International Journal of Health & Allied Sciences

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 10  |  Issue : 4  |  Page : 268--274

Breast cancer awareness and the prevalence of breast cancer risk factors and warning signs among women in Aleppo, Syria: A cross-sectional study


Ahmad Alhamid1, Aya Zazo2, Rima Salem2, Dina Alfarra2, Zain Douba2, Haya Jawish2, Zainab Zeino2, Fatima Muzayek2, Rama Zazo2, Rayan Hamada2, Hala Alayyoubi2, Aya Haji Mohamad2, Rand Massri2, Joud Shiekhoni2, Dania Khudro2, Ayla Baghdadi2, Tasnim Altenji2, Rama Aldakhil2, Ziad Aljarad3, Anwar Chammout4,  
1 Department of Pathology, Aleppo University Hospital, Aleppo, Syria
2 Medical Intern, Faculty of Medicine, University of Aleppo, Aleppo, Syria
3 Department of Gastroenterology, Aleppo University Hospital, Aleppo, Syria
4 Department of Oncology, Aleppo University Hospital, Aleppo, Syria

Correspondence Address:
Dr. Anwar Chammout
Zain Douba, Aleppo; Ahmad Alhamid, Aleppo
Syria

Abstract

BACKGROUND: Breast cancer (BC) is classified as the most prevalent cancer worldwide. The incidence and prevalence of BC in Syria are not determined but expected to be high. Lack of awareness toward BC leads to higher incidence and mortality. There are no studies measuring BC awareness in Syria. Our study aims to evaluate BC awareness and attitudes, the obstacles preventing women from receiving BC-related medical care, and the prevalence of BC warning signs and risk factors among women in Aleppo. METHODS: A cross-sectional, survey-based study was conducted during August 2019 in Aleppo, Syria. Participants were randomly recruited from multiple health-care and social facilities. We targeted adult females aged and avoided current or previous cancer patients and the visitor of oncology and pathology departments. The questionnaire had six main sections: (1) demographic characteristics; (2) knowledge of basic symptomatology and epidemiology of BC; (3) similar previous symptoms that the participant ever experienced; (4) attitude and behavior related to BC screening; (5) obstacles from seeking medical consultation related to BC, and (6) the prevalence of some BC risk factors among participants. RESULTS: BC awareness levels are disappointing. About 9.3% of the participants are confident that they have not ever heard of BC, and only 0.4% know the age-related risk of BC. About 8.7% of the respondents never or rarely self-examine their breasts, and only 10% of the 40 years or older participants screened for BC by the mammogram. Emotional barriers, especially feeling scared about what the doctor might find, were the main barriers preventing women from seeking medical help related to BC. Lack of enough physical activity and smoking headed the list of the prevalent risk factors. CONCLUSIONS: BC awareness levels in Aleppo-Syria are worrying. It is recommended to launch more awareness campaigns, with a concentration on the weak points in women's knowledge.



How to cite this article:
Alhamid A, Zazo A, Salem R, Alfarra D, Douba Z, Jawish H, Zeino Z, Muzayek F, Zazo R, Hamada R, Alayyoubi H, Mohamad AH, Massri R, Shiekhoni J, Khudro D, Baghdadi A, Altenji T, Aldakhil R, Aljarad Z, Chammout A. Breast cancer awareness and the prevalence of breast cancer risk factors and warning signs among women in Aleppo, Syria: A cross-sectional study.Int J Health Allied Sci 2021;10:268-274


How to cite this URL:
Alhamid A, Zazo A, Salem R, Alfarra D, Douba Z, Jawish H, Zeino Z, Muzayek F, Zazo R, Hamada R, Alayyoubi H, Mohamad AH, Massri R, Shiekhoni J, Khudro D, Baghdadi A, Altenji T, Aldakhil R, Aljarad Z, Chammout A. Breast cancer awareness and the prevalence of breast cancer risk factors and warning signs among women in Aleppo, Syria: A cross-sectional study. Int J Health Allied Sci [serial online] 2021 [cited 2021 Dec 1 ];10:268-274
Available from: https://www.ijhas.in/text.asp?2021/10/4/268/330549


