Practice of self breast examination as a strategy in the prevention of breast cancer among women of child bearing age

Introduction

The human system in spite of its natural immune system has played host to several diseases, ranging from viral and bacterial as well as other health related problems such as tumour. Bacterial and viral diseases which are commonly referred to as communicable diseases have almost assumed the status of household awareness, but unlike tumour which may assume terminal status especially when there is late detection, has become a common occurrence affecting both male and female, but it is however rare among the males and it is a major health burden to women (Wodi, 2016).

A tumour, also known as neoplasm, is a swelling of a part of the body, generally without inflammation, caused by an abnormal growth of tissue, or an abnormal mass of tissue which may be solid or fluid-filled. A tumour does not mean cancer – tumours can be benign (not cancerous), pre-malignant (pre-cancerous), or malignant (cancerous).

Cancer is any malignant tumour such as carcinoma and sarcoma which arises from abnormal and uncontrolled growth and division of cells that invade and destroy the surrounding tissues (Watson, 2015). A carcinoma may be any cancers that arise in the epithelial tissues that line the skin and internal organs of the body while a sarcoma may be a cancer that develops in the connective tissues of the breast.

Breast cancer is a type of cancer that is formed in the tissues of the breast. It occurs when malignant tumours develop in the breast, break away from the original tumour and enter blood vessels or lymph vessels, which branch into tissues throughout the body and begin to damage other tissues and organs. Some types of breast cancer may include: Ductal carcinoma in-situ, Invasive or infiltrating ductal carcinoma, Invasive lobular carcinoma, inflammatory breast cancer, paget disease of the nipple, etc.

There are different screening methods for diagnosing breast cancer. Breast cancer screening is a procedure used for testing healthy women in an attempt to detect breast cancer early with the hope that early detection will help to improve outcomes. Some of these screening methods may include: Clinical and self-breast examination, mammography, genetic screening, ultrasound and magnetic resonance imaging.

Breast masses are common during the childbearing years. The majority are benign and harmless. Self-breast examination works best if you are familiar with your breasts; this is why it should be done minimum once a month. If you are over 40 years of age, an annual mammography is suggested.

Self-breast examination is a very important screening measure for early detection of breast cancer. The regular and correct practice of self-breast examination has been found to empower many women, enabling them to take responsibility for their own health. Among women who are aware and also practice it correctly every month, the method has shown to help detect lumps, swelling, tumours, and other abnormalities of the breast early and early diagnosis has been reported to influence early treatment to yield a better survival rate (Petro-Nustra et al., 2012). Despite the benefits associated with self-breast examination, few women regularly perform it. And there has not been systematic approach to increase the awareness of self-breast examination in the prevention of breast cancer.

Conceptual framework

Self-breast examination (SBE)  is a procedure by which the  breast and accessory anatomic structures such as the lobules, lactiferous ducts, areola and nipples, are observed and palpated to detect changes or abnormalities that may indicate the presence of malignancy. It is a screening method used in an attempt to detect early breast cancer. It involves a woman looking at and feeling her breast for possible lumps, distortions or swelling. It is recommended that women undertake self-breast examination once a month.

Bare et al. (2014) described self-breast examination as learning the normal look or feel of the breast and check for changes every month just as patient period is at end.

Kösters & Gøtzsche (2013) stated that self-breast examination can help women become familiar with the individual characteristics of each breast and notice any changes.

The American Cancer Society (2010) recommended that self-breast examination be performed to help women detect changes that would require the attention of the physicians or any other health professional. It also states that early detection of breast cancer through the practice of self-breast examination plays a role in reducing the mortality rate associated with breast cancer and improves the chances of saving a breast by avoiding mastectomy.

According to Jahan et al. (2013) many women miss early detection and treatment opportunities due to lack of information, knowledge and awareness of breast cancer as well as cancer screening practices.

World Health Organization (2011) is of the opinion that to decrease the incidence of breast cancer in developing countries, breast cancer screening programmes should be emphasized which includes self-breast examination.

