Awareness and Knowledge of Breast Cancer among Women in Saudi Arabia: A Literature Review

Mohammad A Albanghali^*

^*Correspondence: Mohammad A Albanghali, Department of Public Health, Faculty of Applied Medical Sciences, Al Baha University, Saudi Arabia, Email:

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Introduction

Breast cancer (BC) is one of the most common cancers, with the number of cases increasing globally. According to the World Health Organization, although this disease occurs in developed countries, its mortality is higher in underdeveloped countries [1]. In Saudi Arabia, BC is the most common cancer, ranked the second cause of cancer deaths among Saudi women. Besides, data between January and December 2015 showed that BC was common in the Kingdom of Saudi Arabia [2]. Among all cancers, there were 1,979 female BC cases with a percentage of 16.7%, and 30.1% of all cancers were reported among women of all ages. The age-standardized incidence rate (ASR) was 24.3/100,000 in the Saudi female population. The five regions with the highest ASR per 100,000 population were in the Eastern region at 37.1/100,000, followed by the Riyadh region with 33.0/100,000, the Makkah region with 26.4/100,000, and the Northern region 25.0/100,000, and Qassim region with 21.7/100,000. The median age at diagnosis was 50 years (range, 14–108 years) [2].

Increased BC awareness will prevent one-third of new cases and improve the survival rate for another one-third of cases detected at an early stage [3]. The low survival rates in less developed countries can be explained mainly by the lack of early detection programs, resulting in a high proportion of women presenting with late-stage disease and preliminary diagnosis. However, increased awareness of and information about BC, awareness of cancer signs and symptoms, and attitudes toward detection methods are an essential part of this strategy [4].

The early detection of BC is essential as mortality increases with late detection. Besides, BC also has an asymptomatic phase where early detection by screening reduces morbidity [5]. In summary, many of the detected cases were in advanced stages [6]. Clinical breast examination and mammograms are screening tools that help in early detection [7,8]. Women should be trained, possess good Knowledge of early BC detection, perform breast self-examination (BSE) and mammography, especially women, aged 40–65 [7]. In Saudi Arabia, very few studies have been carried out to assess the awareness of BC risk factors and screening procedures, the attitude toward the disease, and the BSE practice.

Awareness and education of individuals regarding BC are essential, as studies conducted in Saudi Arabia show a lack of education. Cultural barriers are a significant issue for health education, which affects awareness [9,10]. Women's Knowledge and views of BC play a substantial role in the treatment and health-seeking behaviors, and less Knowledge will lead to delayed case presentation with more advanced disease conditions and a poorer prognosis [11, 12]. Thus, this research aimed to assess the BC knowledge and awareness in various studies that included Saudi women to reduce the morbidity and mortality of the BC by providing younger generations with understanding and educational programs. It is noteworthy that this work aims to evaluate how far we are from the goals of the Saudi 2030 Vision, which seeks to elevate the community health status

Objective

This study aimed to conduct a literature review on the Knowledge, awareness, and practice of BSE among Saudi women.

Materials and Methods

A literature review was conducted by searching the articles in English, focusing on databases and journal websites, including PubMed, Google Scholar, and ResearchGate, by hand-searching and snowballing on the references of the articles based on the inclusion criteria. Primary screening of studies was conducted by reviewing the titles and abstracts of the articles. The search of the article was conducted from August 2020 to October 2020. The vital search is based on BC awareness, Knowledge, self-examination methods, and Saudi Arabia.

Types of participants

Studies included women who were interviewed about the BSE knowledge, awareness, and practice. The study subjects represented the whole population, including students, teachers, health care workers, and primary health care (PHC) visitors.

Types of interventions

Studies evaluated women's knowledge, attitudes, and practices in different parts of Saudi Arabia toward BC

Types of measured outcomes

Studies that included outcome measures of Knowledge, attitudes, and practices of women in different parts of Saudi Arabia toward BC

Types of studies

Cohort, cross-sectional, case-control, and descriptive studies were reviewed.

Search strategy

Search strategy involved. The preliminary examination and registration search detailed electronic searches using electronic search engines, and hand-search/snowballing were conducted based on the inclusion criteria of the preliminary examination and registration search. Searching was limited to studies published in English between January 2010 and October 2020.

Assessment of methodological quality

The reviewers used a checklist that included the study details, authors/year, objectives, participants, context, description of interest, sources of search, number of years (duration), number and type of studies, cities of the region, analysis, outcomes assessed, results, and comments.

Data synthesis

From January 2020 to November 2020, data were based on descriptive findings in a narrative review with no meta-analysis. Two calibrated reviewers screened the initial topic and abstract based on the inclusion criteria before reading the full text. Data were extracted by the clear reading of the full text by the reviewers.

