ATTITUDE, BEHAVIOUR AND AW
ARENESS OF TURKISH
WOMEN CONCERNING BREAST CANCER*
H ü l y a M a r a ş , * * / E n g in K a r a g ö z , * * / B ilg e A k t a ? ,* * E s ra O l g u n , * * / Ç a ğ r ı K a l a ç a , M . D . * * * / B a h a d ır M . G ü llü o ğ lu , M . D . * * * * * ' P h a s e 111 S tu d e n ts , S c h o o l o f M e d ic in e , M a r m a ra U n iv e rs ity , Is ta n b u l, T u rk e y . * * * D e p a r t m e n t o f F a m ily M e d ic in e , S c h o o l o f M e d ic in e , M a r m a ra U n iv e rs ity , Is ta n b u l, T u rk e y . * * * * S u b -d e p a r tm e n t o f B re a s t a n d E n d o c r in e S u rg e ry , D e p a r tm e n t o f G e n e r a l S u rg e ry , S c h o o l o f M e d ic in e , M a r m a r a U n iv e rs ity , Is ta n b u l, T u rk e y . A B S T R A C T
O b je c tiv e : O ver half a million women develop b re ast c a n c e r e ve ry y e a r. D esp ite rising incidence, survival rates can be increased by public health efforts to promote routine self- exam ination and regular m am m ogram s in order to detect can ce r at an early stage.
Th e objective of this study is to determ ine w o m e n ’s a w a re n e s s , p ra ctice and attitudes towards breast ca n ce r and to be a guide for education program m es aimed at making women more informed and enabling them to act with more knowledge.
M e th o d : Q u e stio n n a ire s, com posed of 26 questions, w ere conducted among 375 women living in different a re a s of Istanbul. E a c h com pleted q u estio n n aire w a s a n a ly se d and graded according to p articip an t’s level of information concerning breast cancer.
R e s u lt s : Th e level of information has a direct relationship with ag e, education and fam ily incom e. T h o se with a good level of information
w ere found to be: 5 7 ,6 % of women above 51 ye a rs of age; 60% of all women who stated an income of above one billion T L , and; 6 2 ,2 % of women graduated from a university.
C o n c lu s io n : Health education on breast cancer should be provided especially to those with a poor level of information.
K e y W o r d s : B re a st ca n c e r, A w a re n e ss, Attitude, Practice.
IN T R O D U C T IO N
Breast cancer is the most common form of can cer diagnosed in women (1). O ver half a million women develop breast can cer each year (2). Lifetime risk (0-75 ye ars) of developing breast can cer is 9 ,2 % (1 in 11 women) and the risk of dying from breast can cer is 2,2 % (1 in 45 women) according to epidemiological data in W estern countries (1). The incidence of breast cancer is increasing in both industrialised and developing countries, with rates in urban areas
* P a rtly p re s e n te d in th e 1st C o n g re s s o f W o rld S o c ie ty fo r B re a s t H e a lth , h e ld in Is ta n b u l, T u rk e y , 2 2 -2 6 S e p te m b e r 2 0 0 1.
(Accepted 31 January, 2002)
Marmara Medical Journal 2002; 15(2):97-102
Correspondance to: Bahadır M. Gulluoglu, M.D., M.D, - Breast and Endocrine Surgery Unit. Department o f General Surgery, School o f Medicine, Marmara University Hospital. Altunizade, Istanbul, Turkey
Hülya Maraş, et al
generally exceeding those in rural a re a s (3). According to the Izm ir C a n c e r R e g istry , in women, breast ca n ce r w a s by far the most
common m alig n an cy (in cid e n ce rate
2 4 .4 /1 0 0 ,0 0 0 ) (4 ). D esp ite the increasin g in cid en ce, m ortality ra te s are d e cre a sin g primarily due to treatment, a s well a s increased breast ca n ce r a w are n e ss and screening (5). The fact that survival rates are substantially lower in women with advanced breast ca n ce r than in women w hose d ise a se is diagnosed at earlier sta g e s (6 ), im plies the im portance of early detection methods. M ammography can help to differentiate a benign from a malignant process before it becom es palpable and when it is most curable. Th u s, m am m ography rem ains the most effective imaging method (7). In addition to mammographic screening, monthly breast self- exam ination d e c re a se s mortality from breast cancer (8).
Approximately half of the women who developed breast can cer had no identifiable risk factors, indicating that strategies for prevention of the d ise a se should be directed at the entire population (9).
