INTRODUCTION
Breast cancer, the most frequent malignancy in women, is also the second most frequent among the entire world population. In the year 2018, about 2.1 million women worldwide were diagnosed with breast cancer for the first time, according to the International Agency for Research on Cancer, an organ of the World Health Organization (WHO). This disease is the most frequent cause of cancer death in women. The most frequent cancer diagnosis for women in 154 out of 185 countries, one of four female cancer patients has breast cancer.[1] According to Turkish Cancer Statistics year book which is published 2017, in Turkey, breast cancer is the most common malignancy in the country's women, with a frequency of 43.0 per 100,000 women in 2014.[2] Although it is generally found in women 35 and over, late detection in women aged 20–30 leads to worse prognoses for this age group.[34] Breast cancer cannot be prevented, but the risk of the breast cancer can be reduced and it can be treated if it will be found at an early, more treatable stage. Early diagnosis using a variety of screening methods increases survival rates.[567]
The methods known to provide the earliest diagnosis of breast masses include breast self-examination (BSE), physical examination by a physician and mammography.[689] Due to lack of evidence clinical breast exam and breast self-exam are not part of the breast cancer screening program. Still, all women should be familiar with how their breasts normally look and feel and report any changes to a health care provider right away.[10] Although there are debates about self-breast examination, it is still involved in breast cancer screening programs in many countries. In Turkey, a mammogram every 2 years, clinical breast examination with mammogram and providing consultancy to all women after age of 20 about self-breast examination to make the women aware are included in the National Breast Cancer Screening Program.[11] Monthly regular BSE is an easy, cheap examination accessible to all women. It is an effective, reliable, noninvasive screening method that does not require any special tools and can be performed quickly.[51213] BSE allows the women to know their own breast structure and recognize differences from 1 month to the next.[514] Approximately 80–90% of breast masses are discovered by the afflicted women themselves.[1415]
BSE acquires added importance for women aged 20–30 due to their very infrequent use of routine clinical examination and mammography. Especially all women aged 20 and above should perform BSE monthly, 5–7 days after the end of their menstruation if premenopausal and on the same day every month if postmenopausal.[16] Many women, however, practice BSE either irregularly or not at all. Numerous published reports indicate that the ratio of women practicing BSE is 18–36% in the some countries [171819] and 7.3–32.5% in Turkey.[2021] There are many other reasons for the failure to perform BSE besides not knowing how to do it. Among these, the lack of time, the thought of not being able to use correct technique, the fear of finding a mass, and an oppressive feeling during manual examination have been invoked.[1213] Numerous studies have shown that even with the very significant place it occupies in the early diagnosis of breast cancer, BSE is not well-known by women in our country, and its use is insufficient.[52223] Published studies indicate that young women possess insufficient knowledge about the early diagnosis of breast cancer and either do not or insufficiently practice BSE due to a perception of being at very low risk for breast cancer.[7202425] While the risk of breast cancer is indeed relatively low in university students, it is important to develop at this age a consciousness of breast health and an awareness of breast cancer.[2627] This study aimed to determine university students' levels of knowledge and practice of BSE. Thus we defined two research questions: What is the students' level of knowledge about BSE? and how do the students practice BSE?.
MATERIALS AND METHODS
This descriptive research sought to determine the knowledge and practice of BSE among female university students. The study universe consisted of all the female students (656 persons) studying at a public university in the Western Black Sea region of Turkey. A sample size of 161 was calculated for a predicted event frequency (Faculty of Engineering and Architecture: 84; Faculty of Economics and Administrative Sciences: 34; Vocational High School: 43).
The research data were collected using a questionnaire designed after a review of the relevant literature.[5182026272829] The data questionnaire consists of three parts and 51 questions (11 open-ended, 40 multiple choice):
- 27 questions on the demographic characteristics and health status of the students
- An 11-question section evaluating the students' BSE knowledge
- Another 13 questions to characterize the practice of BSE by the students.