Greenstein (2015) stated that 10% of breast cancers are missed during mammography and so self-breast examination would help a woman to detect any lump missed, bring it to the doctor’s attention and get it evaluated.

According to Lannin (2013), one third of the breast cancer found by the patient herself account for close to 70,000 cancers each year. Dr. Weiss, President and founder of Breast Cancer Association and a leading breast cancer Oncologist in 2014 stated that women who do not perform self-breast examination could seriously endanger their health and lead to later detection of cancer in some women. Early detection of breast cancer is crucial not only to the survivorship of a patient but to her quality of life.

Performing self-breast examination incorrectly can be almost as bad as not doing the examination at all, since it can give women false sense of security. According to Avci (2010), early detection of breast cancer can reduce its morbidity and mortality rates. Mammography, clinical breast examination and self-breast examination (SBE) are considered effective methods for early detection of breast. Although SBE alone is not sufficient for early detection of breast cancer, but it is still an important screening tool for early detection of breast cancer in developing countries, because it is cheap, widely available, and does not require complex technical training (Giridhara et al., 2011). By performing regular SBE, women who are familiar with the structure of normal breasts will be motivated to attend screening clinics for mammography and clinical breast examination (Giridhara et al., 2011;  Tavafian et al., 2012).

The Malaysian Ministry of Health has been promoting SBE and annual breast examinations by trained health workers as part of breast health awareness campaigns since 1995. Soyer et al. (2014), while the majority of women seem to be aware of self-breast examinations, yet many still do not know how to perform it properly. Studies conducted among different groups of women in Malaysia showed that monthly SBE practice ranged from 19.6 to 36.7%, respectively. Although early detection of breast cancer can increase the survival rate, many women miss early detection due to lack of knowledge and information about breast health awareness (Akhtari-Zavare et al., 2015; Rosmawati, 2010).

American Cancer Society (2013), also has proven that, if breast cancer is detected at an early stage (stage I–II), a 100–93 % survival rate can be achieved, and this rate decreases to 72–22 % if breast cancer is diagnosed at later stages (III–IV). According to Tarawneh and Attiyat (2013); Gumus et al. (2010), many investigators have tried to determine the barriers that affect women’s practice of SBE, because these barriers are essential to plan effective intervention programs to improve SBE practice.

Among the multiple barriers identified are lack of  awareness about breast cancer, lack of time, shortage of self-confidence, fear of possible detection of a mass and feeling of awkwardness about breast handling, health related assumptions, anxiety and forgetfulness, low socio-economic status and poor access to health care facilities, negative socio-cultural perception about breast cancer and strong belief in traditional medicine, and lack of motivational support from parents, spouse or friends. George (2015) classified barrier to self-breast examination to include personal, care givers and demographic barrier. Among personal barrier include lack of skill, interest and economic factor, etc.

Rasu et al. (2011), said that current literature showed many barriers to SBE practice, which include social and cultural perceptions of breast cancer and self-breast examination, socio-demographic factors, level of knowledge, and awareness. Result of study done by Bit-Na et al. (2012) among Korean women shows (31.7 %) did not know how to do it, (26.3 %) they would never have breast, and (5.3 %) fear of detecting breast cancer. Also, there is a lack of knowledge about the benefits of SBE among young women.

According to Avci (2010), many young women believe that breast cancer affects only older women and thus, they are not at risk for getting breast cancer. So, their main reasons for not practicing SBE were “don’t know how to do SBE”; “don’t have any symptoms” “scared of being diagnosed with breast cancer”. Also, there is a lack of knowledge about the benefits of SBE among young women. According to Salem and Hassan (2014), as remedies to these identified barriers, there is an immense need for a public health education programme to inculcate the practice of self-breast examination among women to minimize the level of ignorance, fear, denial, myths and misconceptions. The messages and recommendations about breast cancer screening must be clear and the recognized barriers should be taken into consideration for maximization of the outcome. Every effort has to be taken to encourage the practice of SBE not only among women but also among men as there is visible increase in the incidence of male breast cancer.