Outcome variables

Based on the standardization of the methodology quality, articles were selected based on the inclusion and exclusion criteria. The outcome variables were based on the chosen article. To maintain the uniformity of the results, they were grouped into Knowledge, awareness, and practice of BC with BSE and essential methods of prevention. Studies with a high risk of bias were excluded to reduce errors in the outcome

Statistical analysis

The interviewer agreement was analysed using Cohen Kappa statistics with results of <1 within the agreement

Included studies

During the search, keywords such as BC, Knowledge, the attitude of BC, practice of the BSE method for BC, and knowledge awareness of BC in Saudi Arabia. were used. The volume of articles was assessed based on the inclusion criteria, full text, and availability of the articles, and a total of 26 articles were selected.

Results

A total of 26 studies (Figure 1) with 14,211 respondents aged between 12 and 70 years were analyzed. The respondents were university students, medical school students, nurses, and patients attending PHC (see Appendix). The review of the article summary with the findings was based on (1) knowledge of BC, which included the basic Knowledge, risk factors, and barriers of BC and the available resources of BC; and (2) BSE practice and Knowledge

Basic knowledge, risk factors, barriers, and educational resources of breast cancer

Based on the collective study data, the basic Knowledge included whether the respondent knew about BC; 34% of the university students responded positively [13], whereas 67.9% of the patients and their escorts were not aware of BC [4]. In a similar study, 48% of patients from the PHC were unaware of BC [8], and 66.7% of respondents with special needs were aware of BC [14]. Also, Hussein, Alorf [15] reported that 56% of the university students and homemakers perceived BC as abnormal growth. According to Latif [16] most university students showed good BC awareness. In a recent study conducted by Al Otaibi, et al. [17], the university students and the public showed that 56% of women were aware of BC. Medical students had better Knowledge of BC than non-medical students, 37.06% and 26.9%, respectively [18].

Misconceptions of BC were observed, with 27.1% of respondents believing that cancer meant the end of life and 74.2% thought it could appear overnight. In addition, 75.1% and 64.3% believed that fate and curse were the reasons for BC, whereas 25.3% of respondents believed that an evil spirit and 12.4% believed that being suspicious could cause BC [4]. The use of cosmetics was considered one of the risk factors among 37% of respondents [19].

Data on the awareness of BC risk factors were obtained from various studies conducted based on observational and cross-sectional questionnaire surveys; 76%–94% of PHC patients believed that tobacco and 80% believed that alcohol was the major BC risk factor. 54% of respondents considered excessive radiation as one of the risk factors, whereas 8.5% thought that pollution and 47% those oral contraceptives were among the risk factors [4,15,20], like observations by Hussein, Alorf [15] with 19% and Haddad, et al. [21] 38% for the exact cause; oral contraceptive. Advanced age and late pregnancy were seen as BC causes by 13% and 10% of respondents, respectively, and 46% of the common public agreed [19]. Regarding post-menopause, 48% believed that BC risk increased with it, along with being overweight (36%) [7, 19]. Genetic factors were seen as a risk factor for BC by 74% of respondents. In comparison, 42% of respondents with special needs believed the same [22], with 9.8 % with family history, 46% of university students responded the same [21,23].

Over 80% of the respondents believed that a good lifestyle, which included a good diet with fruits and vegetables (87%), breastfeeding (86%), and physical activity (84%), reduced the risk of BC [4]. A similar study reported respondents with poor diet (13%), lack of exercise (11%), and improper dressing (28%) [15]. Most respondents supported the above finding in a study conducted by Nemenqani, et al. [24] and Rasheed et al. [8]. Patients attending the PHC were unaware that BC could be curable (26%) [8]. Interestingly, 43% of respondents showed interest in genetic testing to check the risk factors, with 12% showing conditional interest for testing [25].

The awareness on the importance of mammography in BC detection ranged between 22% and 30% [7,8,23], which is in contrast with the observation among medical students (67%) [24]. The percentage of respondents who underwent mammography was 14% [25]; the use of mammography was higher in women with more than one child, and it decreased with age, as reported by Al-Wassia, et al. [26].

Considering the awareness of the BC signs and symptoms, 57% of the respondents were aware that a lump or thickness in the breast was a sign of BC, 68% responded that bleeding or nipple discharge was a sign of BC [27], and 78% of university students showed good Knowledge on the BC signs and symptoms [28]. Most participants were not aware of the necessity to seek medical help if a lump was felt in the breast [29].

Considering the question about the educational resources regarding BC awareness, university students reported television and radio at 56% and 65%, respectively [4,13], journals at 56%, newspaper 35%, and physicians 15% [13]. As a barrier for the BC referral, Al-Amoudi [22] reported shyness at 33%, unavailability of female doctors at 31%, and refusal by the family at 10% .