The questionnaire was administered after obtaining written approval from the university involved (which was include ethical approval), explaining the study's purpose to the students and obtaining the written and informed consent of the participants. The questionnaires were administered by the researchers in the classroom. The data were evaluated using SPSS statistical software. Data were analyzed using frequency counts, percentages and means, and standard deviation.
RESULTS
The mean age was 20.53 ± 2.3 and 62.1% of students were under 20. The body mass index (BMI) of 80.1% of the students was 20–24. A total of 50.3% of the students reported their income status as middle. One-fourth (25.5%) smoked cigarettes, while about one in seven (16.8%) drank alcohol. The students experienced menarche at the age of 12.9 ± 2.9. Of the students, 39.2% stated that they eat mainly fruit and vegetables, 24.8% fast food and 16.1% greasy and fried foods. Approximately one-third of the students (32.9%) had had an x-ray and one-tenth (9.9%) had taken oral hormonal contraceptives. While 27.3% of the students had a family history of cancer, 8.1% reported cases of breast cancer in their families [Table 1].
;)
Table 1: Distribution of some breast cancer risk factors
Nearly three-fourths of the students (73.3%) had heard about BSE. Only half of these students, however, had obtained additional information about BSE (not shown on the table). While a large majority (83.1%) of the students who were aware of BSE expressed the opinion that its purpose was the early detection of breast cancer, only half (55.1%) said that all menstruating women should practice BSE. When asked about the frequency with which they themselves practiced BSE, slightly over half (52.5%) said monthly. Half the students (50.9%) did not know when BSE should be performed, and 55.9% said that a physician should be consulted whenever a thickening or swelling was found during self-examination. Even though the students were asked how BSE is performed, they either failed to fill in the blank or answered that they did not know [Table 2].
Table 2: Knowledge of students aware of BSE
While half the students indicated that they did perform BSE, only 33.3% reported doing so at regular intervals. Ignorance of how BSE should be done was indicated as the reason for not doing it by 48.5% of the students, and 34.7% considered it unnecessary because they had no breast-related complaints. While 55.5% indicated that they performed a BSE whenever they thought of it, only 13.3% reported doing it regularly every month [Table 3].
Table 3: BSE practice of students
DISCUSSION
Breast cancer, a major health concern in almost every region of the world, is the most common form of cancer among women. About one-eighth of all women having risk factors for breast cancer at some point in their lifetime, and one-third of these women are at risk of dying from breast cancer.[30] BSE is not recommended for early detection of cancer by American Cancer Society (ACS)[31] and WHO [32] because of lack of evidence. But WHO defined awareness and accessing care as a first step in cancer early diagnosis.[33] ACS also stated that women should be familiar with their breasts and report any changes to health care provider immediately.[31] In Turkey, The Ministry of Health recommends health care providers to provide counselling to all women about how to perform BSE to rise their awareness about their breasts.[11] BSE, which should be performed monthly after the age of twenty, is an easy, economical, reliable, effective and non-invasive method that all women can use without needing special tools or investing much time.[34]
Over half the participants in our study (62.1%) were aged 20 or under. Breast cancer incidence increases past the age of 35, while the prognosis of disease acquired at an earlier age is markedly worse, due to late detection. Developing awareness of breast health and breast cancer among young women in their twenties, such as university students, is therefore very significant.[5]
Cancer risk increases along with fatty tissue in the body, and a correlation between obesity and breast cancer has been shown.[535] Even if most of the students in the study have normal BMI, almost half the students reported eating mainly ready-made or fried food indicated that changes in lifestyle are needed to reduce the risk of cancer.
Different published reports point to an increase in the risk of numerous types of cancer, including breast cancer. Although the relationship between breast cancer and alcohol intake has not been entirely explained, some correspondence between the two is reported.[5] The majority of our study's subjects avoid the use of both alcohol and tobacco. Similar results were found in other studies performed in Turkey with university students.[53035] Support for university students to help them continue and improve this healthy behavior is of the extreme importance.
