Cadnaan`s Thesis

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CHAPTER ONE

INTRODUCTION

1.1 Background

Cancer is a group of diseases characterized by uncontrolled growth and

spread of abnormal cells. If the spread is not controlled, it can result in

death. Among them is the breast cancer which is the most frequently

diagnosed cancer in women worldwide with an estimated 1.4 million new

cases in 2008. About half of these cases occurred in economically devel-

oping countries (GLOBOCAN, 2008). Globally, breast cancer is the most

common malignant neoplasm among women, with approximately one in

nine women developing the disease in her lifetime. Every year, about

900,000 women are diagnosed with the disease (Ahmed A M. et al,

2010).

It is the most form of malignant diseases found in women. Meanwhile,

early discovery of breast lumps through breast self-examination (BSE) is

important for the prevention and early detection of such disease (Nadia Y.

and Magda A., 2000).

Female breast cancer is by far the leading cancer in the Sudan. The

alarmingly high frequency of women presenting with advanced breast

cancer to the Radiation Isotope Center Khartoum (RICK) and Gezira

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Institute for Cancer treatment and Molecular Biology (GICMB), which

are the only two oncology centers in the Sudan, has prompted looking for

an investigation that might help in solving this real health problem. The

highest percentages were recorded in 1998 (38.4% of all female cancers),

followed by the years, 1999, 2000 and 2001, which attended 36.03%,

35.2% and 32.4% respectively (Ahmed et al. 2010). Recent studies

carried out on breast cancer percentage in the Gezira state in the National

Cancer Institute in the state in the years 2005, 2006, 2007 and 2008 were

18%, 29%, 25% and 28% respectively compared to all other cancers

(National Cancer Institute of Gezira, 2008).

Apart from the highly increased risk of getting breast cancer related to

rare mutations, for example BRCA1 and BRCA2 (Hofmann 2000; Yang

1999). Other Numerous risk factors are also associated with breast

cancer. One major risk factor is increasing age. Among the factors that

increase the risk of breast cancer the most important ones include either a

personal or a family history of breast cancer and some specific genetic

mutations and hyperplasia that have been confirmed on biopsy. Other

factors that augment the risks of developing breast cancer are: an early

menarche and late menopause, obesity after menopause, use of iatrogenic

hormones (both oral contraceptives and postmenopausal hormone therapy

have been implicated), nulliparity or 'having the first child after the age of

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30', certain ethnic features, radiation, or intake of alcohol on a daily basis

(Shiyam Kumar et al., 2009).

Effective early detection of breast cancer requires both early diagnoses in

symptomatic and asymptomatic patients at risk. In low-resource settings,

any programme for early detection must be focused and sustainable. In

Sudan, It is implemented early screening programmes for only three

cancers, breast, cervical and oral cancer (Hussein M. A., 2006).

Preventive behavior is essential for reducing cancer mortality.

Knowledge is a necessary predisposing factor for behavioral change.

Knowledge also plays an important role in improvement of health seeking

behavior. Not only that knowledge might dramatically improve the

attitude, disbelieve, and misconception and consequently enhance

screening practice (Soheil Mia, 2007).

This study is to assess the Knowledge, attitudes and practices of women

towards early detection of breast cancer in Wad Madani, Gezira state,

Sudan.

1.2 Problem Statement

Breast cancer is the most common cancer among women in Gezira State

according to the report form National Cancer Institute in Gezira state in

2008 which breast cancer constituted about 28% of all cancers. The

mortality rate can be reduced by early detection of the breast cancer. But

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the lack of awareness among women about the Knowledge and positive

attitudes towards the early detection of breast cancer lead to the rise of

incidences of the disease mortality among women. In the light of all

above, this study aims at determining the Knowledge, attitude, and

practices of women towards early detection of breast cancer in Wad

Madani, Gezira state, Sudan.

Effort to reduce breast cancer mortality must focus on early detection

primarily through the use of the following screening techniques as

recommended by the American Cancer Society:

a. Monthly breast self-examination (BSE) beginning at age 20;

b. Clinical breast examination (CBE) every three years for women 20

to 39 years of age and annually after 40 years of age;

c. Annual mammography beginning at age 40 years (American

Cancer Society, 2003).

1.3 Justification

Since the prevalence of breast cancer among women in Gezira state is

high compared to other cancers (the last study in NCI, 28% in 2008), it is

important to detect the breast cancer early because Breast cancer is most

treatable when it is found early – when it is small and has not spread.

There is no way to predict who will develop breast cancer and who will

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not. For these reasons, routine early detection tests (checking for breast

cancer when there are no symptoms present) are recommended.

1.4 Research Questions

The following research questions were examined in this study:

1. What is the women’s knowledge regarding breast cancer (risk

factors, symptoms)?

2. What is the women’s awareness about breast self examination

(BSE)?

3. Is there any association between the level of education and the

knowledge of practice of breast self-examination (BSE)?

1.5 Objectives of the study

1.5.1 General Objective

To determine the Knowledge, attitudes and practices of women towards

early detection of breast cancer.

1.5.2 Specific objectives

To determine the knowledge of the women towards the most

important factors that enhances the development of breast cancer.

To identify the percentage of women who have correct knowledge

about early detection by BSE.

To measure the percentage of women who perform regular BSE.

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To determine the different types of breast cancer among patients.

To determine the most important factors those enhance the

development of breast cancer.

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CHAPTER TWO

LITERATURE REVIEW

2.1 Anatomy and physiology of the breast

The breasts lie between the skin and the pectoral fascia to which they are

loosely attached. Apparently the adult female breast overlies the area

from the second to the sixth ribs and from the lateral border of the

sternum to the anterior axillary line.

2.2.0 Components of the breast

The adult female breast has two components:

The epithelial elements- these are responsible for milk secretion and

transport. Each breast consists of 15-20 radially arranged and each is

drained by a lactiferous duct, the ducts converge at the nipple. A lobe is

made up of 20-40 lobules, each of which consists of 10-100 alveoli. The

alveoli and ducts are lined by a single layer of epithelium and the ducts

are surrounded by contractile myoepithelial cells which are stimulated by

oxytocin and move milk towards the nipple.

The supporting tissues- fibrous septa (coopers ligaments) extend from

the pictoral fascial to the skin and are responsible for the division of the

parenchyma into lobes (Galal and Korashi, 2011).

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2.3 Hormonal control

Breast development is under the control of the following hormone:

Oestrogen, Adenocortical steroids and growth hormone

promote development of ducts

Progesterone stimulates the growth of lobules

Prolactin is essential for alveolar formation (Galal and

Korashi, 2011).

2.3.1 Physiological changes

At puberty: the breast remains dormant until puberty. The onset of

cyclical hormonal activity stimulates growth, branching of ducts and

formation of ductules.

Menstrual changes: during the menstrual years the breast

undergoes cyclical changes which can cause heaviness, discomfort

and increasing nodularity during the latter part of menstrual cycle.