This study w as conducted among women with different socio-dem ographic ch a ra cte ristics in order to determine their knowledge about early detection methods, breast ca n ce r sym ptom s, risk factors; plus attitudes and behaviour - all of which are very important factors for overcoming this d ise a se . The aim w a s to be a guide for health education program m es and other public se rvice s for improving the knowledge and practice in women in order to d e cre a se mortality rates due to breast ca n ce r rates.
M A T E R IA L S A N D M E T H O D S
The study w as conducted a s a cross-sectional survey among fem ales chosen randomly. The survey w as designed to investigate the socio demographic background of the respondents and their level of knowledge, behaviour and attitudes concerning breast cancer.
A self-ad m inistered q u estio n n aire of 26 q uestions - including socio-d em o g rap hic questions about age, marital status, occupation, level of education, p resence of social insurance,
and fam ily income - w a s used a s the survey instrum ent. T h e q u e stio n n aire included 20 q u e stio n s, ranging from th o se about the sym ptom s and risk factors of breast can cer, methods of diagnosis and treatm ent; to the practice of self-breast exam ination, respondents' attitudes and behaviour tow ards breast can cer. T h e last two q u e stio n s w ere open-ended contrary to the others, and aimed at gathering information regarding anxiety about treatment, and any three subjects that they would like to learn about breast can cer.
Th e questionnaires w ere conducted between 7th April 2001 and 7th May 2001. Respondents were from different so cio-d em o g rap hic groups including: M em bers of a N on-G overnm ental O rganization (N G O ) “Ç a ğ d a ş Y a ş a m ı Desteklem e Derneği”(Ç Y D D ); women living in a shanty town centre supported by Ç Y D D ; mothers of som e students studying in phase 1-2-3 of M arm ara University School of Medicine and som e civil servants working at H ayd arpaşa Cam p us of M arm ara University. In order to educate the p articip ants, all resp on d en ts w ere given a brochure (prep ared by M arm ara U n iversity Hospital, Department of Radiology) consisting of general information about breast can cer.
E a ch completed questionnaire w a s graded and classified a s poor (0-24% ), fair (25-49% ), good (50-74% ) and very good (75-100% ) according to the respondents’ knowledge about the sym ptom s of breast can ce r, m ethods of diagnosis and treatm ent, b re ast se lf-e xam in atio n and risk factors for breast ca n ce r. A maxim um of 28 points could be obtained on the knowledge. For cro ss tables the questionnaire w a s graded in two sections instead of four, a s poor (0-49% ) and good (50-100% ). ‘S P S S 10.0 for W ind ow s’ w as used to analyse the data and to prepare graphs, frequency tables and cro ss tables.
RESULTS
P o p u la tio n c h a r a c t e r is t ic s
Th ree hundred and seventy five women returned the q u e stio n n a ire . T h e m ean age of the resp o n d en ts w a s 4 2 ,6 ± 1 1 .6 y e a rs . 4 8 % of women w ere 36-50, 2 8 % w ere 19-35 y e a rs old and 24% w ere above the age of 51. Regarding their educational status, 3 1 ,4 % of women had re ce ive d no e d u catio n , or graduated from
Turkish women and breast cancer
primary or second ary school; w h ereas 30% were high scho ol and 3 3 ,8 % w ere university graduates. Eighty-two women (2 2 ,2 % ) had no so cial in su ra n c e . Am ong 254 wom en who answ ered the related question 137 (5 3 ,9 % ) had an income below six hundred million T L , and the rest had higher incom es.
K n o w le d g e
When classified according to our pre-formed sc a le ; 230 wom en (6 1 ,3 % ) had a satisfactory or more than satisfactory knowledge level, while 145 women (3 8 ,7 % ) had a le ss than satisfactory knowledge level.
One out of four women defined ca n ce r a s a non- treatable d ise a se . 239 women (6 7 ,5 % ) knew that breast ca n ce r w a s the most frequently seen can cer in wom en, while 108 (3 0 ,5 % ) defined b re ast c a n c e r a s uterine c a n c e r. 8 5 ,8 % of women correctly answ ered that the 40-59 age interval has an increased risk for developing breast cancer.
Knowledge about other risk factors associated with breast ca n ce r w a s generally poor. S tre ss, alcohol intake, cigarette smoking and nulliparity w ere com m only known a s risk factors for breast c a n c e r (T a b le I). In order to in c re a se the reliability of the a n sw e rs, two unrelated risk factors w ere introduced in the list.
