Breast cancer awareness and practice of breast self examination among women of childbearing age

Introduction

Breast cancer is the most common type of cancer and it continues to remain the most lethal malignancy in women across the world (Doshi, Keddy, Karunakar & Kulkarani, 2012). It constitutes a major public health issue globally. Although breast cancer is 100 times more common in women than men, men tent to have power outcome due to delay in diagnosis (Fasoranti, 2010). Breast cancer incidence rate are higher in industrialized countries, recent trends shows that the largest increase in risk is occurring in developing country. There is thus a geographical variation in the incidence of Breast cancer with higher incidence in Europe and American compared to Asia and Africa (Otune, 2008).

In Nigeria, the number of women at risk of Breast cancer increases steadily from Approximately 24.5 million in 1990 to approximately 40 million in 2010 and it is projected to over 50 million by 2020 (Akarolo-Athony, Ogundiran & Adebemowo, 2010). Statistic from ministry of health Nigeria showed that Breast cancer had risen at least four times over the decade and 40 percent of women are accounted for cancer (Onyebuchi, 2012). In the present scenario, roughly 1 in 26 women are expected to be diagnosed with Breast cancer in their life time, Majority of cases occurring in premenopausal women (Dosh et al., 2010). According to Salandeen, Akande and Musa (2009), studies from various ethnic populations have reported the demographic profile of Breast cancer especially from the Northern and Southern part of the country. A review of breast biopsies in Warri South general Hospital showed 34 percent of all breast biopsies done over a 10 year period to be malignant and that these patients were pre menopauses (Oluwatosin, 2010).

Moreso, majority of women present with advanced stages of the disease at which time little or no benefit is derived from any form of therapy. The 5 year survival rate of breast cancer is over 85% with early detection while late detection decreases the survival rate to 56% (Fasocranti, 2010). The low survival rate of Breast cancer in less developed countries can attribute to lack of early detection as well as inadequate diagnosis and treatment facilities. Oluwatosun (2012) asserted that women in Nigeria have poor knowledge of the disease. For women to present early, they need to be “breast aware” and must be able to recognized symptoms of Breast cancer through routine practice. Late presentation of patient at advanced stages is thus the cause of Breast cancer death in Nigeria women, 80 percent of breast cancer patient in Nigeria are said to die because of late detection (Otune, 2008).

In an environment where late presentation is predominant there is an urgent need for awareness of Breast cancer and its early detection measures. Early diagnosis has a positive effect on the prognosis as well as limits the development of complication and disability. Changes in the early detection guideline of the American cancer society now recommend that women, beginning from their early 20s should be told about the benefits and limitations of breast self examination. They also recommend that breast self examination be perform monthly beginning from at the age of 20 years, and women should undergo a clinical Breast Examination annually beginning at the age of 25 years. This is essential since nearly 70% of all Breast cancer are found through breast self examination and with early detection quality of life is increased (National Breast Cancer Foundation,2012).

An increased awareness among women in general on Breast self examination as a means of detecting Breast cancer would likely result in a high number of women practicing it. If there is an increased awareness and improvement in the capacity of women to understand themselves, it will enable them seek medical attention early enough. Awareness can be created by health workers such as doctors, nurses, community health workers, even news papers, journals, and internet are also sources where one can read articles written in Breast self Examination (Cosgrave 2009). According to Oluwatosin (2012) women given information and instructions about Breast self examination and Breast cancer by health care professionals demonstrated higher knowledge and confidence and tent to practice Breast self Examination more than those who received information from other sources (Atanga, Atashili, Fuh &Eta, 2012). Regular practice of Breast self examination is the corner stone of the fight against Breast cancer worldwide, especially for black women because clinical Breast examination and mammography  might not be accessible to them for economic or other reason. Though screening mammography is widely practiced in developed countries, it is hardly recommended for those under 30 years because of their dense tissues which make interpretation of the film different. (National Breast Cancer Foundation,2012).

Furthermore, Breast self examination recommended as a general approach to increasing Breast health awareness and thus potentially allow for early detection of any anomalies. This study is designed to determine the Breast cancer awareness and practice of Breast self examination among women in selected rural communities who constitute the majority of women at risk for the disease.

