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Awareness of breast cancer and breast self-examination among nursing students

Breast cancer is a malignant tumour that predominantly affects women but can also affect men. The cancer originates from the cells of the breast tissue and can invade locally or metastasise to other body parts. It is the second leading cause of cancer worldwide among women and cases are on the rise in India. According to a study among Indian women, breast cancer incidence when standardised to age is 22.9 and mortality is 11.19.


INTRODUCTION
Breast cancer is a malignant tumour that predominantly affects women but can also affect men. The cancer originates from the cells of the breast tissue and can invade locally or metastasise to other body parts. 1 It is the second leading cause of cancer worldwide among women and cases are on the rise in India. According to a study among Indian women, breast cancer incidence when standardised to age is 22.9 and mortality is 11.19. 2 The methods of combating breast cancer by early detection are breast self-examination, clinical breast examination, and mammography. These prevention techniques are the most effective tools against breast cancer. 3 Unfortunately, many methods are inaccessible to women in developing countries like India, often due to lack of awareness or lack or resources. 4 Breast self-examination (BSE) is a low-cost procedure that can be frequently repeated without harm to the patient. It is a selfperformed screening measure that is recommended to increase overall breast health awareness as well as for detection of breast lumps. It is free, painless and easy to practice. More than 60% women with breast cancer in India are diagnosed at advanced stage, which may be due to limited use of BSE, despite it being identified as an effective method for early detection of breast cancer. Late stage diagnosis drastically affects the treatment options and survival rates of patients. 5

Selection of subjects
An educational interventional study of 150 girls of VS General hospital, School of nursing, Gujarat, India. The study was carried out from April, 2016 to July, 2016.

Inclusion criteria
Nursing students ≥to 18 years of age

Exclusion criteria
Nursing students <18 years of age. Students who did not give consent for study.
The permission to carry out this study was taken from the Dean of NHLMMC and Dean of the V. S. General hospital, School of nursing. Ethical clearance from the Institutional Review Board was taken.

Methodology
Informed consent of the volunteers was obtained before commencement of the session. 150 nursing students were educated about the prevalence and severity of breast cancer as well as early detection techniques in a lecture supplemented by posters and audio visual aids such as emphasis was put on, prevalence of breast cancer, importance of early detection, methods of early detection and self-assessment techniques.
After the lecture, the students were divided into groups so that questions could be answered in greater depth and proper understanding could be ensured.
Pre-and post-tests were administered before and after the session to quantitate the increase in the level of knowledge of breast cancer and breast self-examination.

Statistical tests and software
Analysis of data was performed by using Epi Info 3.5.3. Results of categorical responses were presented in terms of frequencies and percentages.

Age distribution
The age distribution showed that 86% of the study population belonged to the age group of 18-20 years.

Breast self-examination awareness
Existing knowledge about breast self-examination It was found that 13 out of 150 students had not heard of the practice of breast self-examination. However, an improvement was observed after the seminar as 100% of the students were now aware of BSE.

Source of information
The survey revealed that the most common source of information was books, that is, 86%. This was followed by the factor of friends, and newspapers, which constituted 36% and 28.7% respectively. Only 15.3% of the students performed BSE monthly, as per the survey.
Moreover, a mere 20% believed that females only should perform BSE. Post the seminar, 89.3% were now aware.
Among 150 female nursing students, less than half, that is, 49.3%, believed that the imperative practice of breast self-examination should begin at the age of 20 years as Source of Information that is the age at which the risk to contract the disease increases.
However, the intervention brought the right notion to light as 93.3% of the females came to believe that the right age to commence this healthy practice is 20 years.  Furthermore, the appropriate time to perform BSE, which is 5-7 days after menstruation, was unknown to a whopping 70% of the sample population. Post the seminar, 88% of the students believed in the accurate fact.
A mere one fourth; 26% of the students were aware of the ideal frequency of performing BSE, that is, once a month and after the intervention, the awareness level increased to 83.3% On assessing the knowledge about the technique of BSE, it was found that 72.7% of the sample did not know about the position of hand required. Post the intervention, it was shown that 87.3% now knew about the correct technique of performing BSE. It was observed that about 58% of the students were aware about the areas that should receive special attention during BSE, namely the outer edge of breast, underarm, and the nipple. These numbers were further improved to 68.23%.
On being asked about the advantages of performing the examination by lying flat, only 15.3% were able to give the correct answer, that is, it makes the breast flat and makes it easy to assess. After the seminar, this proportion rose to 87.3%.
Another question was put forward to the students about the advantage of clasping hands behind forehead and pressing them forward, and about 28% of the students answered correctly, whereas after the seminar, 62.85% of the students did so.
78% of the students were unaware of the fact that BSE should be carried out every month after menopause on a fixed date. However, after the lecture, 87.3% were now correctly opinionated.

Breast cancer awareness
It was observed that only 0.7% of the students belonging to the sample, had a history of breast cancer in the family.
When asked about the various signs that could be responsible for breast cancer, following observations were made:  It is observed that there is a significant improvement of 48.74% in the knowledge about the indicators of breast cancer among the sample population.
When asked about the risk factors of breast cancer, the following answers were obtained as mentioned in Table 3. It is observed that there is an improvement in the standard of knowledge by 37.9% about the risk factors of breast cancer as a result of the seminar.
A small proportion of 26% was found to know that the most common age group susceptible to breast cancer is that of women of greater than 40 years of age. A rise in the proportion was seen from 26% to 87.3% after the seminar.

CONCLUSION
This study shows that knowledge about breast selfexamination (BSE) and breast cancer, specifically about the risk factors and indicators of breast cancer is inadequate among the nursing students in Gujarat. It is important to increase awareness of breast cancer and BSE at an early age in women. This knowledge would result in early detection of cancer and prevent late stage detection when minimum treatment options are available. An educational intervention, promoting knowledge among nurses and healthcare workers can go a long way, as they can further pass on the information. This study shows the importance of conducting educational training programs on breast cancer and BSE. More programs should be performed reaching all age groups, regions and societies.