During pregnancy: there is marked lobular development.

Lactation: following delivery, reduction of estrogens increases

sensitivity of mammary epithelium to the lactational complex.

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After menopause: the lobules gradually disappear (Galal and

Korashi, 2011).

Figure (2.1). Anatomy of female breast showing ducts and lobules.

2.4 Cancer overview

The body is made up of trillions of living cells. Normal body cells grow,

divide, and die in an orderly fashion. During the early years of a person's

life, normal cells divide faster to allow the person to grow. After the

person becomes an adult, most cells divide only to replace worn-out or

dying cells or to repair injuries. Cancer begins when cells in a part of the

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body start to grow out of control. There are many kinds of cancer, but

they all start because of out-of-control growth of abnormal cells.

Cancer cell growth is different from normal cell growth. Instead of dying,

cancer cells continue to grow and form new, abnormal cells. Cancer cells

can also invade (grow into) other tissues, something that normal cells

cannot do. Growing out of control and invading other tissues are what

makes a cell a cancer cell.

In most cases, the cancer cells form a tumor. Some cancers, like

leukemia, rarely form tumors. Instead, these cancer cells involve the

blood and blood-forming organs and circulate through other tissues where

they grow.

Cancer cells often travel to other parts of the body, where they begin to

grow and form new tumors that replace normal tissue. This process is

called metastasis. It happens when the cancer cells get into the

bloodstream or lymph vessels of our body.

Not all tumors are cancerous. Tumors that aren’t cancer are called benign.

Benign tumors can cause problems – they can grow very large and press

on healthy organs and tissues. But they cannot grow into (invade) other

tissues. Because they can’t invade, they also can’t spread to other parts of

the body (metastasize). These tumors are almost never life threatening

(American Cancer Society, 2011).

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2.5 History of breast cancer

The origin of the word cancer is credited to the Greek physician

Hippocrates (460-370 B.C.), the "Father of Medicine." Hippocrates used

the terms carcinos and carcinoma to describe non-ulcer forming and

ulcer-forming tumors. In Greek these words refer to a crab, most likely

applied to the disease because the finger-like spreading projections from a

cancer called to mind the shape of a crab. Carcinoma is the most common

type of cancer.

Thus breast cancer is a “malignant neoplasm of the breast.” A cancer cell

has characteristics that differentiates it from normal tissue cells with

respect to: the cell outline, shape, structure of nucleus and most

importantly, its ability to metastasize and infiltrate. When this happens in

the breast, it is commonly termed as ‘Breast Cancer. Cancer is confirmed

after a biopsy (surgically extracting a tissue sample) and pathological

evaluation.

During the mid 1800’s, surgeons first began to keep detailed records of

breast cancer. Those statistics indicate that, even those treated by

mastectomy had a high rate of recurrence within eight years—especially

when the glands or lymph nodes were affected. Nevertheless, the

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common treatment was to remove the breast and the surrounding glands

in an effort to stave off any further tumor development.

In 1949 Raul Leborgne (Uruguay) emphasized breast compression for

identification of calcifications. In 1940s-1950s breast self-examinations

were advocated (Anna H. Israyelyan, 2003).

It is a common cancer in women, a disease in which cancer cells are

found in the tissues of the breast. Each breast has 15 to 20 sections called

lobes. Lobes have many smaller sections called lobules. The lobes and

lobules are connected by thin tubes called ducts. The most common type

of breast cancer is ductal cancer. It is found in the cells of the ducts.

Cancer that begins in the lobes or lobules is called lobular carcinoma.

Lobular carcinoma is found in both breasts more often than other types of

breast cancer. Inflammatory breast cancer is an uncommon type of breast

cancer. In this disease, the breast is warm, red, and swollen. (East African

Breast Cancer, 2009).

2.6 Breast cancer in Sudan

Breast cancer is a public health problem in Sudan; According to the latest

WHO data published in April 2011 Breast Cancer deaths in Sudan

reached 1,968 or 0.53% of total deaths. The age adjusted death rate is

16.31 per 100,000 of population (WHO, 2011).

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The breast cancer incidence in Gezira state exceeds 260 cases annually

and the number of cases of women younger than 40 years of age reaches

about 67.3% of all cases (National Cancer Institute of Gezira, 2008).

Therefore, it is critical that efforts in prevention and early diagnosis of

breast cancer are implemented everywhere. One of the main problems

concerning breast cancer relates to the lack of patients awareness about

the disease. Limitations in implementing breast self-examination and

mammography screening programs are the other important issues.

Overall survival and mortality due to this disease are influenced strongly

by the stage of the disease at diagnosis.

The optimal chances for surviving breast cancer in woman is by detecting

it early; either by breast self examination (BSE) conducted by a woman

herself, clinical breast examination by health staff or by mammography

(Ahmed HG. et al., 2010).

Knowledge of risk factors, as well as, rising of the awareness is

momentous, particularly in a country like the Sudan, where many patients

present from remote areas with poor health services. For that reason, the

incidence and mortality of breast cancer are high, remarkably constant

and the frequency is increasing particularly amongst younger women.

Exposure to endogenous estrogens increases the risk of breast cancer.

Women who start menstruating before age 12 or begin menopause after

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age 55 generally have more monthly cycles and therefore a longer

lifetime exposure to estrogen. This tends to increase their risk of breast

cancer. (Hussein G. Ahmed et al., 2010).

The incidence of breast cancer is lowest in women who have given birth

to babies at an early age and have had multiple pregnancies. In

communities where the custom is for women to marry early and have

their first babies whilst still in their teens, the incidence of breast cancer is

low, whilst in Westernized societies where first babies are commonly

born to women over the age of 30 years, the incidence of breast cancer is

higher. There may also be some protection against breast cancer by

prolonged breast feeding as is common in most developing countries,

although the evidence for this is less clear. Women who have never had a

child, such as nuns, have the highest incidence of breast cancer (Stephens

& Aigner, 2009).

2.7 Breast cancer early detection

Breast cancers that are found because they are causing symptoms tend to

be larger and are more likely to have already spread beyond the breast. In

contrast, breast cancers found during screening exams are more likely to

be smaller and still confined to the breast. The size of a breast cancer and

how far it has spread are some of the most important factors in predicting

the prognosis (outlook) of a woman with this disease. Most doctors feel

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that early detection of breast cancer save thousands of lives each year,

and that many more lives could be saved if even more women and their

health care providers took advantage of these tests. Following the

American Cancer Society's guidelines for the early detection of breast

cancer improves the chances that breast cancer can be diagnosed at an

early stage and treated successfully (American Cancer Society, 2010).

2.7.1 Breast-Self Examination

Breast self-examination is one of the vital screening techniques for early

detection of breast lumps, most especially cancer of the breast. The

procedure, though simple, non-invasive, requiring little time, can only be

practiced with the right attitude to sustain it and achieve the desired goal

(Kayode F. O. et al., 2005).

