Level of Awareness and Practices of Women Regarding Breast Cancer in Chhattisgarh , India : An Institution Based Survey

1Department of Surgery, All India Institute of Medical Sciences (AIIMS), Raipur, Chhattisgarh, 492099, INDIA. 2Department of Community and Family Medicine, All India Institute of Medical Sciences, Raipur, Chhattisgarh, 492099, INDIA. 3Department of Trauma and Emergency, All India Institute of Medical Sciences, Raipur, Chhattisgarh, 492006, INDIA. 4Department of Obstratics and Gynaecology, All India Institute of Medical Sciences, Chhattisgarh, 492099, INDIA.


INTRODUCTION
The breast cancer is the most common cancer diagnosed in females both in developed and developing regions. 1,2The breast cancer is the leading cause of cancer deaths in females (GLOBOCON 2012). 1,2ach year, 55-60% of all new breast cancer diagnosed globally and 62-70% of breast cancer deaths occur in low-and middle-income countries (2010). 2,3In India breast cancer is responsible for 19-34% of all malignant cases (Population and hospital based National Cancer registery 2012-2014). 1,2,4The agestandardised incidence rates in India are lower as compared to the United Kingdom (UK) (25.8 versus 95 per 100,000 in 2010, GLOBOCON). 1,2However mortality rate is comparable (12.7 vs 17.1 per 100,000) with United Kingdom (International Agency for Cancer Research, 2012). 5In India most common cause of high mortality is diagnosis of breast cancer at advanced stages. 4,6The contributing factors for detection of breast cancer at advance stages are poor awareness, tardy and bothersome referral pathways, inadequate accessibility to proper diagnosis and treatment at cancer centers, almost non-existent breast cancer screening programs, women concern about body image, prevalent myths and cultural taboos. 4,7,80][11] In developing countries the average age at diagnosis is 10 years lesser than women in Western countries. 10overnment of India had launched National Cancer Control Program (1975), under the 12 th five year Plan (2012-2017) to increase awareness and early detection behaviors for various diseases including cancer. 12his KAP survey was planned to assess the existing level of awareness of breast cancer at Chhattisgarh to plan further strategy at our hospital for early detection of breast cancer.

MATERIAL AND METHODS
This was a cross-sectional descriptive study conducted at the outdoor Department of Surgery of Medical college and hospital from 2016.The study was carried out after obtaining approval from the institutional ethical committee.The target group was women 16-65 yrs of age (other than known case of breast cancer).Information was collected on the demographic profile, educational level, occupation status and socioeconomic status (Modified B.G. Prasad 2016). 13The study participants were provided a self-administered questionnaire with due assistance in filling the questionnaire.The questionnaire was verified by expert in Hindi literature and English literature.The questionnaire was to assess the basic knowledge of breast cancer symptoms, risk factors, preventive measures, common misconceptions and early detection methods.5][16] Information was collected on age, family history, age at first birth, parity, duration of breastfeeding, obesity, alcohol use, tobacco use, menstrual history etc.,.The oral contraceptive pills and hormone replacement therapy as a risk factor were not incorporated because of substantial heterogenecity. 16,17This was followed by breast cancer awareness education/ interactive session.The session incorporated education about breast cancer symptoms, risk factor, breast self-examination (BSE), clinical breast examination (CBE) and mammography.The interaction session was to clear myths about breast cancer and performance of clinical breast examination by clinician, training of BSE and distribution of education material.Self-made scoring for awareness was done on 45 points for 45 responses in the questionnaire (see Annexure 1).One point was given for correct response and no point for wrong or don't know response.The level of breast cancer awareness was defined as poor awareness (score 0-15), average (score 16-30), good awareness (score 31-45) (see Table 2).

Statistical analysis
The data were entered in MS Excel sheet and analysis was done using Statistical Package for Social Sciences (SPSS) Version 11.Chi square test was applied to test the difference in awareness level by age, occupation, socio economic status and education.