The risk to women with a family history of breast cancer varies according to the closeness of the relationship. The risk for a woman with cancer in a first-degree relative is reported to be 1.7–2.5 fold, while the presence of bilateral breast cancer in a mother or sister increases this risk to a 5–6 fold.[3637] Family history of breast cancer was present in 8.1% of our subject population. Enhancing the awareness of students with such family histories is especially important for early screening and prevention [Table 1].
Although early screening and diagnosis is not a reliable prevention method, with early detection cure rates are relatively high. It is important, therefore, for the population to know that early detection is possible and how to do it. Studies in Turkey of women in a variety of age groups showed that BSE is not well known or sufficiently practiced.[373839] Nearly three quarters of our subjects had heard about BSE. In the opinion of a majority of the students who were aware of BSE, its aim was the early detection of breast cancer.
Even though digital mammography is more sensitive than BSE in younger women and those with dense glandular tissue, there are few studies of this topic. Also, mammography screening is performed every 1-2 years, and BSE is still necessary to detect changes between examinations. BSE is therefore an important detection method, alongside CBE, for young women in their twenties.[40] Several studies of university students in Turkey have found knowledge about the nature, timing and practice of BSE to be insufficient.[14384142] Among the subjects in our study who were aware of BSE, only one indicated that it should be done by women over 20 years of age, one-fourth said that it should take place one week after the end of menstruation, and approximately half said that is should be performed at regular monthly intervals. The students were also questioned about how to do BSE, and they either did not respond or stated that they did not know. These results show that, even if the students were aware of the existence of BSE, they lacked sufficient knowledge and needed counseling about knowing their breast tissue and recognizing alterations in it.
Along with its low cost and easy application, the conditions identify above lead us to think that the early detection potential offered by BSE, although relative, has an important place in the lives of all women. This is particularly true in developing countries with low to moderate income levels, like Turkey, where socioeconomic realities make BSE inevitable and necessary. One should keep in mind, though, that BSE must be performed correctly and effectively to help with the early detection of breast cancer.[38] Many studies have found that, even though women are aware of BSE,[43444546] factors such as the lack of health awareness,[42] forgetfulness, fear of a cancer diagnosis [43] and the lack of information [44] lead to irregular implementation or none at all. While half the subjects, a proportion consistent with the published studies, indicated that they did perform BSE, only 33.3% reported doing so at regular intervals. Ignorance of how BSE should be done was indicated as the reason not practicing it by 48.5% of the students, while 34.7% considered it unnecessary because they had no breast-related complaints. The rate of practicing BSE is lower than the desired level. This easy, cost-free, non-instrumental method, which can be used alongside other early breast cancer screening methods, is insufficiently implemented.
Two limitations of our study deserve mention. First, our results are based on self-reports from the students and we cannot assess the accuracy of these reports. Second limitation is using participants from only one University. So the generalize ability of the results of this study is limited to this study population.
CONCLUSION AND SUGGESTIONS
The majority of the students were aware of BSE and its purpose. Only about half stated, however, that they practice it. Those who practiced BSE were not knowledgeable about how and when to perform it. Therefore we conclude that training should be provided to students to increase their knowledge about BSE and research should be performed to identify the factors that hinder the practice of BSE so that their effect can be countered.
Financial support and sponsorship
Nil
Conflict of interest
There are no conflicts of interest.