Breast self examination consists of two basic steps: tactile and visual

examination:

2.7.1.1 Tactile examination

An effective breast self examination is one that is conducted at the same

time each month, uses the techniques properly and covers the whole area

of each breast, including the lymph nodes, underarms, and upper chest,

from the collarbone to below the breasts and from the armpits to the

breast bone. The breast self examination can be done using vertical strip,

wedge section and concentric circle detection methods. The breasts

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should not be compressed between fingers as it may cause the woman to

feel a lump that does not really exist.

2.7.1.2 Visual examination

The visual examination of the breast is another tool in identifying

possible breast disease. In preparing for the visual examination, the

woman should stand in front of a mirror. When looking into the mirror,

the woman must look for any changes in the contour or placement of the

breasts, changes in the color and shape, discharge from nipples and

discoloration of the skin (Khatib, 2006).

The recent fall of death from breast cancer in western nations is

particularly explained by earlier diagnosis as a result of early

presentation. In most of the developing countries patient comes for

treatment in an advance stage when little or no benefit can be derived

from any sorts of therapy. Early diagnosis can be successfully achieved

by mass screening either by Mammography, Clinical Breast Examination

(CBE) and Breast self examination (BSE) or by the combination of three.

Though it is well documented that mammography is the best choice for

screening, breast self examination is also equally important and beneficial

for mass awareness especially in country with limited recourses (Soheil

Mia., 2007).

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If cancer awareness among the general public is limited then people are

ill equipped to make informed decisions about their health, which may

consequently lead to delayed presentation and poorer survival (Ramirez

et al, 1999; Richards et al, 1999; Coleman et al, 2003; MacDonald et al,

2006).

2.7.2 Clinical Breast Examination:

Clinical Breast Examination (CBE) is a standardized procedure whereby

a health care provider examines a women’s breast, chest wall, and axillae.

The examination consist of 1) Visual inspection of the breast while the

women in upright position and her arms relaxes and then raised above her

head. 2) Palpation of the axillae and supraclavicular fossae when the

women in the upright position and 3) palpation of the breasts while the

women both in upright and supine positions. The examiner inspects the

breast visually for symmetry, skin of the breast, areola, and nipple for

oedema, erythema, puckering, dimpling, or ulceration, all of which can be

evidence of underlying masses. The provider palpates the regional

axillary nodes. Enlarged hard, matted or fixed nodes can indicate cancer

(Benjamin O. Anderson et al., 2003).

2.7.3 Mammography

A mammogram is a special X-ray of the breast that may show the

presence of cysts, dense fibrous tissue, or a cancer in the less-dense fatty

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tissue of the breast. Small amounts of X-rays only are needed so this

examination is safe if not used excessively. Although mammograms

produce some false negatives and some false positives they are

nevertheless very useful, safe and inexpensive in screening for breast

cancer. However, even the small doses of X-rays needed for

mammography are better avoided in women who may be pregnant or

wish to have further pregnancies as even this exposure to irradiation can

cause genetic mutation of fetal cells or of actively functioning ovarian

tissue. This usually means that mammography is not routinely

recommended in women younger than 40 (Stephens & Aigner, 2009).

2.8 Risk factors of breast cancer

Although the causes and natural history of breast cancer remain unclear,

epidemiological research has uncovered genetic, biological,

environmental, and lifestyle risk factors for the disease.

A risk factor is anything that affects your chance of getting a disease,

such as cancer. Different cancers have different risk factors. Having a risk

factor, or even several, does not mean that you will get the disease. Most

women who have one or more breast cancer risk factors never develop

the disease, while many women with breast cancer have no apparent risk

factors (other than being a woman and growing older). Even when a

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woman with risk factors develops breast cancer, it is hard to know just

how much these factors may have contributed to her cancer.

There are different kinds of risk factors. Some factors, like a person's age

or race, can't be changed. Some are related to personal behaviors such as

smoking, drinking, and diet.

2.8.1 Gender

Simply being a woman is the main risk factor for developing breast

cancer. Although women have many more breast cells than men, the main

reason they develop more breast cancer is because their breast cells are

constantly exposed to the growth-promoting effects of the female

hormones estrogen and progesterone. Men can develop breast cancer, but

this disease is about 100 times more common among women than men.

2.8.2 Aging

The risk of developing breast cancer increases as the women gets older.

About 1 out of 8 invasive breast cancers are found in women younger

than 45, while about 2 of 3 invasive breast cancers are found in women

age 55 or older(American Cancer Society, 2010).

2.8.3 Genetic risk factors

About 5% to 10% of breast cancer cases are thought to be hereditary,

resulting directly from gene defects (called mutations) inherited from a

parent.

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BRCA1 and BRCA2: (which are abbreviated BR from breast and CA

from cancer) the most common cause of hereditary breast cancer is an

inherited mutation in the BRCA1 and BRCA2 genes. In normal cells,

these genes help prevent cancer by making proteins that help keep the

cells from growing abnormally. If a woman has inherited a mutated copy

of either gene from a parent, she will have a high risk of developing

breast cancer during your lifetime (Trunbull C. & Rahman N., 2008).

2.8.4 Family history of breast cancer

Women whose close blood relatives have breast cancer have a higher risk

for this disease. Having a first-degree relative (mother, sister, or

daughter) with breast cancer almost doubles a woman's risk. Having 2

first-degree relatives increases her risk about 3-fold. Although the exact

risk is not known, women with a family history of breast cancer in a

father or brother also have an increased risk of breast cancer.

2.8.5 Lifestyle-related factors

2.8.5.1 Parity

Women who have not had children or who had their first child after age

30 have a slightly higher breast cancer risk. Having many pregnancies

and becoming pregnant at an early age reduces breast cancer risk. The

higher parities and earlier age at first pregnancy of women in many

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developing countries might account for lower incidence of breast cancer

in relation to developed countries.

2.8.5.2 Oral contraceptives

Studies have found that women using oral contraceptives (birth control

pills) have a slightly greater risk of breast cancer than women who have

never used them (American Cancer Society, 2010).

2.8.5.3 Breast-feeding

Some studies suggest that, breast-feeding may slightly lower breast

cancer risk, especially if it is continued for 1½ to 2 years. For example,

the US Cancer and Steroid Hormone Study found that breast feeding for a

total of 25 months or more reduced the risk of cancer by 33% in over

4500 women studied. (Sherif O. Jarques et al., 2010).

2.8.5.4 Alcohol

Consumption of alcohol is clearly linked to an increased risk of

developing breast cancer. The risk increases with the amount of alcohol

consumed. Compared with non-drinkers, women who consume 1

alcoholic drink a day have a very small increase in risk. Those who have

2 to 5 drinks daily have about 1½ times the risk of women who drink no

alcohol. (American Cancer Society, 2010).