RESULTS
From September 2016 to March 2017, 1200 women (excluding known case of breast cancer) were asked to participate in the survey.Only 1000 women (response rate 83.33 %) gave consent.The data analysis was done for randomly selected 495 survey questionnaires.The mean age of the women was 35.17 years (range 16-65 years).The demographic profile of participant is shown in Figure 1.Majority (30.0 %) of women were in the age group of 26-35 years.The married women were 36.96(n =181) % and 34.94% (n =173) women belongs to rural area.The maximum participants in the study were housewives.Illiteracy rate of women in the study was 7.9%.According to Modified BG Prasad's (2016) 71.31 % (n=353) were in upper class.Most of the women were aware of breast cancer relationship with family history of breast cancer (50.5%) and previous radiation exposure (68.2 %) to breast.Their knowledge of the influence of lifestyle, dietary habits, alcohol intake and personal reproductive and menstrual history as a risk factor for breast cancer were poor.More than 50% were aware of genetic factor as risk factor for breast cancer.Wearing brassier (60.2%), physical trauma or repeated infection in the breast (58.58%) and stressful lifestyle (39.39%), were wrongly identified risk factors for breast cancer (see Table 3).Around 34.14% women identified painless breast lump as a symptom of breast cancer.Around 39% women identified an ulcer over the breast and increase in size of breast as the only symptom of breast cancer.The response rate for skin texture change, colour change, nipple changes were subtle (see Table 3).None of the participant were aware that lump in the axilla can be related to breast cancer.None of the participant was aware of all symptoms of breast cancer.Although 19% women had heard about breast self-examination (BSE), but only 10.10% of women perform BSE and none of them know the correct method and recommended frequency of BSE.Most of the women agree that regular clinical breast examination (CBE) is the most important method for early detection of breast cancer.But none of them were aware of recommended frequency and age for the CBE.Only 5.50% women knew about mammography, these were women who consulted for breast pain and underwent screening mammography.About 19% (95/495) of women have Good Breast cancer awareness.Twenty one percent have average awareness while more than half (60%) have poor awareness (see Figure 2).The print media (magazine and newspaper) is the most common source of providing information about breast cancer to the participants.On enquiring about the preferred mode of receiving information regarding breast cancer, social media and television were preferred by urban women and frequent health camps or personnel information by health care provider by rural women.No significant association was observed between awareness and age.However, participant scored good level of knowledge of breast cancer were maximum in number within 18-35 year (58.9%, n= 56/95).The    found knowledge of family history as a risk factor for breast cancer was high (50.5%)similar to Khokhar et al. (58%). 23While our study population have 60.4 % urban population vs exclusive urban population (New Delhi) in Khokhar study.Alcohol consumption which is a well proven risk factor of Breast cancer was not responded to by most of our study participant (80%), contrary to Ahuja et al. (85%) study from Mumbai. 24][20][21][22][23][24] It was seen in our study that majority of the women (12.72, 63/495) did not associate a painless lump in the breast with breast cancer while (39.39%, 195/495) thought that an ulcer over the breast (an advance stage of breast cancer) is a cancer.This shows that most of the women didn't recognize the most common presentation or the most common symptom (painless breast lump) of early breast cancer.These results are similar to those observed by other authors (Somdutta et al. from India, Okobiya et al. from Nigeria). 19,30None of the participants recognized a lump in the axilla as a possible symptom of breast cancer.Hence there is an urgent need for focused breast cancer awareness campaigns to educate the community on all the alarming sign of breast cancer.
The American College of Obstetricians and Gynecologists (ACOG) and the American Cancer Society recommend BSE once in a month beginning at the age of 20 years, one week after the menstrual flow. 31Many studies have suggested that monthly BSE is a reliable screening tool for breast cancer. 32The trends of breast cancer in developing countries is changing and the average age at diagnosis here is 10 years lower than that in western countries. 5Monthly BSE started from a younger age alerts women about abnormal changes in their breast so they can seek medical advice accordingly. 25Education of all women (irrespective of age) about monthly BSE promotion is an utmost demand of time. 31,32BE which is performed by doctor or trained nurse practitioner, is important as it may detect lumps which are missed on BSE. 33,35,36CBE may also detect those lumps which may be missed on conventional mammography if the affected area is not being specifically targeted in mammography. 37The recommendation of ACOG is to perform CBE annually for women over 40 yrs, every 3 years for women between 20 and 40 yrs and more frequent examination for high risk patients. 37,38It is highly unfortunate that in our study no women were aware of correct time and frequency of performing BSE and CBE (our study and Somedutta et al. study). 19The World Health Organization stresses increasing CBE in all women attending primary health care or hospital. 37The governmental and non-governmental agencies working in the field of health in India, have been constantly trying to educate the women with initiatives like rallies, celebration of October month as breast cancer awareness month, regular health checkups, awareness cum screening camps etc. 6,[39][40][41] In developing countries, the major hindrances to increasing awareness are, poor access to treatment, inadequate knowledge of health professionals, (Breast Health Global Initiative 2010), lack of proper referral, financial constraints and abysmal involvement of media (television / newspaper/ social media). 42,43The Indian media has traditionally focusing on spreading awareness about the ill effects of tobacco use. 44They should also highlight the issues related to breast cancer. 45iteracy is an important factor towards accepting breast cancer screening methods.But educational interventions, the attitude and practices regarding breast cancer are still poor because of the non-compliant attitude of women toward breast cancer screening, fear of stigma, discrimination denial within community and distrust in the health system. 45t is suggested that hospital based education, BSE and CBE for all female patients should be mandatory at all health care centers.Their hospital visit should be used as an opportunity to educate them for breast cancer and correct method of BSE.In underdeveloped and developing countries because of paucity of funds and trained manpower we may target awareness level was found to be significantly associated with the education, occupation, urban and economical status (see Figure 3).