Tab le II sh o w s the resp o n d en ts’ knowledge about b reast c a n c e r sym ptom s. L e s s than half
T a b l e I: K n o w le d g e o f R is k F a c to rs fo r B re a s t C a n c e r
Factors n %*
Stress 237 63,2
History of alcohol and cigarette 175 46,7
Nulliparity 158 42,1
Estrogen replacement
therapy after menopause 131 34,9
Colon, ovarian or uterine cancer 85 22,7
Late menopause (>50) 70 18,7
Nutrition 65 17,3
Late conception of
their first child 43 11,5
Early menarche (<12) 41 10,9
Cardiovascular diseases 13 3,5
Diabetes Mellitus 12 3,2
* Women were asked to give more than one risk factor
of the study group knew the sym ptom s correctly. S am e procedure explained above w as repeated here to increase the reliability.
O nly 33% of women p o sse sse d sufficient knowledge about breast self-exam ination. 78% of women did not know when to perform breast self-examination (Table III).
High school or university graduates, a high income and advanced age were factors behind a higher level of knowledge (Table IV). Interestingly, there w as no significant relationship between the level of knowledge and presence of any relative with breast cancer (p=0,434;x2 =0,828).
Information regarding b re ast c a n c e r w as obtained from m edia, their p h y sic ia n s, and through "mouth-to-mouth" in 76% , 39% and 23% of women, respectively.
P ra c tic e
Sixty-seven point three percent of the women (59.4% of women with poor knowledge and
T a b l e II: K n o w le d g e o f S y m p to m s of B re a s t C a n c e r
Symptoms n %*
Breast lump 336 89,6
Swollen lymph nodes In
the axilla 271 72,3
Abnormal nipple discharge 209 55,7
Change In the shape of nipples 170 45,3
Change In the color of the skin
of the breast, areola, or nipple 116 30,9
Thickening in the breast skin 82 21,9
Heart disorders 11 2,9
Dyspnea 11 2,9
* Women were asked to give more than one symptom
T a b l e III: L e ve l o f K n o w le d g e o f B re a s t S e lf-E x a m in a tio n
“ Which of the following
is correct about BSE?” % n
Axilla should also be examined 248 71,5
Performed in front of a mirror 189 54,5
Symmetrically performed 142 40,9
Not performed in the first days of period 76 21,9
Heard but no idea 40 11,6
Annually examined 21 6,1
Hülya Maraç, et al
82.7% of women with good knowledge) reported that they performed breast self-exam ination; but only 42% of them knew how to do it properly. “Having relatives with breast cancer" did not affect the rate of breast self-exam ination practice (p=0,051 ;x2 =4,069).
Thirty-eight point nine percent of the women (20% of women with poor knowledge and 50% of
wom en with good know ledge) had had
mam m ographies at least once in the past. Respondents who underwent m am m ographic exam ination w ere th o se who thought their probability of having breast ca n ce r w a s high, who are older, and better educated. However, there w as no significant relationship between having mammography and “having relatives with breast can ce r” (p=0,48; x 2 =4,449, and family income p=0,42; x 2 =4,219) (Table IV).
Thirty-six percent of women w ere not aw are of mammography, a s the tool for diagnosis and
3 7 % did not know that having regular
mammography after a certain age is strongly advised for early diagnosis. 6 3% of the women
had m am m ography a s a result of
recommendation by their physician and 30% b ecau se they requested it th em se lves.