Conceptual framework

The normal breast

The Breast is the tissue overlying the chest (pectoral) muscles, which lies on the anterior chest wall between the second and sixth ribs and from the second sternum to the mid auxiliary line (Smeltzer, Bare, Hinkle & Cheever, 2010). Women Breasts are made up specialized tissue that produced milk (glandular tissue) as well as fatty tissue. The amount of fat determines the size of the Breast. The milk producing part of the Breast is organized into 15 to 20 sections called lobes, each with a duct that opens onto the surface of the nipple. Each lobe consists of clusters of secretary ducts, formed by the union of smaller hairs and areola glands, visible as small bumps on the surface. These glands are intermediate between sweat gland and mammary glands in their degree of development. Internally, the non lactating Breast consists mostly of adipose and collagenous tissue. Suspensory ligaments attach the Breast to the dermis of the over lying skin and to the fascia of the pictorials major. Although the non lactating Breast contains little glandular tissue, it does not have a system of ducts branching through it fibrous stroma and converging on the nipple. Each lobe is drained by a lactiferous duct, which dilated to form lactiferous sinus opening onto the nipples.

The Breast is an international, multidisciplinary journal for researchers and clinicians, which focuses on translation and clinical research for the advancement of Breast cancer prevention, diagnosis and treatment of all stages. The Breast is undeveloped in both sexes until puberty. In females the Breast enlarges during puberty as a result of accumulation of adipose tissues and collagenous connective tissue with increase branching of lactiferous ducts (Otune, 2008). The male breast remains rudimentary throughout life. Breast cancer in men is a rare disease less than 1 % of all Breast cancer occur in men, and only one in a thousand men will ever be diagnosed with Breast cancer. This type of Breast cancer starts in the Breast lobules and grows into fatty tissues of the Breast. The lymphatic of the auxiliary tail are especially as a route for Breast cancer metastasis. Facial bands called the cooper’s ligament support the Breast on the chest wall. The cylindrical projection on the skin surface forms the nipple which is perforated by duct orifices.

The blood supply to the Breast is abundant. It is derived from the internal mammary arteries and branches of the thoracic and inter-costal arteries (Saladin, 2010). A large proportion of the lymph in the Breast is channeled through the auxiliary lymph nodes, and the reminder drains through mediastinal nodes. The Breasts are subjected to menstrual cyclical changes, associated with alterations in the concentration of various hormones. Oestrogen initiates growth of the ducts system and promote fat deposition on the Breast. They are responsible for the characteristic, external appearance of the areola. Intertropic hormone and progesterone are considered the chief stimulants for the development of the secretary cell in the lobules and alveoli. Progesterone causes the Breast swelling and tenderness that many women experience during the three days preceding menstruation. This is due to increase fluid in the subtanoeus tissue as well as distention of the ducts and hyperemia. All these changes decreased during menstruation. During pregnancy, the lobes and ducts enlarge for secretion of milk. Progesterone acts on the oestrogen primed ductal tissue and support the secretary functions of the Breast during lactation. Lactation is a function of the Breast that occurs in response to proclactin stimulation after the birth of a child.

 Concept of breast cancer

Breast cancer is a group of cancer cells (malignant tumour) that starts in the cells of the Breast. It is also the second leading cause of death among women. Breast cancer also occurs when abnormal cells in the Breast grow in an uncontrolled way (Cancer Australia, 2012). It usually arises from the epithelial cells of the duct, not from the alveoli. The cells in which Breast cancer begins are the building block that makes up tissue. Tissue makes up the organs of the body. According to Otune (2008) cells grow and divide to produce more cells only when the body needs them. As cells die, other reproduces to replace them in an orderly fashion and this cell division cycle proceeds under the regulation of body intricately tuned control system. This control system ensures that organs and tissues maintain their correct shape and size. When cells in the body did not die when they ought to, the extra cells can form a mass of tissue called a growth or tumours.

Tumour can be benign or malignant. Benign tumour is rarely threatening while malignant tumours are threatening as they can invade and damage nearby tissue and organ. For a cell to become cancerous, usually three to seven different mutations must occur in a single cell (Otune, 2008). Breast cancer is a type of cancer originating from Breast tissue most commonly from the lining of the milk ducts or the lobules that supply the ducts. These genetic mutations may take many years to accumulate but the  coverage of mutations enable the Breast cells to become cancerous with presenting characteristic such as nipple discharge, usually bloody, Breast lump, swelling and pain.