DISCUSSION
The mortality rates for breast cancer continue to rank the highest in India. 1,2,15Studies have proved that one-third of newly diagnosed cancer patients could experience increased survival if detected in early stage. 180][21][22][23][24][25][26] Early detection will lead to earlier intervention, possible breast conserving surgery and personalizing adjuvant systemic therapy. 25here are various methods of early detection of breast cancer.These include: breast self-examination (BSE), clinical breast examination (CBE) and mammography screening.BSE involves visualization and palpation of the breast by oneself for lumps, shape, texture, size and contour.The purpose of BSE is for a woman to learn the topography of her breasts, know how her normal breasts feel and be able to identify changes in them should they occur in the future. 25he presence of risk factor does not always invite the disease but they help in identifying women who would be benefitted from screening.Gupta et al. review of Indian studies (2005-2013) on breast cancer awarenes found no changes in the awareness level for symptoms, risk factor and screening methods over the 8-year period. 67][28][29] The knowledge deficit of risk factors of breast cancer such as early age at menarche, late menopause, age at birth of first child, breast feeding practices prevents the women screening seeking behavior.By increasing the level of knowledge we can positively modulate their behavior toward screening behavior and practices. 26The knowledge of modifiable risk factor (alcohol consumption, physical activity, weight control) will be beneficial as preventive measures adoptability in life. 15In our study majority (64.06 %) participants was from urban area and we found a significant difference in the awareness level in urban versus rural population.We found 58% of identified trauma to breast and repeated infection in breast as a risk factor of breast cancer (vs 20% in Somedutta et al. study at New Delhi). 195][16] We

FrequencyFigure 1 :
Figure 1: Proportion of participant in respective age group, their education standard, Occupation status and socioeconomic status (Modified G.B. Prasad 2016).

Figure 2 :
Figure 2: Breast cancer awareness level (based on self made scoring).

Figure 3 :
Figure 3: Correlation of Breast Cancer awareness level with age, education standard, Occupation status and Socio-economic status of participants (Modified B.G. Prasad 2016).