REFERENCES
1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries CA Cancer J Clin.Last cited on 2018 Oct 03 Available from:
https://onlinelibrary.wiley.com/doi/abs/10.3322/caac.21492
2. Turkish Cancer Statistics 2017.Last cited on 2017 Aug 15 Available from:
http://kanser.gov.tr/Dosya/ca_istatistik/2014-RAPOR._uzun.pdf
3. De Santis C, Ma J, Bryan L, Jemal A. Breast cancer statistics 2013 CA Cancer J Clin. 2014;64:52–62
4. Evans DG, Brentnall AR, Harvie M, Dawe S, Sergeant JC, Stavrinos P, et al Breast cancer risk in young women in the national breast screening program: Implications for applying NICE guidelines for additional screening and chemoprevention Cancer Prev Res (Phila). 2014;7:993–1001
5. Alpteker H, Avci A. Determine the
knowledge of the women about breast cancer and their
practice about breast self-examination J Breast Health. 2010;6:74–9
6. Beacham AO, Carpenter JS, Andrykowski MA. Impact of benign breast biopsy upon breast self-examination Prev Med. 2004;38:723–31
7. Yarbrough SS, Braden CJ. Utility of health belief model as a guide for explaining or predicting breast cancer screening behaviors J Adv Nurs. 2001;33:677–88
8. Nahcivan ON, Secginli S. Attitudes and behaviors toward breast cancer early detection: Using the health belief model as a guide J Cumhuriyet Univ Sch Nurs. 2003;7:33–8
9. Ozmen V, Boylu S, Ok E, Canturk NZ, Celik V, Kapkac M, et al Factors affecting breast cancer treatment delay in Turkey: A study from Turkish federation of breast diseases societies Eur J Publ Health. 2015;25:9–14
10. American Cancer Society. American Cancer Society Detailed Guide: Breast Cancer. 2014Last cited on 2015 Sep 03 Available from:
www.cancer.org/Cancer/BreastCancer/DetailedGuide/index
11. Turkish Public Health Institution. Breast cancer screening program national standards. 2013Last cited on 2018 Oct 03 Available from:
https://hsgm.saglik.gov.tr/tr/kanser-tarama-standartlari/listesi/485-meme-kanseri-tarama-programı-ulusal-standartlarıhtml
12. Agars J, McMurray A. An evaluation of comparative strategies for teaching breast self-examination J Adv Nurs. 1993;18:1595–603
13. Attia AK, Abdel Rahman DA, Mohamed B, Kamel LI. Effect of an educational film on the Health belief model and breast self-examination
practice East Mediterr Health J. 1997;3:435–43
14. Gercek S, Duran O, Yildirim G, Karayel H, Demirlicakmak H. Determining the breast cancer and self-breast examination belief and the effecting factors among the schoolgirls in state dormitory J Breast Health. 2008;4:157–61
15. Kabatas M, Kizil H, Duman D. Evaluation on
knowledge, attitude and behavior about breast cancer and breast self-examination J Breast Health. 2010;6:150–5
16. World Health Organization, International Agency for Cancer Research. Breast Cancer/Breast Self-Examination (BSE).Last cited on 2018 Oct 03 Available from:
http://screening.iarc.fr/breastselfexamination.php
17. Erblich J, Bovbjerg DH, Valdimarsdottir HB. Psychological distress, health beliefs, and frequency of breast self-examination J Behav Med. 2000;23:277–92