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2.9 warning signs of breast cancer

Early breast cancer is usually symptom less. But there are some

symptoms develop as the cancer advances. Breast lump or breast mass is

the main symptoms of the breast cancer. Lump is usually painless, firm to

hard and usually with irregular borders. Every lump is not cancerous,

sometimes some lumps or swelling in the breast tissue may be due to

hormonal changes or benign (not harmful) in nature. Beside these some

others symptoms are important, like:

Lump or mass in the armpit

A change in the size or shape of the breast

Abnormal nipple discharge

- Usually bloody or clear-to-yellow or green fluid

- May look like pus (purulent)

Change in the color or feel of the skin of the breast, nipple, or

areola

- Dimpled, puckered, or scaly

- Retraction, "orange peel" appearance

- Redness

- Accentuated veins on breast surface

Change in appearance or sensation of the nipple

- Pulled in (retraction), enlargement, or itching

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Breast pain, enlargement, or discomfort on one side only

Any breast lump, pain, tenderness, or other change in a man

Symptoms of advanced disease are bone pain, weight loss, swelling

of one arm, and skin ulceration (Medline plus Encyclopedia, 2011).

2.10 Stages of breast cancer and survival rates

The staging systems currently in use for breast cancer are based on the

clinical size and extent of invasion of the primary tumor (T), the clinical

absence or presence of palpable axillary lymph nodes and evidence of

their local invasion (N), together with the clinical and imaging evidence

of distant metastases (M). This is then translated into the TNM

classification which has been subdivided into Stage 0 called carcinoma in

situ (lobular carcinoma in situ (LCIS) and ductal carcinoma in situ

(DCIS) and four broad categories by the Union Internationale Centre

Cancer (UICC), which are the following.

Stage 0 :( Carcinoma in Situ) Carcinoma in situ is very early breast

cancer. In this stage cancer has not invaded into the normal breast tissue

and is contained in either the breast duct (ductal carcinoma in situ) or the

breast lobule (lobular carcinoma in situ). By definition, this type of

cancer is not invasive and is not able to travel to the lymph nodes or other

parts of the body.

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Stage I – early stage breast cancer where the tumor is less than 2 cm

across and hasn't spread beyond the breast.

Stage II – early stage breast cancer where the tumor is either less than 2

cm across and has spread to the lymph nodes under the arm; or the tumor

is between 2 and 5 cm (with or without spread to the lymph nodes under

the arm); or the tumor is greater than 5 cm and hasn't spread outside the

breast.

Stage III – locally advanced breast cancer where the tumor is greater than

5 cm across and has spread to the lymph nodes under the arm; or the

cancer is extensive in the underarm lymph nodes; or the cancer has spread

to lymph nodes near the breastbone or to other tissues near the breast.

Stage IV – metastatic breast cancer where the cancer has spread outside

the breast to other organs in the body. (Anna H. Israyelyan, 2003).

The five-year survival rate from breast cancer among women age 15 and

older is 89% in the United States, 82% in Switzerland, and 80% in Spain.

Breast cancer survival rates in developing countries are generally lower

than in Europe and North America, with rates as low as 38.8% in Algeria

, 36.6% in Brazil, and only 12% in Gambia. The stage at diagnosis is the

most important prognostic variable. For instance, the overall five-year

relative survival among US women diagnosed with breast cancer at early

stage is 98%, compared to 84% and 23% when the disease is spread to

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regional lymph nodes or distant organs, respectively (GLOBOCAN,

2008).

5-years Relative Survival Rate

Table (2.1). 5-years Relative Survival Rate

Stage Survival rate%

Stage 0 100%

Stage I 100%

Stage IIA 92%

Stage IIB 81%

Stage IIIA 67%

Stage IIIB 54%

Stage IV 20%

(American Cancer Society, 2005).

2.11 Previous studies

A number of articles have been found on breast cancer knowledge,

attitude and Practice.

Samira H. AbdElrahman and Magda A. Ahmed conducted a

longitudinal interventional study in 2003 in the University of Gezira; the

study was the role of medical students in the Faculty of Medicine about

self examination of the breast for early detection of breast cancer. The

study was done in three phases.

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Phase one: training of students, phase two: students intervention and

phase three: evaluation of students intervention.

Pre-test assessment and post-test assessment was done, it comprised 200

students and 340 women. In the pre-test assessment 66.5% of students

have heard about BSE, 8.0% rated BSE as very important and only 7.2%

used to practice it. After the intervention the last figures rose to 100% and

73.9% successively. Prior to study, only 12.0% of the women have heard

about BSE. By the end of student’s intervention 60.5% of the women

adhered to regular monthly BSE. No lump was detected by a student.

Olumuyiwa O,Odusanya and Olufemi O.Tayo conducted a cross

sectional survey in 2001 among nurses in general hospital in Lagos,

Nigeria. 204 nurses were included in the study. Knowledge about

symptoms methods of diagnosis, and Self breast Examination was above

60%. In response to question on 5 risk factors more than 50% identified

positive family history and that bruising the breast is a potential risk

factor for developing breast cancer. The nurses were well informed about

frequency of Breast Self Examination (BSE). More than one third

(39.7%) of the respondents knew that, BSE should be done monthly

interval. Majority (78.4%) of the respondents agreed that breast cancer is

a curable disease if diagnosed and treated early. Majority (90%)

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considered that, the disease is serious and would see a doctor within one

month. BSE was most frequently done (89%).

Among them 39 % conducted the procedure at monthly interval. Use of

all 3 methods of screening was more common among those who had a

greater knowledge about breast cancer. Perceived cancer risk assessment

was done, 61% claimed not at risk.

Another cross-sectional study was conducted among one thousand

community-dwelling women from a semi-urban neighborhood in Nigeria

by Michael N Okobia and et al conducted a study in 2006 to elicit

knowledge, attitude and practices towards breast cancer. The Study result

showed poor knowledge on breast cancer. Mean knowledge score was

42.3% and only 214 participants (21.4%) knew that breast cancer present

commonly as a painless breast lump. In response to questions about

etiology of breast cancer, 40% believed that evil spirit causes breast

cancer and 259 (25.9%) indicated that breast cancer result from an

infection. In terms of methods of diagnosis 432(43.2%) were able to

answer correctly identified that BSE is a method of diagnosis. There was

an indication of positive health seeking behavior as a majority of the

participants mentioned that visiting the doctors was the best approach for

breast cancer treatment. In terms of practices, 34.9% participants practice

BSE. Only 91participants (9.1%) had clinical breast examination (CBE)

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in the past year and no one had the history of mammography

examination. Majority of the respondents did not take part in BSE or

clinical breast examination due to having no breast problem.

Grunfeld E A et al conducted a survey in 2002 on 1830 general female

population of UK to elicit knowledge and believe about breast cancer. In

the study it was found that, women had limited knowledge on risk factors

and breast cancer related symptoms. Only 23% correctly indicated that 1

in 10 have a chance to developed breast cancer. Less than one third

recognized the role of advancing age as a potential risk factor. More than

70 % of the sample identified that painless breast lump, lump under

armpit, nipple discharge are potential symptoms.