Risk factors for breast cancer

Risk is an uncertain event or condition that if it occurs will have a negative or positive effect on one or more project objectives. Advanced Learner’s Dictionary defined risk as the possibility that something bad or unpleasant (such as an injury or a loss) will happen. It is also a potential adversity or threat or consequences e.g. hazard etc. having one or more several risk factors does not necessary means one will develop a particular disease such as cancer. Breast cancer is associated with women Reproductive life style, early manacle, null parity or advanced age or late pregnancy, late menopause inadequate diet and lack of physical activities in addition to hormonal factors, whether endogenous (high levels) or exogenous (prolonged use of oral contraceptives) or hormonal replacement during menopause. Fletcher (2009) group risk factors into three which are;

1. Moderate risk factors
2. Strong risk factors
3. Other risk factors

 Moderate risk factors 

1. Biopsy abnormalities: women who have Breast biopsies have an increase risk of Breast cancer especially if the biopsy showed a change in Breast tissue.
2. Exposure to radiation: according to National Breast Cancer Foundation (2012) women who as children or young adults had radiation therapy to the chest area as a treatment for another cancer such as Hodgkin disease or non Hodgkin lymphoma, have a significant increase risk for Breast cancer. Radiation treatment after age 40 does not seem to increase Breast cancer risks. The risk is higher if radiation was given during Adolescent, when the Breast was still developing.

Strong risk factors

1. Age: The risk of developing the disease increases with age. The majority of Breast cancer cases occur in women who are 50 years and above.
2. Family history of the disease: Breast cancer among first degree relative (sister, mother and daughter) increases a woman chance of developing it.
3. Personal history of breast cancer or abnormality: According to National Breast Cancer Foundation (2012) two Breast abnormalities such as ductal carcinoma in situ and lobular carcinoma in situ are associated with increased risk of developing invasive Breast cancer.

Other risk factors

1. Height and weight: tall women are likely to have Breast cancer than short women. Weight also plays a role. This is because body fat alters a woman’s oestrogen metabolism and also obese women are likely to have it than thin women after menopause (Acta, 2011).
2. Age at time of reproductive event: such as if a woman began menstruating at or before 11 years of age or if she experience menopause at age 55 or older.
3. High consumption of alcohol has an increase risk: This is perhaps due to elevated level of oestrogen in the body. Researchers concluded in 2013 that the risk increases with the amount of alcohol consumed.
4. Women of high socio-economic status: these women are most likely to develop the disease than women of low socio-economic status. This can be attributed to their diet and life style. According to Otune (2008) high fat diets may contribute to the development of Breast cancer while high fibre food may reduce the risk. Women who also smoke are not excluded.
5. Race, ethnicity and region: Flecher (2009) noted that these also appear to play a role in Breast cancer. Black women are more likely to develop Breast cancer before the age of 40 years whereas, white women are more likely to develop it at age of 40 and even older.

Diagnosis of breast cancer

Finding Breast cancer early increases a woman’s chance of surviving the disease. Mammogram, clinical Breast examination and self examination are tools women have at their disposal to detect cancer at it earliest. Other methods are, Diagnostic mammogram, Biopsy, ultra sound, magnetic Resonance imaging, and screening mammogram.

1. Screening mammogram: women in their 40’s should have mammogram every 1 to 2 years. A mammogram is a picture of the Breast made with x-ray. Annual mammogram should be for women age 50 or older. Women who are younger than 40 and have risk factor for Breast cancer should ask their Health care provider whether to have mammogram and how often to have it.
2. Clinical Breast examination: clinical Breast examination by a trained health professional, together with monthly Breast examination is safe, effective and at lease low in cost. It is done to feel for suspicious lumps. A hard oddly lump that feels firmly attached within the Breast is most likely to be Breast cancer.
3. Diagnostic mammogram: diagnostic mammogram often show a Breast lump before it can be felt. It takes clearer, more detailed image of area that look abnormal on a screening mammogram.
4. Ultra sound: an ultra sound device sends out sound waves that people cannot hear. The waves bound off tissue. The picture may show whether a lump is solid or filled with fluid. This exam may be used along with a mammogram.
5. Biopsy: this is usually done by a surgeon or Breast specialist. Fluid or tissue is removed from the Breast to help out if there is cancer.
6. Magnetic resonance imaging: it uses power magnet linked to a computer. It makes detailed pictures of Breast tissue which can be viewed on a monitor or printer on a film. It may be used along with mammogram.