Approxim ately 5 0 % of the wom en who had in su ra n ce from G o ve rn m e n tal In su ran ce Organization for civil se rva n ts, Governm ental Insurance Organization for artisan s or private insurance had m am m ography, while it d ecreased to 36% in w orkers with insurance from the goverment and to 18% who had no insurance. A ttitud e
W hen their attitude tow ards breast ca n ce r w as asked , 40% of the women with poor knowledge and 16% of women with good knowledge said they never thought about it. Half of the women were afraid of the treatment for breast can cer. The rate of performing breast self-examination and having mammography in cre a se s in women
T a b l e IV : C o m p a ris o n s o f k n o w le d g e a n d m a m m o g ra p h y s c re e n in g a m o n g d iffe re n t g ro u p s
education family income age presence of relatives
with breast cancer secondary school and below high school and higher 599 milllonTL and below 600 milllonTL and higher 19-35 36-50 51 and ulder Yes No n % n % n % n % n % n % n % n % n % Knowledge good 55 42 173 71,5 79 57,7 92 78,6 41 41,4 120 69,4 61 71,8 51 65,4 175 59,7 poor 76 58 69 28,5 58 42,3 25 21,4 58 58,6 53 30,6 24 28,2 27 34,6 118 40,3 Mmg. Screen yes 36 28,6 104 43,9 51 38,3 60 51,3 10 10,4 77 45,6 52 62,7 38 49,4 103 36 no 90 71.4 133 56,1 82 61,7 57 48,7 86 89,6 92 54,4 31 37,3 39 50,6 182 64 T a b l e V : “T h re e s u b je c ts to b e in fo rm e d ” n % Treatment 119 35,4 General information 63 18,8 Etiology 58 17,3 Diagnosis 58 17,3 Prevention 36 10,7 Genetic relation 28 8.3 Symptoms 27 8 Breast self-examination 24 7,1 Mammography 17 5,1 Others 70 20,1
who think they have a possibility of having cancer. A nsw ers for “W hat frightens you the most about the therapy?” were chem otherapy, m astectom y, being late for the treatment, operation itself and unsuccessful treatment in 25 % , 2 0 % , 13% , 12% and 12% of patients, respectively. 18% said “others” including “everything about the therapy”, “even its nam e”, econom ic problems, adverse affects, absen ce of psychological therapy, to be in need of help, to die, etc.
Tab le V includes the details of respondents’ request for having more information about any three subjects regarding breast can cer.
Turkish women and breast cancer
D IS C U S S IO N
Th e objective of this study w a s to determine knowledge, attitude and a w a re n e ss of women towards breast can ce r. Approxim ately 60% of women had good knowledge. But w e must admit that there might h ave been m ethodological m istakes while grading. Knowledge and practice increase with age. T h is result m ay be due to the high education levels of the elderly, but when education level and age w ere com pared, no significant relationship w a s found.
Most women knew that breast ca n ce r is the most common ca n ce r in wom en, and the age interval with higher risk but knowledge about risk factors, sym pto m s and b re a st se lf-e xam in atio n w a s found to be insufficient.
Other than “s tre s s ” and “nulliparity", most of the risk factors a sso ciated with breast can cer were unknown by half of the wom en. E sp ecially “late m enopause” and “early m enarche” w ere the least known factors, sim ilar to another study (10). Other least known facto rs include; nutrition, which is a preventable risk factor (11), late conception of their first child and a history of colon, ovarian and uterine cancer.
Most of the women knew that “breast lumps" and “swollen lymph nodes in the axilla” are sym ptoms of breast ca n ce r but other sym ptom s w ere not well known.
Though a s m any a s 6 7 ,3 % of women reported that they are performing breast self-exam ination, only 4 2 % of them had sufficient knowledge. Th is low level of knowledge may be contributory in part to late d ia g n o sis and , in turn, poor prognosis. According to a previous study, 89% of women practicing breast self-exam ination at the time of diagnosis discovered their tumour by this method (12). Therefore there should be more education p ro g ram m es about b re ast self- exam ination.
Although having m am m ography in c re a se s to 6 3% in 51 year-old or elder wom en, in Isparta, in another study 8 6 ,3 % of the women who should have m am m ography due to their age had no m am m ography sc re e n in g (1 3 ). T h e re is no information about m am m ography proportions among women who should have mammography,
since no attempt w as made to estimate the women in risk groups with this study. 63% of the women had mammography due to a physician’s recommendation. Th is result is com parable with another study reporting that one of the strongest predictors of m am m ography screen in g Is a p hysician’s recommendation, com pliance with such recommendation may be complicated by distrust of the medical profession in som e patient populations (14-15).
Significant relationship w as found between age, education, fam ily incom e and breast health scores. However, another study docum ents the reverse where age w as not found to be related to knowledge (16).
No significant relationship w as found between the presence of breast can cer in relatives and
know ledge and p ractice. Know ledge and
behaviour w as found to be affected by attitudes suggesting that increasin g p erceptions of personal vulnerability m ay increase screening behaviour a s sim ilar results found in another study (17).
Strategies should be developed to increase the level of knowledge and utility of screening tools among women, particularly those who are young, have a low level of education and low family Incom es. Few women perform breast self-
exam ination properly, therefore education
programmes teaching breast self-exam ination should be organized. Th e role of media is important since it is the most common source for obtaining information in society.
A C K N O W L E D G E M E N T S
W e thank M iss Pegah Golabi and Mr. David Thom as for their contribution to this study.
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