Full Text



 Introduction



According to GLOBOCAN database, breast cancer (BC) is classified as the most prevalent cancer worldwide, accounting for 11.6% of new cases in 2018, both sexes, all ages. It is also the most common cause of cancer-related mortality among women worldwide, with a cumulative risk of 1.41/unit of population in 2018.[1]

The incidence of this disease is increasing in both developed and developing countries.[2] No recent data are available in Syria, but depending on the statistics of the neighboring countries, the GLOBOCAN 2018 report estimated that BC had the highest rate of cancer incidence among females from all ages in 2018 (38.5%). BC was also considered the second most common cause of cancer-related mortality in Syria, with a cumulative risk of 2.82.[1]

As far as we are concerned, one of the important causes behind these worrying statistics is the lack of awareness of BC signs, risk factors, and absence regular breast examination. In addition, hardness of having an appropriate BC-related health care plays an important role in increasing mortality rates. All of these will lead to increasing incidence of BC and late-stage diagnosis of this disease.[3]

There are three parameters to detect BC earlier: Clinical breast examination, X-ray mammography, and breast self-examination (BSE).[4] The American Cancer Society recommends that BSE is a significant screening test for economic and cultural poor areas where approach to mammography machine is limited or unavailable, like in Syria.[5]

In Aleppo province in Northern Syria, free BC screening programs are available, and awareness campaigns are regularly launched but are not covering all regions in Aleppo, especially rural ones. There are no studies measuring the BC awareness, the accessibility to BC health-care facilities, and the prevalence of BC signs and risk factors among Syrian women.

Our study aims to evaluate BC awareness among adult females in Aleppo, regarding the BC signs and symptoms, the prevalence and age-related incidence, information, and attitude about different BC screening methods, the obstacles preventing women from receiving the convenient BC-related medical care, and the prevalence of BC warning signs and risk factors among women in Aleppo. This study will help directing future public health policies in terms of spreading awareness about BC and clearing the obstacles from the way of BC screening and care. To our knowledge, this is the first study of its kind organized in Aleppo and Syria in general.

 Methods



This study is a cross-sectional, survey-based study, conducted from August 1 to 31, 2019. It evaluated the BC awareness and attitudes, the trammels preventing women from seeking BC-related health care, and the prevalence of BC warning signs and risk factors among adult females in Aleppo province.

The questionnaire was self-designed with the help of BC Awareness Measure questionnaire[6] and available literature. The questionnaire had six main sections: (1) demographic characteristics of the participants; (2) knowledge of basic symptomatology and epidemiology of BC; (3) similar previous symptoms that the participant ever experienced; (4) attitude and behavior related to BC screening; (5) obstacles from seeking medical consultation and care related to BC, and (6) prevalence of some BC risk factors among participants.

We collected data from Aleppo University Hospital; the central governmental hospital of the province, Aleppo University Hospital of Obstetrics and Gynaecology, Syrian Specialized Private Hospital, Aleppo Private Hospital, and Al-Hamdaniyah Primary Health-care governmental centre. We also collected data from mosques, churches, and hairdresser shops.

We randomly assigned women aged 18 years or older, admitting to the previously mentioned centers. Participants may be patients or visitors. We excluded women coming to oncology or pathology departments, women with current or past cancer and health-care providers.

Patients were invited to an interview-based questionnaire, but they were allowed to complete the questionnaire alone if they preferred but with the facilitation of data collectors. Participants received a detailed explanation of the nature and aims of the survey. An informed verbal consent was obtained from every single participant before the questionnaire was delivered.

A pilot study was conducted on 100 participants, and depending on the results and the data collector's notes, we modified some questions to be understood by all socioeconomic groups. We also added the choice of I do not know and not sure to the relevant questions.

Sample size had been calculated using sample size equation according to Kish (1965), which is widely used in medical research.

N = z2 (P [1 − P]/d2)

Where; n = sample size, z = z statistic for the level of confidence, P = expected prevalence, and d = allowable error. We calculated it putting in consideration confidence interval 95%, z = 1.96, d = 5%.