Bener A et al conducted a cross sectional community base line survey in

2001 to explore the knowledge, attitude and practice related to breast

cancer screening among women of United Arab Emirates. They found

that only 30% of the women agreed that family history was a risk factor,

and 45 % incorrectly stated that most of the breast lump would become

cancerous. One third (33%) of the women knew that early breast cancer

was painful. Most of the women (79%) agreed to have breast examination

by a doctor but only 14% had experienced a clinical breast examination.

Only 13% performed breast self examination regularly on monthly basis.

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Pinar Erbay et al in their study of “The knowledge and attitude of breast

self examination and mammography in a group of women in a rural area

in western Turkey” found that majority (76.6%) had heard about breast

cancer but only 56.1% of them had sufficient knowledge about breast

cancer. TV and radio programs were identified as the main source

(39.3%) for information. Most of the respondents (72.1%) had knowledge

about Breast self Examination but only 40.9% of the women had

practiced BSE in the previous 12 months.

Pöhls U G et al conducted a study in 2004 on “Awareness of breast

cancer incidence and risk factors among healthy women” in Düsseldorf,

Germany found that78.8% were well aware of breast cancer in general

terms. Most of the women (94.9%) considered that former history of

breast cancer is a risk factor Interestingly 37.1% considered breast

feeding 32.0% considered age at menopause and 23.7% considered

childlessness as a potential risk factors. Two -third of the participant

estimated their personal risk of developing breast cancer was low to

average. Gynecologists were the main source of information (59.9%) on

breast cancer.

Jebbin NJ and Adotey JM conducted a study in 2004 on “Attitude,

knowledge and practice of breast self-examination (BSE) in port

Harcourt, Nigeria” and found that 85.5% of the respondent had heard of

30

Breast self examination but 39.0% practiced BSE only occasionally. The

news media nurses and physicians were the commonest sources of

information on BSE.

WA Milaat conducted a cross sectional study in 2000 on 6380 female

secondary-school student in Jeddah to identify their knowledge of breast

cancer and attitude towards breast self-examination (BSE). Knowledge of

risk factors was very low. Over 80% of students failed to answer 50% of

the questions correctly. Only 47.1% of students reported that they had

heard of or read some scientific information about breast cancer in

various media and 39.1% reported that lump in the breast is the warning

sign of breast cancer. Only15.2% agreed that use of contraceptive pill is a

potential risk factor. Few (16.2%) knew that breast cancer could appear

as a change of or bleeding from the nipple.

Ahmed HG et al; Conducted a case control study in the Sudan in 2010,

risk factors for breast cancer were evaluated among 150 women with

breast cancer (ascertained as cases) and 100 apparently health women

(ascertained as controls); their ages ranging from 20 to 65 years with a

mean age of 40 years old. The majority of patients were at the age range

36 - 45 years constituting 60(40%); hence the distribution was similar in

respect to the upper and lower limits from the mean. Results showed Out

of the 150 patients with breast cancer (cases), and 100 apparently healthy

31

individuals (controls); 38 (25.3%) and 38(38%) were identified as having

a previous history of oral contraceptives usage, respectively. Information

concerning the type of oral contraceptives were available for only 35

patients, of whom 28 (80%) were using progesterone only pill and the

remaining seven (20%) were using combined pill.

Out of the 150 cases and 100 controls, 22 (14.7%) and 14(14%) were

found with a family history of breast cancer (First degree mother side), as

well as, 20 (13.3%) were detected as having a previous history of breast

cancer, respectively. Furthermore, 11(7.3%) of the cases and 27 (27%) of

the controls have claimed other cancers in their families.

32

CHAPTER THREE

MATERIALS AND METHODS

Figure (3.1) Map showing Gezira State and Wad Madani, the capital city

3.1 Study Area

Sudan is a country in North Africa that is often considered to be part of

the Middle East as well. It is bordered by Egypt to the north, the Red

Sea to the northeast, Eritrea and Ethiopia to the east, South Sudan to the

south, the Central African Republic to the southwest, Chad to the west,

and Libya to the northwest.

33

3.1.1 Location

Gezira state is one of the 15 states of Sudan. It is located in the middle of

Sudan, bordered in the north by Khartoum State, in the south by Sinnar

state, in the west by White Nile State and in the east by Gedarif State.

The State has an overall population of 3,575,280 people. The region has

benefited from the Gezira Scheme, a program to foster cotton farming

begun in 1925. At that time the Sennar Dam and numerous irrigation

canals were built. Gezira became the Sudan's major agricultural region

with more than 2.5 million acres (10,000 km²) under cultivation.

Wad Madani is the area of current study which is the capital city of the state;

it has a population of 345,290 people according to the last national census in

2008. It is located on the west bank of the Blue Nile River, agriculture is the

central economic activity, like wheat, peanuts, barely and livestock. It is the

home of Gezira University, Wad Madani Ahlia college and other

institutions.

3.2 Study Design

Type of study: this analytical Case control hospital based study

conducted at Madani teaching hospital and National Cancer institute for

cancer treatment (NCI).

Study period: The study was conducted from November, 2011-

February, 2012.

34

Study population: the population under study was women residing in

Wad madani town from 20 years of age who attended to Madani

Teaching Hospital and National Cancer Institute (NCI).

3.3 Inclusion Criteria:

In this study women in Wad Madani Town were included to evaluate

their knowledge attitudes and practices towards early detection of breast

cancer. The reason why women of 20 years of age included the study is

that screening methods especially the breast self examination is

recommended after 20 years of age.

The control women in the survey were female patients and co-patients

who visit to Wad Madani Teaching Hospital, those patients were non

breast cancer patients.

The cases in the study were breast cancer female patients who attended in

the National Cancer institute for cancer treatment in Gezira state in the

period of January 2011 to December 2011.

3.4 Sample technique

The overall women that are 20 years of age and above are about 71,000

women projected from 2008 Population and Housing Census.

35

And the annual breast cancer treated estimated in the NCI was 934 with

an incidence rate of 34%.

At 95% confidence level and 5 %( 0.05) margin error. So the sample size

was calculated using the formula below:

N0 = Z² P Q / d²

When:

N0: sample size

Z²: value of selected α level of 0.25 in each tail (1.96)

P: anticipated population proportion

Q: 1 – p (anticipated population proportion)

D: absolute population required on either side of the population

(incidence point) (Lewanga K. & Lemeshow S., 1991).

n0 =

n0 = 345

So the finite population correction proportion can be calculated:

n = = = 252

36

Patients’ sample: The cases were incident, diagnosed with breast cancer

patients and they were entered in the study because they had a confirmed

pathological breast cancer and admitted to National Cancer Institute

(NCI).

