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Creating Awareness About the Painless Nature of Early Breast Cancer Lump is Important in Low‐Income Countries

To the Editor: In low-income countries, early breast cancer constitutes only 30% of the entire breast cancer load compared to 70–80% in the developed nations (1,2). Consequently, 5-year survival rates in developing countries range between 10% and 40% compared with over 70% in developed nations (3,4). To inquire into reasons for this anomaly, we studied the awareness levels of urban Indian women about breast cancer; as breast cancer is the commonest cause of cancer-related mortality in urban women in India. We intended to pinpoint the key issues hindering the early detection of breast cancer and sought to define interventions to address these issues so as to improve the early detection as well as outcome of breast cancer. A total of 970 urban women were recruited between November 1, 2006 and February 28, 2007 in Chandigarh, an affluent city in North India with high literacy rates. Participants were administered a 23point multiple choice format questionnaire related to risk factors, clinical symptoms, signs, and screening modalities of breast cancer. Only adequately attempted questionnaires (>50% answered questions) were considered. The age ranged from 18 to 71 years with a mean of 26.2 ± 7.4 years. Sixty-seven per cent of the participants were college students, 18% were housewives, and 15% were working women. Only 39% and 22% of women knew that family history and higher age are important risk factors for breast cancer, respectively. Similarly <10% women were aware that early menarche and late menopause increase the risk of breast cancer. Sadly, only 32% of women were aware of the protective effects of the breast feeding on breast cancer. Lastly, only half the women (51%) were aware of the risk posed by fatty diet and obesity. Regarding screening modalities, only 16% of participants felt that they had some knowledge about breast self examination (BSE). Furthermore, a meager 10% and 25% of participants, respectively, were aware of the appropriate timing and right frequency for performing BSE. Similarly, only 27% women were informed of the appropriate age and 82% of the importance of undergoing clinical breast examination (CBE). More than 71% participants had no clue about mammography. Of the rest, 57% knew of its clinical benefits and 27% about the recommendations for screening mammography. Only half of the women (51%) were aware that lump in the breast was a sign of early breast cancer. Seventeen per cent of the women felt that lump in the armpit was a sign of early breast cancer and 16% also knew that early breast cancer could have a bloody nipple discharge. One-third of women thought that breast pain was the important symptom of early breast cancer. Majority (82%) of women were unaware of the fact that early breast cancer lump could be painless. In India, majority of early breast cancers present as a breast lump (5). In our study, only half the women were aware of this fact. The notion that ‘‘cancer is painful’’ is highly prevalent in many developing countries. In the study in Nigeria, up to 75% of nurses regarded breast pain as a symptom of breast cancer (6). In our study, 33% of the women thought that a patient of early breast cancer presents with breast pain. Furthermore, only 18% women were aware of the fact that a patient of early breast cancer could present as a painless breast lump. These results reconfirm the observations made in Africa, where <25% women were aware that painless breast lump could be a sign of early breast cancer (7,8). This could be one of the key reasons for the delay in seeking healthcare by the women with painless lump in the breast. Mammography is currently considered the gold standard for early detection of breast cancer. Address correspondence and reprint requests to: Dr. Pankaj Garg, MBBS, MS, 1139, Sector-11, Panchkula, Haryana 134112, India, or e-mail: drgargpankaj@yahoo.com.