The questionnaire was administered by 5–6--year-old female medical students, and they were all trained before the beginning of the study on participants' recruitment, questionnaires distribution, and completion facilitation.

Ethical approval was obtained from the research committee at University of Aleppo.

We conducted the statistical analysis using SPSS (Version 22.0; SPSS Inc.: Chicago, IL, USA). Categorical variables were presented as frequencies and percentages, while continuous data were summarized as mean ± standard deviation.

 Results



We invited 1700 participants, of whom 1474 (86.71%) participants completed the questionnaire. Because of the lack of surveys and questionnaires culture in the Syrian society, the sensitive security situation and the cultural and traditional thoughts about BC and gynecological questions, a considerable number of participants did not answer all the questions, leading to having missing data as shown in the following tables.

The mean age was 39.39 ± 12.71 years, ranging from 18–85 years. Demographic and socioeconomic characteristics of the study sample are presented in [Table 1].{Table 1}

Out of the 1474 participants, 137 (9.3%) do not know what is BC or even heard about it, and 29 (2%) are not sure if they do. Only 734 (54.9%) participants out of the 1337 that know or may know BC can mention at least one warning sign of BC. Only five participants (0.4%) answered the question of age-related BC risk correctly. Two hundred and ninety participants (21.7%) answered the question of lifetime risk correctly. Nine hundred and fifty-four (66.1%) of the women surveyed believed that BC can be diagnosed early. Social media were the most common source of information about BC among the 811 participants who answered the related question (n = 399; 49.2%). A breast lump or thickening was the most commonly recognized symptom (n = 608; 75.0%), whereas nipple rash was the least recognized (n = 132; 16.3%).

[Table 2] demonstrates the participant's answers to BC awareness questions. Regarding the question of circling the signs of BC, we invited only the 811 women who can or may be able to mention at least one warning sign.{Table 2}

In terms of the behavior and attitude of the participants toward breast examination and BC screening, we found that 120 participants (8.7%) never or rarely self-examine their breasts. Only 69 (10%) of the 40 years or older participants have done breast mammogram just for screening. Notably, 641 participants (44%) prefer a female doctor to examine their breasts. [Table 3] shows the distribution of the participants' behavior and attitude toward breast examination and BC screening.{Table 3}

One hundred and eighty-seven of 1441 women (13%) were confident that they have never noticed a change in their breast. [Table 4] presents the prevalence of the BC warning signs ever noticed by the participants.{Table 4}

In general, most of the barriers to seeking medical advice are emotional, feeling worried about what the doctor might find was the most common (n = 659; 45.1%). [Table 5] shows the emotional and practical barriers to BC-related medical consultation.{Table 5}

The prevalence of BC risk factors among the participating women is presented in [Table 1]. The prevalence of obesity was not investigated. The absence of enough physical activity was the most common risk factor (n = 826; 56.8%).

 Discussion



Overall, the awareness level of BC in this study is disappointing. About 9.3% of the participants are confident that they have not ever heard of BC, and only 0.4% know the age-related risk of BC. About 8.7% of the respondents never or rarely self-examine their breasts, and only 10% of the 40 years or older participants screened for BC by mammogram. Emotional barriers, especially feeling scared about what the doctor might find, were the main barriers preventing women from seeking medical help related to BC. Lack of enough physical activity and smoking headed the list of the prevalent risk factors.

To our knowledge, this is the first study in Syria about BC awareness and the prevalence of BC warning signs and risk factors. Taking into account the difficult economic, security, and health situation and the high prevalence and mortality of BC in Syria, well-planned prevention policies and effective programs for early detection are only way to decrease BC incidence and mortality rates.

Other studies showed better knowledge of age-related and lifetime BC risk.[7],[8] Elshami et al.,[9] in a study from Gaza strip in Palestine, reported that 2.2%–42.6% answered correctly to the age-related and lifetime BC risk questions, respectively, while the percentages in our study were 0.4%–21.7%.