The initial unit in this study was woman with breast cancer treated at

National Cancer Institute by using the statistical formula of a sample size

and a simple random sampling. The sample size calculated was 345.

The patients of breast cancer treated at (NCI) in the year is 934. These

were the new cases treated each year. After the correction formula used

the final overall sample size n= 252. So the recorded data needed to

survey in the patients sample is half of the overall sample which is 126

medical records.

Control Sample: The control women needed to recruit the study of

Knowledge, attitudes and practices of early detection of breast cancer was

randomly selected among women without any history of breast cancer

residing in Wad Madani Town and attended to Madani Teaching

Hospital.

They were also asked whether they have some risk factors of breast

cancer.

37

The control sample equal to the remaining half of the sample which is

126 samples from women attending to Madani Teaching Hospital.

3.5 Data collection and analysis

Data collection was accomplished using interviewer-administered

questionnaires manuscript in Arabic language. The questionnaire was

developed by the researcher using information on breast cancer from the

literature and from questionnaire conducted in the other studies.

The questionnaire used was in three parts. The first part was to elicit

socio-demographic data on age, occupation, and marital status of each

study participant. The second part was about the knowledge of breast

cancer and the risk factors that enhance the development of breast cancer.

Participants’ awareness of breast cancer and early detection methods

were assessed in the third section. The attitudes and practice of BSE,

CBE and Mammography among participants were also assessed in the

last section.

In the case section of the study medical recorded data was collected from

the National Cancer Institute of breast cancer patients attended to the

institute for treatment in the year 2011, the data was collected in a master

sheet.

Obtained data is arranged and finally data analyzed by using SPSS 16.0

software (SPSS Inc., 2008). Demographic characteristics will be simply

38

present in frequency and chi-square test is be used to compare Cases with

Control about the risk factors that enhance the development of breast

cancer.

39

CHAPTER FOUR

RESULTS AND DISCUSSION

4.1 RESULTS

4.1.1 CONTROL

Table (4.1) Distribution of the respondents According to their Age

Table (4.1). Shows the respondents’ frequency and their percentage with

age group (20-29) being the most age group participated the survey of

about 47.6%.

Age Frequency and Percent

Valid 20-29 60 (47.6%)

30-39 24 (19.0%)

40-49 19 (15.1%)

50+ 20 (15.9%)

Total 123 (97.6%)

Missing System 3 (2.4%)

Total 126 (100.0%)

40

Table (4.2) Distribution of Respondents according to their marital

status

Marital Status

Frequency and Percent

Valid Single 36(28.6%)

Married 80(63.5%)

Widowed 6(4.8%)

Divorced 3(2.4%)

Total 125(99.2%)

Missing System 1(.8%)

Total 126(100.0%)

Table (4.2). shows that most married were about 80 (63.5%) and single

were the second 36(28.6%).

41

Table (4.3). Distribution of respondents according to their occupation

Occupation Frequency and Percent

Valid Housewife 80(63.5%)

Employed 16(12.7%)

Student 25(19.8%)

Retired 3(2.4%)

Total 124(98.4%)

Missing System 2(1.6%)

Total 126(100%)

In this table (4.3) results show that most respondents were housewife 80

(63.5%), followed by students of 25 (19.8%).

42

Table (4.4). Association between Education level to the heard of

Breast cancer

In table (4.4). Results show that most participants heard of breast cancer

101(80.1%) of them have heard the breast cancer whereas 25(19.8%) of

them didn’t hear of breast cancer.

Graduates were the most participants heard the breast cancer 39 (30.9%)

followed by the secondary school participants of 23 (18.2%) participants.

There is a significance according to Chi-square test between the

Educational level and hearing of Breast cancer with P-value = 0.000.

Did you hear about breast cancer

Total Education Level Yes % No %

Education Khalwa 13(10.3%) 4(3.1%) 17(13.4%)

Primary school 17(13.5%) 5(3.9%) 22(17.4%)

Secondary school 23(18.2%) 2(1.6%) 25(19.8%)

Graduate 39(30.9%) 1(0.8%) 40(31.7%)

Illitrate

9(7.1%)

13(10.3%)

22(17.4%)

Total 101(80.1%) 25(19.8%) 126(100%)

43

Table (4.5). Association between Level of Education and heard of breast

self examination BSE.

Did you hear of breast self

examination- BSE?

Total Yes No

Education Khalwa 8(7%) 7(6.1%) 15(13.1%)

Primary school 10(8.8%) 9(7.8%) 19(16.6%)

Secondary school 10(8.8%) 14(12.2%) 24(21%)

Graduate 36(31.5%) 4(3.5%) 40(35%)

Illitrate 4(3.5%) 12(10.5%) 16(14%)

Total 68(59.6%) 46(40.4%) 114(100%)

In table(4.5). Results show that more than half of the participants heard of

breast self examination 68(59.6%) respondents heard of BSE.

Graduates were the highest group to hear about BSE 36(31.5%)

participants, followed by secondary and primary of 10(8.8%) respondents

each. We can also see here in this table a significance between the level

of education and hearing of BSE according to Chi-square test with p-

value= 0.000.

44

Table (4.6). Association between the level of education and the knowledge

of method of breast self examination BSE.

In table (4.6) results show that 40(42.2%) knew the method of breast self

examination whereas 54(57.4%) do not know the breast self examination.

The graduate respondents have the highest knowledge of breast self

examination of 28(29.7%) knew the method of BSE. There was a

significance relationship between the two variables with a p-value of

0.000.

Did you know the method of breast

self examination

Total Level of Education Yes % No %

Education Khalwa 4(4.2%) 7(7.4%) 11(11.6%)

Primary school 2(2.1%) 13(13.8%)) 15(15.9%)

Secondary school 4(4.2%) 12(12.7%) 16(16.9%)

Graduate 28(29.7%) 11(11.7%) 39(41.4%)

Illitrate 2(2.1%) 11(11.7%) 13(13.8%)

Total 40(42.2%) 54(57.4%) 94(100%)

45

Table (4.7) Distribution of respondents according to their practice of

BSE

Do you practice breast self examination

BSE?

Frequency and Percent%

Once a month 11 (8.7%)

Sometimes 19 (15%)

Knew but never practice 10 (7.9%)

Don’t know how to practice 86 (68.2%)

Total 126 (100%)

The table (4.7) shows that the practice of BSE is very low among

respondents only 11 (8.7%) practice monthly regular breast self

examination while 19 (15%) practice it only sometimes but the most

respondents don’t know how to practice it 86 (68.2%).

46

Table (4.8). Association of level of education with the knowledge of early

warning signs of breast cancer

In table (4.8). Results showed that painless lamp is the most known sign

among respondents of 31(32.6%) participants.

Graduates have the highest awareness of early warning signs of breast

cancer of 33 out of 95 participants knew at least one early warning sign.

There was a significance p-value 0.009.