Palpation perimeter

The examination area is bound by the line which extends down from the middle of the armpit to just beneath the breast, continues across the underside of the breast to the middle of the breast bone, and then moves up and along the collar bone and back to the middle of the armpit. Most breast cancers occur in the upper outer area of breast.             

Think of each of your breasts as a “clock.” Looking in the mirror and starting “12 o’clock” is your collar bone, your arm pit and outer quadrants are between “7 and 11 o’clock.” The midline base of the breast is the “6 O’clock position and the inner quadrants are between “1 and 5 O’clock.” See the nipple as the centre of the clock.

Techniques for performing self-breast examination

Feeling the breast is also called “palpation” of the breast. There are different patterns or methods used for carrying out SBE. You should always be feeling and looking for any new changes, lumps or thickenings of the breast, any rapidly growing lump or hot areas.  It is important to learn how to use either pattern correctly and perform a thorough examination of each or both breasts.

There are three different patterns you can use to examine your breasts, they include:

1. Circular motion or “small circles” pattern.
2. “Strips” or “up and down” pattern.
3. “Wedges” or radial spokes pattern.

Circular motion pattern

Place one hand behind your head or under the breast you are going to examine. With your other hand, begin with a careful examination of your armpit exploring with the flat part of your fingers and the gently move to the “9 or 10 o’clock” position. Now begin by moving your hand in a circular fashion, clockwise around the breast. You will feel a ridge of tissue in the lower curve of your breast and go just below it. When you reach the top of your breast, move your fingers a bit and continue circling around your breast feeling all breast tissues you can. Continue inward until you reach your nipple. Now gently squeeze your nipple as suggested above when you finish with one breast repeat these steps with your other.

Lines, “up and down” or “stripes” pattern

Once again after completing the examination of the armpit, move your hand to a starting point at about “11 o’clock.” Begin moving your hand from the top of the breasts to the bottom of the breast feeling all tissues in between. In large breasted women use the hand on the same side of the breast (that is left hand on the left breast, right hand on the right breast) to hold up your breast so that you can examine the upper portion of your breast carefully. Always start at the top of the breast and go as far as you can down the face of the breast feeling the breast tissue between your “palpating” fingers and either the chest wall or your hand beneath your breast until you have checked your entire breast.

After completing palpation of the top part of your breast, the area you can most easily feel, then take your left hand (for the left breast) or the right (for the right breast) and use it to push up against the upper part of your breast pulling the top part of the breast upward so that you can now use your opposite hand to palpate the lower portion (underside) of your breast in the exact same way. Women with smaller breasts can examine the entire breast in up and down motion from the top of the breast to the bottom of the breasts without having to hold up the breast.

Wedges or radial stroke pattern

Once again after completing the examination of the armpit, move your hand to a starting point at about “11 O’clock.” Begin moving your hand from the top of the breasts to the bottom of the breast feel all tissue in between. Now starting at “11 O’clock,” consider that the breast is divided up into a series of wedge-shaped areas, like one cut up a pie. For example the area between “11 O’clock” and “12 O’clock” is one wedge, while the area from “12 O’clock” and “1 O’clock, 1 to 2 O’clock, 2 to 3 O’clock, 3 to 4 O’clock” and so on are all wedges shaped areas each of which must be examined thoroughly. No matter which pattern you use, remember to check the area above the nipples and to squeeze the nipple to see if there is any discharge.

Steps for performing self-breast examination

Each month inspect your breasts looking at a good mirror in a well-lighted room and then palpate your breast thoroughly by one or more of the methods described above. Set up a regular scheduled day each month to check your breasts. Record this date and what you find for your own records. When doing SBE, choose a quiet time when you will not be interrupted. You should also be in a good state of mind, unstressed and unhurried. The use of a favourite hand lotion will often allow your hands to slide easily and smoothly over your breast.