Grunfeld et al.[8] showed that 38% of people realized that nipple retraction was a sign of BC, compared with 17.1% in our study and 43.1% in Elshami et al. study. In line with similar studies conducted in the middle east,[9],[10] breast lump or thickening was reported as the most recognized sign of BC, reflecting the common thought that BC presents as a lump.

In concordance with the current study, 47% of the participants in Forbes et al. study in East London reported that they were worried about what the doctor may find, making it the most frequent barrier.[7] This may be a result of the poor outcomes of BC treatment in Syria because of the late-stage presentation. However, Elshami et al. study reported embarrassment as the most common barrier,[9] while it was the second in our study.

Surprisingly, the participants in our study practiced BSE more than the women in East London, Gaza, Jordan, and Kuwait.[7],[9],[10],[11] However, only 15.5% of participants 40 years or older were received breast X-ray, while 26.5% of the participants from all age groups included in Liu et al. study did.[12]

The poor knowledge and low awareness of BC in Syria may be a result of the poor public health education.

The main strengths of this study are the large sample size, and the coverage of different demographic groups. However, we still have major limitations. We have a significant amount of missing data as previously mentioned. In addition, we did not include obesity in the risk factors investigated, because we were not able to measure the weight and height of the participants.

 Conclusion



The BC awareness levels in Aleppo-Syria are worrying. It is recommended to launch more awareness campaigns, with concentration on the weakness points in the women's knowledge, and on the most prevalent risk factors and signs, as described in this study. Moreover, it is important to plan better screening policies to clear the emotional and practical barriers from seeking medical advice and to make screening methods more accessible. Further studies are needed to study the effectiveness of different educational and public health interventions to decrease BC mortality in Syria.

Acknowledgment

We have not received substantial contributions from nonauthors.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1GLOBOCAN 2018. Lyon: International Agency for Research on Cancer/World Health Organization; 2018. Available from: https://gco.iarc.fr/databases.php.
2Kurian AW, Clarke CA, Carlson RW. The decline in breast cancer incidence: Real or imaginary? Curr Oncol Rep 2009;11:21-8.
3Modeste NN, Caleb-Drayton VL, Montgomery S. Barriers to early detection of breast cancer among women in a Caribbean population. Rev Panam Salud Publica 1999;5:152-6.
4Dikshit R, Gupta PC, Ramasundarahettige C, Gajalakshmi V, Aleksandrowicz L, Badwe R, et al. Cancer mortality in India: A nationally representative survey. Lancet 2012;379:1807-16.
5Bullock K, McGraw SA. A community capacity-enhancement approach to breast and cervical cancer screening among older women of color. Health Soc Work 2006;31:16-25.
6Linsell L, Forbes LJ, Burgess C, Kapari M, Thurnham A, Ramirez AJ. Validation of a measurement tool to assess awareness of breast cancer. Eur J Cancer 2010;46:1374-81.
7Forbes LJ, Atkins L, Thurnham A, Layburn J, Haste F, Ramirez AJ. Breast cancer awareness and barriers to symptomatic presentation among women from different ethnic groups in East London. Br J Cancer 2011;105:1474-9.
8Grunfeld EA, Ramirez AJ, Hunter MS, Richards MA. Women's knowledge and beliefs regarding breast cancer. Br J Cancer 2002;86:1373-8.
9Elshami M, Abu Kmeil H, Abu-Jazar M, Mahfouz I, Ashour D, Aljamal A, et al. Breast cancer awareness and barriers to early presentation in the gaza-strip: A cross-sectional study. J Glob Oncol 2018;4:1-13.
10Alsaraireh A, Darawad MW. Breast cancer awareness, attitude and practices among female university students: A descriptive study from Jordan. Health Care Women Int 2018;39:571-83.
11Alharbi NA, Alshammari MS, Almutairi BM, Makboul G, El-Shazly MK. Knowledge, awareness, and practices concerning breast cancer among Kuwaiti female school teachers. Alex J Med 2012;48:75-82.
12Liu LY, Wang F, Yu LX, Ma ZB, Zhang Q, Gao DZ, et al. Breast cancer awareness among women in Eastern China: A cross-sectional study. BMC Public Health 2014;14:1004.