What are the early warning signs of breast cancer

Level of

Education

Painless

lump Swelling

skin

changes

nipple

retraction

I don’t

know Total

Khalwa 2 4 2 0 3 11

Primary school 6 1 1 0 9 17

Secondary

school 7 5 2 0 5 19

Graduate 16 5 2 1 9 33

Illitrate 0 1 0 0 14 15

Total 31 16 7 1 40 95

47

4.2 Cases

Table (4.9). Distribution of medical recorded cases of breast cancer

according to their age

Age Frequency and Percent

Valid 20 – 29

30 - 39

2(1.58%)

28(22.22%)

40 - 49 38(30.15%)

50+ 58(46.03%)

Total 126(100.0%)

In this table (4.9) results show that in Cases the most recorded age group

was (50+) age group with 46.03%.

48

Table (4.10) Distribution of medical recorded cases of breast cancer

according to their marital status

Frequency and Percent

Valid Married 96(76.2%)

Single 14(11.1%)

Widowed 9(7.1%)

Divorced 7(5.6%)

Total 126(5.6%)

The table (4.10) shows that the most recorded patients were married

76.2% followed by single patients with 11.1%.

49

Table (4.11) Association of age with the type of breast cancer

Age * type of Breast Crosstabulation

Type of Breast Cancer

Total Age DCIS IDC LCIS ILC Others

Age 20-29 2 0 0 0 0 2

30-39 11 14 0 1 2 28

40-49 18 16 3 0 1 38

50+ 26 26 1 1 4 58

Total 57(45.2%) 56(44.4%) 4(3%) 2(1.58%) 7(5.55%) 126(100%)

In table (4.11) results show that age crosstabulated with type of breast

cancer without any significance, the most type of breast cancer in the

patients was ductal carcinoma in Situ DCIS of 57 patients(45.2%), followed

by Invasive ductal carcinoma IDC of 56 patients (44.4%), and lobular

carcinoma in situ LCIS, invasive lobular carcinoma ILC represent 6 patients

only (4.58%) an lastly other rare types of breast cancer which constitute

7(5.55%).

50

4.3 Case control section

Table (4.12) Association of Cases and Controls regarding breast

cancer risk factors

Parameter Cases(n=126)

Number %

Controls (n= 126)

Number % P-value

Age groups (years)

0.000

20-29 2(1.58%)

60 (47.6%)

30-39 28(22.22%) 24 (19.0%)

40-49 38(30.15%) 19 (15.1%)

50+ 58(46.03%) 20 (15.9%)

Missing system 0(0%) 3(2.4%)

Marital status

0.42

Single 14(11.1%) 36(28.6%)

Married 96(76.2%) 80(63.5%)

Widowed 9(7.1%) 6(4.8%)

51

Parameter Cases(n=126)

Number %

Controls (n= 126)

Number % P-value

Divorced 7(5.6%) 3(2.4%)

Missing system 0(0%) 1(0.7%)

Family history of breast cancer

0.12

No 105 (83.3%) 108 (85.7%)

Yes 21 (16.6%) 9 (7.1%)

Don’t know 0(0%) 9(7.1%)

Onset of Menarche

0.000

14 and below 35 (27.7%) 40 (31.7%)

15 and above 21 (16.6%) 73 (57.9%)

Do not remember 70 (55.6%) 13 (10.3)

Parity

0.62

Parous 81 (64.2%) 72 (57.1%)

52

Parameter Cases(n=126)

Number %

Controls (n= 126)

Number % P-value

Nulliparous 45 (35.7%) 54 (42.9%)

Age at First Birth

0.000

<20 13 (10.3%) 28 (22.2%)

20-29 33 (26.1%) 35 (27.7%)

30-39 9 (7.1%) 5 (4%)

Nulliparous 45 (35.7%) 51 (40.4%)

Don’t remember 26 (20.6%) 7 (5.5%)

Smoking

0.50

Yes 1 (0.8%) 3 (2.3%)

No 125 (99.2) 123 (97.7%)

Hypertension

0.14

Yes 18 (14.3%) 6 (4.7%)

53

Parameter Cases(n=126)

Number %

Controls (n= 126)

Number % P-value

No 108 (85.7%) 120 (95.2%)

54

4.4 Discussion

The study carried out determines the knowledge attitude and practices of

women about the early detection of breast cancer and also the risk factors

that enhance the development of the disease, the study was done in

Madani Teaching Hospital and National Cancer Institute for cancer

treatment during the study period of November 2011 to February 2012.

The study revealed that most control participants were married about 80

(63.5%) See table (4.2) and also in Cases the most recorded patients were

also married 96 (76.2%) as explained in table (4.9). The study showed

that the majority of control respondents were housewives 80 (63.5%),

followed by students of 25 (19.8%) as shown in table (4.3). It is obvious

that knowledge and awareness about the breast cancer can have an impact

directly upon behavior leading to modify breast cancer risk. It also plays

an important role in an improvement of health seeking behavior. (Soheil

mia, 2007).

The current study showed that majority of participants heard about breast

cancer 101(80.1%).The percentage of those heard about breast cancer

was more among graduates of about 39(30.9%) as shown in table (4.4).

There is a significance according to Chi-square test between the

Educational level and awareness of Breast cancer with (P-value = 0.000).

55

Here we can realize that the education plays a great role to the awareness

of health related issues.

The current study also revealed that most participants heard of breast self

examination 68 (59.6%) respondents heard of BSE.

Graduates were also among the highest group of awareness about BSE

36(31.5%) followed by secondary and primary of 10(8.8%) respondents

each. We can also see here a significance between the level of education

and hearing of BSE according to Chi-square test with (P-value= 0.000).

The study also showed that 40(42.2%) knew the BSE whereas 54(57.4%)

do not know the breast self examination. Also here the graduates were

among the highest group of knowledge about BSE and the chi-square test

showed significance (P-value 0.00). The practice of BSE was very low

among respondents about 11(8.7%) only practice it monthly regular BSE

while 19(15%) practice it sometimes whereas most respondents 86 (68.2)

don’t know how to practice BSE. So we can say that the practice of BSE

was poor among respondents due to lack of knowledge about the method

of practicing it.

Also in the study respondents were asked whether they know about the

early warning signs of breast cancer, 31 (32.6%) said they know that

painless lump is a warning sign of breast cancer, followed by swelling of

the breast as the second most known sign with 16 (16.8%) respondents

56

whereas 40 (42.6) said they do not know any sign. This shows that about

one third of the respondents do not know any sign of breast cancer

thereby making difficult to go for screening or doing clinical breast

examination.

The results also revealed that age crosstabulated with type of breast

cancer has no any significance p-value=0.6, the most type of breast

cancer in the patients studied was ductal carcinoma in Situ (DCIS) of 57

patients(45.2%), followed by Invasive ductal carcinoma (IDC) of 56

patients (44.4%) as shown in table (4.10). In a study conducted in central

Sudan on breast cancer stages, on 1255 women results showed that

infiltrating ductal carcinoma IDC constituted the majority of breast

cancer diagnosed about 82% of the patients whereas other types of breast

cancer, such as infiltrating lobular carcinoma, ductal carcinoma in situ

and infiltrating medullary carcinoma represented a small fraction of the

diagnosed breast cancer (Elgaili et al., 2010).