Breast self-examination practice and knowledge

The respondents' data showed that the Knowledge of BSE was 42% among women attending the PHC and 61% among the public compared to 92% among university students [7,16,27]. Regarding the spread of the Knowledge on BSE, Hussein, Alorf [15] reported that 70% of participants were willing to communicate with others than 30% who were fearful of spreading Knowledge on or discussing BC and 50% feared the test results [21]. Sait, et al. [23] reported that 72% of students were very interested in a Self-breast examination training course.

 Regarding the awareness of BSE methods, 4% of the nurses and 30% of respondents attending the PHC practiced the BSE methods compared to 62% of university students [7,14,21]. Regarding monthly BSE practices, 89.2% of medical students and 55% of university students confirmed carrying BSE monthly [23,24]. One of Al-Amoudi [22] studies on women with special needs revealed that 41.7% of women who were deaf and mute practiced BSE. According to Sait, et al. [23], 55% of respondents answered that BSE should be performed after the monthly period and not before, as recommended. Rasheed, et al. [8] reported that women aged ≥ 46 years practiced BSE 2 times more frequently than women in their 30s. There was a statically significant finding on the BSE practice according to which college/university-educated women were 4 times more likely to be involved than the less educated group; workers in the health care field and homemakers were almost 3.5 times more likely to practice BSE than students, but in contrast with Elsadig Yousif Mohamed, et al. [30], who found that 28% of medical students and 30% of non-medical students practiced BSE regularly [8]. A total of 5% of medical students had undergone a screening test, compared to 14% of non-medical students [18].

Discussion

A total of 14,211 respondents (university students, medical school students, nurses, and patients who were attending PHC centers) aged 12–70 were included in the study. The respondents came from different parts of the Mecca, Riyadh, Hail, Taif, Abha, Asir, and Najran regions. The Knowledge of BC varied across the regions according to respondents' answers

From the public health point of view, it is necessary to know the impact of BC in the community, as BC is one of the most common diseases both globally and in the Kingdom of Saudi Arabia [28]. Some data have revealed the rising mortality and steps needed to increase awareness and reduce morbidity and mortality rates. The present study found that awareness programs regarding the basic pathogenesis and etiology of BC and basic BSE methods were necessary, as stated by Hegazy, et al. [28], who mentioned that an increase in awareness would lead to the right message in uplifting, positive Knowledge. The present study showed data from 26 articles in which it was observed that the Knowledge of BC and basic BSE methods were higher among medical students compared to the general public or patients attending PHC, possibly because of a lack of education or available resources. The strong Knowledge among medical students can be used to create awareness among women in the community, which agrees with findings [31].

Overall, the studies revealed less knowledge of the various risk factors associated with BC. Few respondents showed misconceptions accompanied by fear, one of the significant barriers to health awareness and health promotion. This agrees with a study conducted in Kenya, which identified barriers to the awareness of BC risk factors [32]. The awareness of mammography in the detection of BC was better in medical than in non-medical students. An effective screening method using mammography is essential in early detection, as confirmed by the Cochrane study, which showed that mammography screening leads to a sharp increase in the earlier cases younger group and a sharp decrease in the number of advanced cases, which indicates a reduction in mortality and morbidity [33]. The practice of BSE was good among medical students in comparison with other groups. This finding helps to motivate medical students to practice BSE methods among themselves and their patients

This review has a few limitations; the uniformity of the studies was not considered, as all the studies included had different designs and respondents. Since our study focused on Knowledge and awareness, this was not considered in the inclusion criteria. Thus, further meta-analysis of each research is necessary based on uniformity

Appendix I

Table 1: Summary of findings from various studies, including the participant characteristics, conducted on the Saudi women based on the breast self-examination and knowledge of breast cancer.

Conclusions

The present study's findings suggest that it is necessary and essential to encourage and educate younger generations in major cities and small towns on the basics of BC, prevention, and BSE practice. More Knowledge on the risk factors will help to reduce BC morbidity and mortality. However, it is necessary to conduct a nationwide study on awareness and Knowledge focusing on involving all women communities in Saudi Arabia, especially those in rural cities, and plan a program for their education and training on BSE methods. There is a need for targeted awareness and practice for health regarding early screening, onsite counselling, and cost mitigation. In addition, precaution should be taken not to hurt cultural sentiments and educate the women community considering all demographic parameters and support from religious organizations. The Saudi Vision 2030 should be education, screening, motivation, and good lifestyle practices

Declaration

The authors declare no conflict of interest.

Funding

This study was funded by the deanship of scientific research, Albaha University, Albaha, SA, project number (3/1439).

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