few of
them practiced monthly.
The study also revealed that one third of the respondents knew at
least one warning sign of breast cancer while one third of them
don't know any sign about the early warning signs of breast cancer.
The study also showed that educated people had access to
knowledge about breast cancer and breast self examination, while
those non educated had poor knowledge about the disease and its
signs.
In the section of case control study of risk factors comparison
between cases and controls, the study showed that advancing age
was the main risk factor among breast cancer patients, other risk
factors studied were age at first birth, age of onset of menarche all
showed significance different while the rest such as marital status,
60
family history, parity, smoking and hypertension all showed no
significance and hence have no influence on the risk of developing
breast cancer.
The most type of breast cancer suffered the patients recorded was
infiltrating ductal carcinoma and ductal carcinoma in situ. Other
types were rare.
61
5.2 RECOMMENDATION
Promote early detection measures through breast cancer education
and awareness to let the women seek medical help earlier.
Educate women about the importance of screening practices
especially breast self-examination and to practice it regularly every
month.
Improvement of medical records regarding breast cancer patients in
the National Cancer Institute for cancer treatment.
62
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APPENDIX
Knowledge, Attitudes and Practices among women towards early
detection of breast cancer
Questionnaire
I am a postgraduate student in the University of Gezira preparing my
master degree thesis in KAP study of women towards the early detection
of breast cancer. Breast Cancer is a Global public health problem. To
ensure primary prevention and treatment population based screening
program as well as breast awareness is necessary. To assess the
knowledge attitude and practice regarding breast cancer some information
is required from you. Your response will contribute a big effort to
conduct this study. Your participation would be kept confidential. Do you
agree to share this scientific research ____
Section One: Socio-demographic data
1. Age:
□ 20-29 □ 30-39 □ 40-49 □ 50+
2. Marital status:
□ Single □ Married □Widowed □Divorced
If Married:
70
a. At what Age you married? ____
b. Do you have children? □Yes □ No
If Yes,
3. How many children do you have?
□ One Child □ 2-5 Children □ 6-10 Children □ More than 10
4. What was your age at first child birth? _____
5. Occupation
□ Housewife □ Employed □ Student □ Retired
6. Education:
□ Illitrate □ Khalwa □ Primary school
□ Secondary School □ Graduate □ Postgraduate
7. Family size _____________
8. Family history of breast cancer? □ Yes □ No
If yes, mention relative degree :
□ Mother □ Grandmother □ Aunt □ Sister □ Other____
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9. Which of the following do you have?
Smoking □ Yes □ No
Not breastfeeding □ Yes □ No
Early onset of menarche □ Yes □ No
Nulliparity □ Yes □ No
Hypertension □ Yes □ No
Section Two: Knowledge about breast cancer
10. Did you hear about breast cancer? □ Yes □ No
If yes,
a. What is breast cancer?
□ A fatal disease □ A disease that can be prevented
□ A disease that cannot be prevented □ A common disease in women
b. Where is the source of information?
□ Radio □ Magazines □ TV □ Friends □ Posters
□ Other, __________
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11. What are the factors that cause breast cancer?
□ Hereditary □ Smoking □ Obesity
□ Nulliparity □ Not breastfeeding □ Age above 40
□ Magic and evil spirits □ Other______
Section Three: attitudes and practice about breast cancer
12. Did you hear of breast self examination? □ Yes □ No
If yes,
13. Do you know the method of breast self examination? □ Yes □ No
If yes, frequency of application
□ Once in a month □ Occasionally
□ Never □ Other
14. Do you believe Breast cancer is common in women with big
breasts?
□ Yes □ No □ I don’t know
15. Do you believe Lumps in the breast that are cancer are pain
full?
□ Yes □ No □ I don’t know
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16. Did you hear clinical breast examination? □ Yes □ No
If yes frequency of application?
□ Once in a month □ Occasionally □ Never
17. Did you hear mammography? □ Yes □ No
If yes, at what age mammography is done?
□ 20 years above □ Before 40 years
□ 40 years and above □ I don’t know
18. What are the early warning signs of breast cancer?
□ Painless lump
□ Swelling
□ Skin changes
□ Discharge from nipple
□ Nipple retraction
□ I don’t know
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19. Have you ever been educated about breast cancer? □ Yes □ No
If yes, what is the source of education?
□ Doctor
□ Healthcare provider
□ Peers
□ Radio programme
□ TV programme
□ Internet
□ Other ____
Thank you for your cooperation