In the section of case control study regarding to breast cancer risk factors

126 records of breast cancer patients in NCI were ascertained as cases

whereas 126 others are ascertained as controls, the controls were patients

and co-patients attended to Madani teaching hospital but not with breast

cancer patients, many risk factors for breast cancer development have

been described and some of them including age, family history of breast

57

cancer and reproductive factors are well established ( Henderson IC,

1993).

The results of current study aimed to compare the risk factors that are

present in controls with those of patients recorded, results showed that

about half of the recorded cases were fifty years and above of age that is

58 (46.03%) of breast cancer patients, whereas in controls about half of

them 60 (47.6%) belong to the age group (20-29) as summarized in table

(13) with (P-value= 0.000), this showed a statistically significant

differences between the two groups, being the advanced age as a risk

factor for the development of the breast cancer. Also the age of Onset of

menarche was different among cases and controls and showed

statistically significant difference only 21 (16.6%) of cases their onset of

menarche was between the ages 15-17 years of age and 35 (27.7%) their

ages of menarche were between 11-14 years, but the remaining patients

were uncertain of their age at onset of menarche, on the other hand about

two third of controls' age of onset of menarche was 15-17 years. The age

of first birth also showed significant difference among cases and controls,

only 13 (10.3%) had their first babies before the age of twenty in patients

of breast cancer whereas about double of that percentage 28(22.2%) of

controls had their first child before the age of twenty. So according to this

study giving birth at an early age gives some kind of prevention against

58

the breast cancer. There was no significant difference among cases and

controls with regard to marital status, parity, smoking and hypertension

and hence have no any influence on the risk. A university hospital based

study conducted in turkey in 2009 about the breast cancer risk factors

among Turkish women for the study period from 200-2006. It was found

that increasing age >50 was a risk among the patients, also age at first

birth >34 and positive family history were among the risks found (Vahit

O. et al., 2009).

59

CHAPTER FIVE

CONCLUSION AND RECOMMENDATION

5.1 CONCLUSION

The results of the study indicated that most participants have heard

of breast cancer but with different knowledge among them, also

they have heard about breast self examination but only small

portion knew the method of breast self-examination and few of

them practiced monthly.

The study also revealed that one third of the respondents knew at

least one warning sign of breast cancer while one third of them

don't know any sign about the early warning signs of breast cancer.

The study also showed that educated people had access to

knowledge about breast cancer and breast self examination, while

those non educated had poor knowledge about the disease and its

signs.

In the section of case control study of risk factors comparison

between cases and controls, the study showed that advancing age

was the main risk factor among breast cancer patients, other risk

factors studied were age at first birth, age of onset of menarche all

showed significance different while the rest such as marital status,

60

family history, parity, smoking and hypertension all showed no

significance and hence have no influence on the risk of developing

breast cancer.

The most type of breast cancer suffered the patients recorded was

infiltrating ductal carcinoma and ductal carcinoma in situ. Other

types were rare.

61

5.2 RECOMMENDATION

Promote early detection measures through breast cancer education

and awareness to let the women seek medical help earlier.

Educate women about the importance of screening practices

especially breast self-examination and to practice it regularly every

month.

Improvement of medical records regarding breast cancer patients in

the National Cancer Institute for cancer treatment.

62

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APPENDIX

Knowledge, Attitudes and Practices among women towards early

detection of breast cancer

Questionnaire

I am a postgraduate student in the University of Gezira preparing my

master degree thesis in KAP study of women towards the early detection

of breast cancer. Breast Cancer is a Global public health problem. To

ensure primary prevention and treatment population based screening

program as well as breast awareness is necessary. To assess the

knowledge attitude and practice regarding breast cancer some information

is required from you. Your response will contribute a big effort to

conduct this study. Your participation would be kept confidential. Do you

agree to share this scientific research ____

Section One: Socio-demographic data

1. Age:

□ 20-29 □ 30-39 □ 40-49 □ 50+

2. Marital status:

□ Single □ Married □Widowed □Divorced

If Married:

70

a. At what Age you married? ____

b. Do you have children? □Yes □ No

If Yes,

3. How many children do you have?

□ One Child □ 2-5 Children □ 6-10 Children □ More than 10

4. What was your age at first child birth? _____

5. Occupation

□ Housewife □ Employed □ Student □ Retired

6. Education:

□ Illitrate □ Khalwa □ Primary school

□ Secondary School □ Graduate □ Postgraduate

7. Family size _____________

8. Family history of breast cancer? □ Yes □ No

If yes, mention relative degree :

□ Mother □ Grandmother □ Aunt □ Sister □ Other____

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9. Which of the following do you have?

Smoking □ Yes □ No

Not breastfeeding □ Yes □ No

Early onset of menarche □ Yes □ No

Nulliparity □ Yes □ No

Hypertension □ Yes □ No

Section Two: Knowledge about breast cancer

10. Did you hear about breast cancer? □ Yes □ No

If yes,

a. What is breast cancer?

□ A fatal disease □ A disease that can be prevented

□ A disease that cannot be prevented □ A common disease in women

b. Where is the source of information?

□ Radio □ Magazines □ TV □ Friends □ Posters

□ Other, __________

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11. What are the factors that cause breast cancer?

□ Hereditary □ Smoking □ Obesity

□ Nulliparity □ Not breastfeeding □ Age above 40

□ Magic and evil spirits □ Other______

Section Three: attitudes and practice about breast cancer

12. Did you hear of breast self examination? □ Yes □ No

If yes,

13. Do you know the method of breast self examination? □ Yes □ No

If yes, frequency of application

□ Once in a month □ Occasionally

□ Never □ Other

14. Do you believe Breast cancer is common in women with big

breasts?

□ Yes □ No □ I don’t know

15. Do you believe Lumps in the breast that are cancer are pain

full?

□ Yes □ No □ I don’t know

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16. Did you hear clinical breast examination? □ Yes □ No

If yes frequency of application?

□ Once in a month □ Occasionally □ Never

17. Did you hear mammography? □ Yes □ No

If yes, at what age mammography is done?

□ 20 years above □ Before 40 years

□ 40 years and above □ I don’t know

18. What are the early warning signs of breast cancer?

□ Painless lump

□ Swelling

□ Skin changes

□ Discharge from nipple

□ Nipple retraction

□ I don’t know

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19. Have you ever been educated about breast cancer? □ Yes □ No

If yes, what is the source of education?

□ Doctor

□ Healthcare provider

□ Peers

□ Radio programme

□ TV programme

□ Internet

□ Other ____

Thank you for your cooperation