Step 1: Standing-in front of a mirror 

• Standing undressed facing a mirror that allows you to see your breasts.
• Check for any changes in the shape or look of your breasts.
• Carefully inspect your breasts noticing the contour and shape looking for any unusual skin or nipple changes, such as puckering skin, dimpling, scaling, colour changes or discoloration, discharge or fluid coming from the nipple of your breasts.
• Look carefully at your breasts with both arms at your sides.
• Watching closely in the mirror, move your arms above your head and clasp them behind your head and press elbows forward. You should be able to feel your chest muscles tightened.
• Watch as you move both arms straight up over your head, place both hands on your hips and press firmly on each hip to flex your chest muscles, move forward and look for any dimpling or any unusual changes in contour.
• While pressing on your hips and flexing chest muscles bend forward, roll your shoulders and elbows forward to tighten your chest muscles. Your breasts will fall forward. Look for any changes in the shape or contour of your breasts.
• Now palpate your armpits and breasts as described above.
• Gently squeeze the breast just above your nipple palpating gently to see if there is any lump under the nipple areas.
• Milk the tissue down toward the nipple between thumb and index finger.

Any discharge, whether clear or bloody, should be reported to your physician.

Step 2: While lying down

• Place a pillow or folded towel under your right or left shoulder. This position flattens the breast over your chest wall and makes the exam easier.
• Raise one hand over your head.
• As stated above, using the flat pads of the fingers of your opposite hand, press gently against your breast.
• Begin with exploring your armpit and then with your index finger next to your collarbone.
• Move your hand clockwise around your breast gently palpating both breasts.
• You may start with small circles and then follow with using the up-and-down “strip” palpation or wedge pattern of examination.
• Use light, medium, and firm pressure over each area of your breast.
• You will feel a ridge of tissue in the lower curve of your breast.
• Continue until you reach the nipple and then check all around it.
• Repeat this step with your other breast by first changing to your opposite side and then repeating the steps listed above.
• Gently squeeze the nipple of each breast for any discharge. Take your time and thoroughly exam both of your breasts.

Step 3: While in the bath or shower

This can replace the standing or lying down procedures or, for best result, be done along with each of the other evaluations.

• Raise your right arm. With soapy hands and fingers flat, check your right breast. Your hands will glide easily over breasts when your skin is wet.
• Repeat the same steps outlined above for the standing and lying positions.
• You may use the small circles, up-and-down (strips) or wedge patterns described in the section on Pattern.
• Repeat the same procedures on your left breast.

Time to perform self-breast examination

Women using oral contraceptive are encouraged to do their self-breast examination each month on the day they begin a new package of pills (Nelson et al., 2016). Women who are no longer menstruating should do their self-breast examination on the same day every month. A day which is easy to remember such as the first or fifteenth of every month should be picked and self-breast examination should be performed on that day (Nelson et al., 2014).

Women who are menstruating, usually have hormonal changes due to the menstrual cycle which may cause the breast to become more lumpy or swollen. Therefore, self-breast examination should be performed from a few days to about a week after menstruation has ended, when the breasts are usually less tender or swollen and the hormones are at their lowest levels (Nelson et al., 2014).

Signs and symptoms of breast cancer

The first noticeable symptom of breast cancer is typically a lump that feels different from the rest of the breast tissue. More than 80% of breast cancer are discovered when the woman feels a lump (America Cancer Society, 2010). Lumps found in lymph nodes located in the armpits can also indicate breast cancer. Others include:

1. Thickening different from breast tissue.
2. One breast becoming larger or lower.
3. A nipple changing position, shape or becoming inverted.
4. Skin puckering or dimpling.
5. Discharge from the nipple or nipples.
6. Constant pain in part of the breast or armpit.
7. Breast enlargement and discomfort.
8. Swelling beneath the armpit or around the collar born.
9. Redness
10. Accentuated veins on the breast surface.
11. Change in the colour or feel of the skin of the breast, nipple or areola.
12. Symptoms of advanced disease are bone pain, weight loss, swelling of one arm and skin ulceration.