Concept of breast examination

Breast self examination is one of the three steps recommended by American Cancer Society for screening of Breast cancer. It is the inspection and palpation of the Breast by a person on his or her own. It is a health promotion behaviour that can help empowered women to take some control and responsibility over their health and will set the stage for younger women for adherence to clinical Breast examination and mammogram screening later in life.

Breast self examination involves visualization and palpation of the Breast for lump, shape, texture, size, and contour. It can be taught in varieties of setting either on a one to one basic or in a group. It can also be initiated by a health care practitioner during a patient’s routine physical examination. It is estimated that only 25% to 30% of women perform Breast self examination proficiently between normal changes and worrisome findings. The goal of Breast self examination is to detect Breast cancer when they are at their earliest stages, and this can be achieved through regular practice of Breast self examination. Studies have showed that Breast self examination has a positive effect on the early detection of Breast cancer.

In Nigeria, Breast self examination would most likely be the only feasible approach to wide population coverage as it is a cheap and easy method. For places where the radio therapy is available in only a few centres, the knowledge of Breast self examination is necessary. It is a free evidence based modality of Breast cancer screening in low resources settings. Unlike clinical Breast examination and mammogram, which require hospital visit and specialization equipment and expertise. Breast self examination is carried out by women themselves. Another reason is that radiation from routine mammography possesses significant cumulative risks of initiating and promoting Breast cancer.

There are two ways to think about Breast self examination (Mercola, 2011) one is a particular technique that has to be practice and done consistently and correctly. Another way is being familiar with the land scope of the Breast, this is Breast familiarity. Breast examination contributes greatly to Breast awareness, which involves being familiar with the normal consistency of the Breast and underlying tissues (Mayo 2009).

Breast self awareness

Awareness is a relative concept (Capra,2009). Awareness provides the raw material from which animals develop subjective ideas about their experience. According to advance learner dictionary, awareness involves knowing that something exist and it’s important. In biological psychology, awareness comprises a human’s or an animal’s perception and cognitive reaction to a condition or event. This event could be Breast self examination. As one grows in self awareness, he will better understand why he behaves as he behaves. This understanding gives the opportunity and freedom to change those things that need to be changed. Awareness in general may refer to public or common knowledge or understanding about a social, scientific, or political issues. Seld discovery of the Breast and clarity about the benefit and limitation of Breast self examination empowers one to consciously and actively practice it. Most Breast tumours are self discovery but without awareness of the Breast, self acceptance and change become impossible. Mercola (2011) is of the view that many experts have began recommending a more relaxed approach known as Breast awareness for them to keep tract of anything unusual in their Breast. However, a patient should contact their physician if any of the following symptoms develop.

• Development of a lump in the Breast or under arm area.
• Irregular thickening of Breast tissue
• Swelling
• Skin irritation
• Dimpling or puckering
• Nipple pain
• Nipple retraction (turning inward)
• Redness or scaling of the nipple or Breast
• Discharge from the nipple (other than Beast milk)

Knowing the normal feel of the Breast makes it easier to notice subtle but potentially serious changes. These changes may become apparent quickly over the course of just a few months. When Breast cancer is found early, more treatment choices and better chances of recovery are possible

Sources of information on breast self awareness/examination

Information is the communication or reception of knowledge or intelligence. (Jameson, 2012) it is a processed data which increases the users knowledge. Furthermore, it could be seen as knowledge communicated or received concerning a particular fact such as Breast cancer or Breast self examination. Sources of information could be a person, book, or document that provides information especially for study, a piece of written work or rows. It could also be observation, people, speeches, documents, pictures or organization etc. person could include Health workers, friends, neighbours, traditional leaders and religious leaders.

Moreover, health care providers in the community can help to create awareness on Breast self examination. Community health workers through health education could disseminate information on Breast self examination in such a way that the recipient will be motivated to use the information for the promotion, protection and maintenance or restoration of health. Traditional means of accessing or obtaining information include printed material found in libraries, policy and procedure manual and journals articles as well as variety of electronic sources. Cosgrave (2009) also listed magazine, newspaper, and library as sources of information. On the other hand, sources of information mentioned by Jameson (2012) include personal experience, books, articles, expert opinion, the web etc. this means that information on Breast self examination can come from virtually everywhere.

