Knowledge, Screening, and Practices Surrounding Iraqi Female Breast Cancer: An Observational Cross-Sectional Survey Study View PDF

Globally, breast cancer (BC) is the most common form of cancer, and the second highest cause of death in women, despite developments in early diagnosis and screening programs [1]. According to GLOBCAN 2018, there were 2,088,849 (11.6% of all other cancer types) new cases of BC, with 626,679 (6.6%) deaths [1]. In Iraq, in 2011, the incidence of BC was 18.96%, with a morbidity rate of 11.53% [2], but these figures increased to 25.65% and 21.9%, respectively, in 2014, and 33.5% and 22.3%, respectively, in 2015, according to the World Health Organization and ICR [3,4]. The most powerful preventive measure for BC is screening, with three methods considered useful for early detection, which are breast self-examination (BSE), clinical breast examination (CBE), and breast mammography [5-7]. Screening can yield a 20-35% decline in BC mortality between the ages of 50 and 70 years [7]. A CBE every 1 to 3 years and periodic self-examination, generally beginning in young adulthood, is recommended by the National Comprehensive Cancer Network [6]. In the United States, it is recommended that annual CBE and screening mammography are offered to women aged between 40 and 50 years [8]. In developed countries, where screening programs have become the standard for care, BC mortality has recently begun to decrease [9].

In Iraq, the sequence of wars (1980-1988, 1990-1991, 2003-2006 and 2014-2016), low socioeconomic status, and low levels of education have led to poor knowledge and incorrect beliefs about BC prevention, and is the reason why this study was conducted. The aim of the study was to increase awareness of BC and the practice of BSE among Iraqi women, since there are strong negative perceptions around the treatability of a tumor detected in the early stages and of the efficacy of screening programs.

Study design

A cross-sectional survey study was conducted among Iraqi women to assess their knowledge relating to BC, BC screening and screening practices.

Settings

The study was conducted at the Clinical Pharmacy Department, College of Pharmacy, Baghdad University, Baghdad, Iraq, from 1^st January 2019 to 30^th August 2019. The recruitment period began on the first day of the study until the date the study ended. All participants were asked all the questions. Data collection was performed at the end of each month.

Participants

A total of 807 Iraqi women, aged from 18 to 74 years, were included, comprising only women who lived in Iraq. We excluded women aged less than 18 years and women who lived outside of Iraq. Participants were sought using targeted messages on various social media platforms.

Data collection

A questionnaire was constructed based on the aims of the study and included questions related to personal, demographic, socioeconomic, and educational data. The questionnaire also investigated participants’ knowledge of risk factors regarding BC, BSE, and CBE.

Variables

Participants’ knowledge about BC was assessed by six questionnaire items. BC risk factors were assessed by eight questionnaire items. Knowledge of BSE practice and CBE were assessed by asking nine questions about BSE and one question about CBE. Knowledge of BC symptoms was assessed by one question. The study questions are available in Box 1.

Ethical considerations

The Medical Ethical Committee of the Clinical Pharmacy Department, College of Pharmacy approved this study (code: 77855).

Data analysis

Microsoft Excel (v. 2010) and SPSS (v. 20) were used to analyze the data. Descriptive statistics with cross-tabulations were obtained. The chi-squared test (x²) was used to examine any associations between variables. The level of significance was set at p≤0.05 using a two-sided test. The likelihood ratio of goodness of fit for a multinomial logistic regression model was used to determine the most important factors considered as predictors of having knowledge about BC, its risk factors, and BSE and CBE practice for BC.

The participants in this study comprised 807 women who were residents in one of 18 major cities in Iraq. All women confirmed as eligible by meeting the study criteria were included, all of whom completed the survey study with a response rate to questionnaire items of 100%, and all questionnaire results were subjected to the data analysis process. The mean age of participants was 25.8±16.5 years (range: 18-74 years). Most women (597; 74.1%) belonged to the 21-30-years age group. Mostof the participants (590; 73.1%) were educated to undergraduate level. The largest proportion of participants lived in Baghdad city (517; 64.1%), with a medium socioeconomic status (562; 69.6%). Just over half of participants (410; 50.8%) were single, while 379 (47%) were married (Table 1).