18. Foxall MJ, Barron CR, Houfek J. Ethnic differences in breast self-examination
practice and health beliefs J Adv Nurs. 1998;27:419–28
19. Haji-Mahmoodi M, Montazeri A, Jarvandi S, Ebrahimi M, Haghighat S, Harirchi I. Breast self-examination:
Knowledge, attitudes, and practices among
female health care workers in Tehran, Iran Breast J. 2002:222–5
20. Aydin I.
Knowledge and practices about self-breast examination of university students J Atatürk Univ Sch Nurs. 2004;7:26–34
21. Karadag M. Determination of breast self-examination behavior and beliefs of midwifery and nursing students at a university Turk Klin J Nurs. 2010;2:1–9
22. Avci IA, Kumcagiz H, Altinel B, Caloglu A. Turkish
female academician self-esteem and health beliefs for breast cancer screening Asian Pac J Cancer Prev. 2014;15:155–60
23. Celik S, Tasdemir N, Sancak H, Demirel M, Akman O, Kara M. Breast cancer awareness among Turkish nursing students Asian Pac J Cancer Prev. 2014;15:8941–6
24. Najem GR, Passannante MR, Foster JD. Health risk factors and health promoting behavior of medical, dental and nursing students J Clin Epidemiol. 1995;48:841–9
25. Ozturk M, Engin VS, Kisioglu AN, Yilmazer G. Effects of education on
knowledge and attitude of breast self-examination among 25+ years old women East J Med. 2000;5:13–7
26. Gursoy AA, Yigitbas C, Yilmaz F, Erdol H, Bulut HK, Mumcu HK, et al The effect of peer education on university students'
knowledge of breast self-examination and health beliefs J Breast Health. 2009;5:135–40
27. Igci A, Asoglu OTopuz E, Aydiner A, Dincer M. Screening methods on early detection of breast cancer Breast Cancer (Turkey). 2003 Istanbul Nobel Medical Press
28. Aygin D, Uludag C, Sahin S. The evaluation of
knowledge, attitude and behaviors of young's about breast self-examination and breast cancer Nurs Forum. 2004;7:1–6
29. Gencturk N. Risk factors of breast cancer Nurs Forum. 2006;4:106–12
30. Golbasi Z, Cetin R, Kalkan S, Durmus T. The
knowledge and behaviors of
female university students about breast cancer and breast self-examination J Breast Health. 2010;6:69–73
32. World Health Organization. Breast Cancer Early Diagnosis and Screening.Last cited on 2017 Aug 15 Available from:
http://www.who.int/cancer/prevention/diagnosis-screening/breast-cancer/en/
34. Uzun O, Karabulut N, Karaman Z. The
knowledge and behaviors of nursing students about breast cancer and breast self-examination J Ataturk Univ Sch Nurs. 2004;7:10–9
35. Gok-Ozer F, Beydag KD. Determination of nursing students'
knowledge about breast cancer and how they perform breast examination Pamukkale Med J. 2009;2:15–9
36. Lowery JT, Ahnen DJ, Schroy PC, Hampel H, Baxter N, Boland CR, et al Understanding the contribution of family history to colorectal cancer risk and its clinical implications: A state-of-the-science review Cancer. 2016;122:2633–45
37. Guner IC, Tetik A, Gonener HD. Determination of women's
knowledge, attitude and behaviors about self-breast examination Gaziantep Med J. 2007;13:55–60
38. Altunkan H, Akin B, Ege E. Awareness and
practice of breast self-examination (BSE) among 20-60 years women J Breast Health. 2008;4:84–91
39. Erkoc A, Yorulmaz H. The effect of training on nursing students'
knowledge about the breast self-examination (BSE) J Breast Health. 2011;7:101–5
40. Akyolcu N, Ugras GA. Breast self-examination: How important is it in early diagnosis? J Breast Health. 2011;7:10–4
41. Alpteker H, Gumus D, Dogan S, Bilir S, Onal M. To determine the
knowledge and practise of
female students about breast cancer and breast self-examination J Breast Health. 2011;7:176–81
42. Beydag KD, Yurugen B. The effect of breast self-examination (BSE) education given to midwifery students on their
knowledge and attitudes Asian Pac J Cancer Prev. 2010;11:1761–4
43. Akhtari-Zavare M, Juni MH, Said SM, Ismail IZ. Beliefs and behavior of Malaysia undergraduate
female students in a public university toward breast self-examination
practice Asian Pac J Cancer Prev. 2013;14:57–61
44. Arslan M, Sahin D. The effect of planned education on women's
knowledge about breast cancer and breast self-examination Yıldırım Beyazıt Univ Nurs E-Journal. 2013;1:8–16
45. Erbil N, Bolukbas N. Health beliefs and breast self-examination among
female university nursing students in Turkey Asian Pac J Cancer Prev. 2014;15:6525–9
46. Pengpid S, Peltzer K.
Knowledge, attitude and
practice of breast self-examination among
female university students from 24 low, middle income and emerging economy countries Asian Pac J Cancer Prev. 2014;15:8637–40