Practice of breast self examination

Practice according to Oxford Advanced Learner Dictionary is a thing that is done regularly such as habit or custom. The practice of Breast self examination involved checking of the Breast at specific time each month according to a set technique. If it is performed appropriately and regularly, may help in early detection of some type of Breast cancer as it involves feeling for possible distortions or swelling.

Frequent practice is important as it help to create a time sense of security. The Breast time for a woman to examine her Breast is when the Breast is not tender or swollen such as just after the end of her period (Sweltzer &Bare, 2010). Older women may do it the first or last day of every month. In timing of Breast examination, therefore there is a prescribe period, this is because of variations in Breast tissues that occur during the menstrual cycle, pregnancy and onset of menopause women on hormones therapy can also experience fluctuations. Therefore Breast self examination is best performed after menses (day 5 to 7) counting the first day of menses as day one. (Mayo, 2009) younger women may find Breast self examination particularly difficult because of the density of their Breast tissues. As women aged, their Breast become flatter and may be easy to examine (Sweltzer & Bare, 2010). Women can also take responsibility for their own health by taking convenient opportunity such as bathing or dressing to become familiar with their Breast at different times of the month.

For appropriate and regular performance of Breast self examination some steps need to be followed. The steps are stated by Smeltze, Bare, Hinkle and Cheever (2010) and they are;

Step 1

• Stand in front of a mirror
• Check both Breast for anything unusual
• Look for discharge from the nipple, pucking, dimpling or scaling of the skin

Step 2

• Watch closely in the mirror as you clap your hands behind your head and press your hands forward
• Note any change in the contour of your Breast

Step 3

• Press your hands on your hips and bow slightly toward the mirror as you pull your shoulder and elbows forward
• Note any change in the contour of your Breast

Step 4

• Raise your hands
• Use three or four fingers of your right hand to feel your left Breast firmly, carefully and thoroughly.
• Beginning at the outer edge, press the flat part of your fingers in small circles, moving the circle slowly around the Breast as many times as necessary.
• Be sure to cover the whole Breast
• Pay special attention to the area between the Breast and the under arm, including the under arm itself.
• Feel for any unusual lumps or masses under the skin.
• If you have any spontaneous discharge during the month, whether or not it is during Breast self examination, see your doctor.
• Repeat the examination on the right Breast.

Step 5

• Step five should be repeated lying down
• Lie flat on your back with your left arm over your head and a pillow or folded towel under your left shoulder. (This position flattens the Breast and makes it easier to check).
• Use the same circular motion described above
• Repeat on the right Breast

Theoretical framework

The health belief model

The health belief model is a psychological model developed by Rosen stock in the 1950s for studying and promoting the social psychologists. This model intended to predict which individuals would or would not use preventive measures. It is one of the most widely used conceptual frame work for understanding health behaviours and has had great success in promoting greater seat belt use and health screening use. Since it has been used successful, in promoting the listed conditions, it can be used to promote Breast self examination which is a self care. Thus individual can use it as a preventive measure for screening for early detection of Breast cancer (Berman et al.,2008).

Individual perception includes the following.

• Perceived susceptibility: Personal risk or susceptibility is one of the powerful perceptions in promoting people to adopt healthier behaviour. The greater the perceived risk the greater the likelihood of engaging in behaviours that will decrease the risk. This may motivate her to practice Breast self examination in order to detect abnormalities such as Breast lump and discharge.
• Perceived seriousness: The construct of perceived seriousness speaks of an individual’s belief about the seriousness or severity of a disease. This perception of seriousness is often based on medical information and knowledge of the disease. If the individual perceived the seriousness of the disease, he/she will know that the disease causes death or have severe consequences and decide to carry out prevent screening measures such as Breast self examination in order to avoid the consequences of late and increased mortality.
• Perceived threat: According to Booker (1974) perceived susceptibility and perceived seriousness combine to determine the total perceived threat of the illness to a specific individual. It is logical that when people believed they are at risk for a disease, they will do something to prevent it from happening. If a person have a family history of Breast cancer however, the perceived threat of the disease is likely to increased, thus such a person may be motivated to adopt Breast self examination.