Table 1: Demographic characteristics (n=807).

Regarding to the knowledge of BC, the proportion of women who answered “Yes” to Q1 was 453 (56.1%), to Q2 was 312 (38.7%), to Q3 was 14 (1.7%), to Q4 was 617 (76.5%), to Q5 was 737 (91.3%), and to Q6 was 548 (67.9%) (Table 2).

Table 2: Knowledge of breast cancer in a sample population of Iraqi women (n=807).

Data relating to knowledge of the risk factors for BC are shown in the table (Table 3). The proportion of women who answered “Yes” to Q1 was 251 (31.1%), to Q2 was 579 (71.7%), to Q3 was 584 (72.4%), to Q4 was 372 (46.1%), to Q5 was 454 (56.3%), to Q6 was 139 (17.2%), to Q7 was 522 (64.7%), and to Q8 was 531 (65.8%).

Table 3: Knowledge of breast cancer risks in a sample population of Iraqi women (n=807).

Data concerning BSE practice are presented in the table (Table 4). A total of 741 (91.8%) women had heard about BSE. The number of participants who thought that BSE is a way to enable early detection of BCwas 465 (57.6%), whereas 12 (1.5%) participants said it was not. Most participants (715; 88.6%) believed that the ideal age for BSE was <40 years. Most participants (439; 54.4%) also thought that the breasts and axilla should be examined during BSE. Approximately half (403; 49.9%) of the participants said that BSE must be repeated monthly. The ideal time to perform BSE was unknown by 322 (39.9%) women, whereas 313 (38.8%) women said that the perfect time for BSE is following menses. About to the optimal position for BSE, 222 (27.5%) of participants did not know this, whereas 381 (47.2%) women believed it was preferable to perform BSE in a standing position. Just over half of the women (425; 52.7%) answered that the fingers are used to perform a BSE. Most participants (585; 72.5%) thought that a woman should lift her arm up during a BSE.

Table 4: Knowledge of breast self-examination in a sample population of Iraqi women (n=807).

The table shows that 388 (48.2%) participants thought that a woman should have her breasts checked by a clinician if she is >50 years of age, if symptoms are present, or if a member of her family has been affected (Table 5). Just less than one-third (257; 31.8%) of women answered that a woman who meets any two of the three conditions mentioned previously must go for a check-up. Only three women believed that there was no need to go to be checked. The knowledge about BC symptoms is shown in the table (Table 6). All answers to the question were valid choices and mostof the women 698 (86%) participants choose multiple answers for this question.

Table 5: Knowledge of clinical breast examination in a sample population of Iraqi women (n=807).

Table 6: Knowledge of breast cancer symptoms in a sample population of Iraqi women (n=807).

The multinomial logistic regression model of the participants’ knowledge included 23 covariates. In total, 13 covariates showed a significant statistical association after modeling the likelihood ratio of goodness of fit, with knowledge, risk factors, and the practice of BSE found to be most powerful among participants who had known about those questions: Q2A for education x²=14.06; p=0.007 and marital status (x²=21.34; p=0.000); Q3A for age x²=45.56, p=0.000; Q6A for education x²=13.13; p=0.011 and city of residence x²=33.98; p=0.018; Q1B for economic status x²=6.06; p=0.048); Q4B for level of education x²=11.45; p=0.022; Q5B for age x²=55.22; p=0.044; Q7B for age x²=55.84; p=0.039; Q8B for city of residence x²=43.04; p=0.001; Q5C for age x²=82.58; p=0.000; Q6C for socioeconomic status x²=16.53; p=0.035; Q8C for city of residence x²=44.88; p=0.000 (Table 7).

Table 7: Likelihood ratio of goodness of fit for multinomial logistic regression model of knowledge about breast cancer and demographic variables of the population of Iraqi women (n=807).