For inflammatory breast cancer, symptoms may include: itching, pain, swelling, nipple inversion, warmth and redness throughout the breast as well as an orange peel texture to the skin referred to as pseudo orange. For Paget’s disease of the breast, symptoms may include skin changes resembling eczema, such as redness, discoloration or mild flaking of the nipple skin. As the disease advances, it may include symptoms of itching, tingling, increased sensitivity, burning and pain (National Cancer Institute, 2015).

Advantages of self-breast examination

1. It helps women to increase their self-awareness of their breast.
2. It helps women to be familiar with the normal feel of their breast and the tissue underlying them.
3. It helps to pick up masses or lumps that are not being picked in mammography.
4. It helps in early diagnosis and treatment of breast cancer thereby decreasing mortality rate associated with it.
5. It allows women to perform self-breast examination independently (that is, without relying on a healthcare professional).
6. It is relatively simple, convenient, non-invasive way of detecting any abnormality in the breast.
7. It is cheap and provides minimal risk for early detection of breast cancer.
8. It provides a means for discovering tumours at a stage where treatment and clinical cure are possible.

Prevention of breast cancer

1. Limit alcohol: The more alcohol you drink, the greater your risk of developing breast cancer. The general recommendation – based on research on the effect of alcohol on breast cancer risk – is to limit yourself to less than 1 drink per day as even small amounts increase risk.
2. Don’t smoke: Accumulated evidence suggests a link between smoking and breast cancer risk, particularly in premenopausal women. In addition, not smoking is one of the best things you can do for your overall health.
3. Control your weight: Being overweight or obese increases the risk of breast cancer. This is especially true if obesity occurs later in life, particularly after menopause.
4. Be physically active: Physical activity can help you maintain a healthy weight, which, in turn, helps prevent breast cancer. For most healthy adults, the Department of Health and Human Services recommends at least 150 minutes a week of moderate aerobic activity or 75 minutes of vigorous aerobic activity weekly, plus strength training at least twice a week.
5. Breast-feeding: Breast-feeding play a role in breast cancer prevention. The longer you breast-feed, the greater the protective effect. Women who breast feed their babies for at least a year in total have a reduced risk of developing breast cancer later in life.
6. Limit dose and duration of hormone therapy: Hormone therapy for more than three to five years increases the risk of breast cancer. If you’re taking hormone therapy for menopausal symptoms, ask your doctor about other options. You might be able to manage your symptoms with no hormonal therapies and medications. If you decide that the benefits of short-term hormone therapy outweigh the risks, use the lowest dose that works for you and continue to have your doctor monitor the length of time you are taking hormones.
7. Avoid exposure to radiation and environmental pollution: Medical-imaging methods, such as computerized tomography, use high doses of radiation. While more studies are needed, some research suggests a link between breast cancer and radiation exposure. Reduce your exposure by having such tests only when absolutely necessary.
8. Eat healthy diets: Women who eat a Mediterranean diet supplemented with extra-virgin olive oil and mixed nuts might have a reduced risk of breast cancer. The Mediterranean diet focuses mostly on plant-based foods, such as fruits and vegetables, whole grains, legumes and nuts. People who follow the Mediterranean diet choose healthy fats, like olive oil, over butter and fish instead of red meat. Eat red meat in moderation. Take adequate protein, and choose vegetable oils over animal fats .Eating a healthy diet might decrease your risk of some types of cancer, as well as diabetes, heart disease and stroke.
9. Regular breast cancer screening: Recommendations provided by the healthcare provider must be followed to decide what type of screening is needed and how often it may be done.
10. Prophylactic surgery to remove breast and/or ovaries: Women who have had both breasts surgically removed reduce their risk of breast cancer by over 90 per cent. Women who have had both ovaries removed have about half the risk of developing breast cancer compared to women with intact ovaries.

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