Factors that modify a person’s perceptions include the following

• Culture: The beliefs, customs, arts, etc of a particular society, group, place, or time.
• Demographic variable: These include age, gender, race and ethnicity.
• Cue to action: These are events, people or things that can move people to change their behaviour.

Empirical review

Many studies have been carried out on Breast self examination as it has been the focus in developed and developing countries. This study investigate the knowledge and practice of Breast self examination and to determine knowledge of risk for Breast cancer.

References

Acta P. (2011) Concept of Risk for Breast Cancer in Nursing Research . Enferm. (24)Influencing Factors and Effects of In-service Education. Journal of Clinical Nursing (24)

Akarolo, S., Ogundiran, T., Adebamowo, C., (2010) Emerging Breast Cancer Epidermic: Evidence from Africa. Breast cancer research .com/SB. Retrieved10/04/13.

Alexia, J., (2013) Descriptive/survey Research.www.appstate.edu/../Descriptivehw.doc.Retrieved10/04/2013

American Cancer Society (2012) What Are the Risk Factors for Breast Cancer.www.cancer.org. Retrieved 14/04/13

Berman, A., Snyder, S., Kozier, B. and Erb, G. (2008). Kozier and Erb’s Foundamentals of Nursing Concepts Process and Practice. 8th Edition. NewJessy: Upper Saddle.

Cosgrave, T. (2009) All Resources About Kpi Definitionebooks.com. Retrieved4/01/2014

Doshi, D., Reddy, B., Kulkarn, S., and Karunakar, P., (2010) Breast Self Examination: knowledge, Attitude and Practice among Students in India. Indian Journal of Palliative care (1). 66-7

Fletcher, S. (2009) Patient Information: Risk Factor for Breast Cancer. Harvard Medical School. www.yourdiseaserisk.havour.edu. Retrieved 28/10/2013

Karayurt, O., Ozmen, D. and Cetinkaya, C. (2008). Knowledge and Practice of Breast Self Examination and to Determine knowledge of Risk Factors for Breast Cancer Among High School Students. www.biomedcentral.com. Retrieved28\10\2013.

Jebbin, N. J. and Adotey, J. M. (2009). Attitudes to, Knowledge and Practice ofBreast Self – Examination in Port Harcourt. Nigeria Journal of Medicine.13:166-17

Jameson, L. (2012) Merriam-webster Dictionary Information.www.merriam.webster.com/../ information. Retrieved 14/4/13

Mayo Staff Clinic (2009). Mayo Foundation for Medical Education and Research(MFMER).www.Nn.nil.gov/medineplus/breastcancer.hotmail. Retrieved 4/01/13

National Breast Cancer Foundation, (2012) www.nationalbreast cancer.org/aboutbreast cancer/breast self-exam. Retrieved 06/08/13.

National Cancer Institute, (2012). What You Need to Know About Breast Cancer htpp:///www.cancer.gov. Retrieved 5/3/13

Oluwatosin, O. (2010). Assessment of Women’s Risk Factors for Breast Cancer and Predictors of the Practice of BSE in Two Rural Areas in Ibadan, Nigeria. Cancer Epidemiology. 34: 425-428.

Oluwatosin, O. (2012). Primary Healthcare Nurses’ Knowledge, Practice and Clients Teaching of Early Detection Measures of Breast cancer in Ibadan. BMCNursing.11:

Onyebuchi, C. (2012). Are Cancer Cases Increasing in Nigeria. The nationonlinng.net >home >health. Retrieved 14/4/13

Otunne, C. (2008). Breast Cancer: Causes and Therapies; Rex Press, CKC. Aba.

Saladin, K. S. (2010) Anatomy and physiology: The unity of form and function. McGraw-Hill companies, Inc.

Salaudeen, A., Akanda, T. and Musa, O. (2009). Knowledge and Attitude to Breast Cancer and Breast Self Examination Among female Undergraduates in State in Nigeria. European Journal of social sciences. 7 (3): 158.

Smelter, S.C., Bare, B.G., Hinkle, J.L., and Cheever, K.H. (2010) Brunner and Suddarth’s Textbook of Medical Surgical Nursing. Lippincott Williams and Wilkins.