In Iraq, BC is the most common type of cancer and is the predominant form of cancer in women [4]. It usually presents at an advanced stage and is more frequent in young women in comparison with developed and neighboring countries [10-19]. We noticed that, among women in Iraq, there was a relatively low level of knowledge relating to breast cancer. To the best of our knowledge, no studies have investigated this topic in our country. Our study found that there was unsatisfactory and insufficient knowledge among women about BC risk factors and screening programs. Data from the American National Cancer Opinion Survey revealed low levels of knowledge among the poorest and least educated women around risks related to cancer [2], similar to the findings of our study.

The aim of screening for BC is to reduce mortality from this disease by detecting and treating it at an earlier stage. In the UK and the USA, the current target screening group is women aged 50 to 70 years. Women <50 years of age are not invited for screening because the incidence of cancer is lower in this age group [6, 8]. Two studies, one in the UK and one in Canada, have evaluated the effectiveness of screening by BSE alone [20]. By using BC registry data, Constanza and Foster found fewer deaths from BC (14% vs.26%) and improved estimated 5-year survival rates (75% vs. 59%) among women who reported performing BSE compared with those who did not [21,22]. In the BC Detection Demonstration Project, the estimated overall sensitivity of BSE in detecting BC was 26%, compared with 75% for CBE and mammography combined [20,23]. CBE and BSE are complementary to mammography, but while it is evident that clinical screening is not as sensitive as mammography, a combination of CBE and mammography can give optimal results in early detection [20,23,24].

Poor socioeconomic status, lower level of education, and incorrect beliefs about BC prevention are responsible for the negative perceptions among some women of the successful treatment of cancer that is detected early and of the efficacy of screening tests [20].

VainioH and BianchiniF (2002) noted that BSE is appealing as it is a patient-centered, noninvasive screening procedure that allows women to become comfortable with their own bodies [25]. The regular performance of this procedure does not self-detection, but it does increase awareness [20]. It is the best way for repeated screening for BC for all women, but it is not the best method for early detection; the best approach is a combination of BSE with CBE and mammography, which have a sensitivity and specificity reaching more than 90%.

In our study, many factors were significantly linked to a better level of BC knowledge, including higher or postgraduate education, increased age, living in a major city, and good socioeconomic status, as determined by a multinomial logistic progression model. Other factors that may play an important role in the development of better BC knowledge levels include the media and health care workers. However, the role of health care workers is very poor in Iraq compared with their role in western countries. These differences and variations could be attributed to poor health education activities of local organizations and the incorrect application of screening programs.

Powe BD (2003) suggested that a fatalistic attitude of participants towards BC curability and attribution of its risk to God or the “evil eye” could be a factor leading to low levels of knowledge and low uptake of screening behaviors. This has led many studies to consider fatalism as a barrier to acquiring knowledge about cancer and participation in cancer detection and treatment programs [26].

Any woman who begins to practice BSE significantly increases her knowledge of BC, its risk factors, and its symptoms. Therefore, these women need accurate information about the risks of BC and the benefits of screening, which should be provided by the Ministry of Health, national health societies, and local organizations.

There are some limitations to our study. These include the fact it was an internet survey study, which may be significantly influenced by participants’ knowledge; women were only recruited from major cities; and there may also be bias about participants answering multiple questionnaires, therefore replicating their data.

There was found to be a low level of knowledge about BC among Iraqi females. A higher level of education, higher income, and increased age were predictive factors for better knowledge of BC. The best-known screening method for BC is BSE; however, most of the women surveyed did not practice BSE. Knowing a friend or relative with BC led to better knowledge of the disease. Accordingly, massive educational programs are necessary to improve the knowledge among women regarding BC, its risk factors, and its symptoms. Screening programs are required to increase awareness around this disease, because early detection enhances BC management, which in turn leads to improved prognoses and better survival rates.

1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, et al. (2018) Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 68:394-424.
2. Iraqi Cancer Registry (2011) Ministry of Health, Iraqi Cancer Board, Baghdad, Iraq.
3. World Health Organization (2014) World Cancer Report 2014, United States.
4. Iraqi Cancer Registry (2015) Annual Report. Iraqi Cancer Registry Board, Ministry of Health and Environment. Baghdad, Iraq.
5. MacMahon B (2006) Epidemiology and the causes of breast cancer. Int J Cancer 118:2373-2378.
6. National Comprehensive Cancer Network (2019) Clinical practice guidelines in Oncology. Breast Cancer updated Version 2, United States.
7. Sherma CD, Hossfeld DK (2010) Breast Cancer. In: Manual of Clinical Oncology. (5^thedtn), Springer, United States.
8. American College of Radiology (2003) ACR BI-RADS Atlas^®-5th Edition. ACR Breast Imaging Reporting and Data System, Breast Imaging Atlas, United States.
9. Reynolds T (1999) Declining breast cancer mortality: What’s behind it? JNatl Cancer Inst 91: 750-753.
10. Almohammadawi KOM, Alhilfi HSQ, Alshewered ASH (2018) Epidemiological data of 1418 Cancer Cases of Inpatient in Al-Sadder Teaching Hospital, Misan Province from 2011-2018 (Surveillance Study). Med Sci 22: 455-461.
11. Al-Naqqash MA, Al-Bdaer EK, Saleh WA, Al-Shewered AS (2019) Progression free survival in Iraqi breast cancer patients treated with adjuvant 3D conformal radiotherapy: A cross-sectional study. F1000Res 8:71.
12. Murthy RK, Valero V, Buchholz TA (2016) Breast cancer, overview. In: Clinical Radiation Oncology. (4^thedtn), Elsevier Inc., Netherlands.
13. Pegram MD, Takita C, Casciato DA (2012) Breast cancer. In: Manual of Clinical Oncology. (7^thedtn), Lippincott Williams & Wilkins, United States.
14. Goyal S, Buchholz TA, Haffty BG (2015) Breast Cancer: Early Stage. In: Perez and Brady’s principles and practice of radiation oncology. (6^thedtn), Lippincott Williams & Wilkins, United States.
15. Fawzi HA, Al-Naqqash MA, Radhi SM, Kareem TF (2019) Young age Iraqi Women with Breast Cancer: an overview of the correlation among their clinical and pathological profile. MedSci23: 6-11.
16. Al-Alwan NAS, Tawfeeq FN, Mallah NAG (2019) Demographic and clinical profiles of female patients diagnosed with breast cancer in Iraq. J Contemp Med Sci 5:14-19.
17. Al-Rawaq MK, Naqqash (2016) Molecular classification of Iraqi breast cancer patients and its correlation with patients’ profile. J Fac Med Baghdad 58.
18. Al-Alwan NAS, Kerr D, Al-Okati D, Pezella F, Tawfeeq FN (2018) Comparative study on the clinicopathological profiles of breast cancer among Iraqi and British patients. The Open Public Health Journal 11: 177-191.
19. Kasib DM, Al-Naqqash MA, Alshewered ASH. Breast cancer among Iraqi female in their fifth decade: A retrospective study. TMR cancer 62: 407-413.
20. Buchholz TA, Wazer DE, Haffty BG (2015) Breast Cancer: Early Stage. In:Perez and Brady’s principles and practice of radiation oncology. (6^thedtn), Lippincott Williams & Wilkins, United States.
21. Costanza MC, Foster RS Jr. (1984) Relationship between breast self-examination and death from breast cancer by age groups. Cancer Detect Prev 7:103-108.
22. Foster RS Jr, Costanza MC (1984) Breast self-examination practices and breast cancer survival. Cancer 53:999-1005.
23. Seidman H, Gelb SK, Silverberg E, LaVerda N, Lubera JA (1987) Survival experience in the Breast Cancer detection demonstration project. CA Cancer J Clin 37:258-290.
24. Berg WA, Blume JD, Cormack JB, Mendelson EB, Lehrer D, et al. (2008) Combined screening with ultrasound and mammography vs mammography alone in women at elevated risk of breast cancer. JAMA 299:2151-2163.
25. Vainio H, Bianchini F (2002) Breast Cancer Screening. In International Agency for Research on Cancer (IARC) Handbooks of Cancer Prevention. (Volume 7), IARC Press, France.
26. Powe BD, Finnie R (2003) Cancer fatalism: the state of the science. Cancer Nurs 26: 454-467.