CHAPTER ONE

INTRODUCTION

1.1 Background
Cancer is a group of diseases characterized by uncontrolled growth and spread of abnormal cells. If the spread is not controlled, it can result in death. Among them is the breast cancer which is the most frequently diagnosed cancer in women worldwide with an estimated 1.4 million new cases in 2008. About half of these cases occurred in economically developing countries (GLOBOCAN, 2008). Globally, breast cancer is the most common malignant neoplasm among women, with approximately one in nine women developing the disease in her lifetime. Every year, about 900,000 women are diagnosed with the disease (Ahmed A M. et al, 2010). It is the most form of malignant diseases found in women. Meanwhile, early discovery of breast lumps through breast self-examination (BSE) is important for the prevention and early detection of such disease (Nadia Y. and Magda A., 2000). Female breast cancer is by far the leading cancer in the Sudan. The alarmingly high frequency of women presenting with advanced breast cancer to the Radiation Isotope Center Khartoum (RICK) and Gezira
1

Institute for Cancer treatment and Molecular Biology (GICMB), which are the only two oncology centers in the Sudan, has prompted looking for an investigation that might help in solving this real health problem. The highest percentages were recorded in 1998 (38.4% of all female cancers), followed by the years, 1999, 2000 and 2001, which attended 36.03%, 35.2% and 32.4% respectively (Ahmed et al. 2010). Recent studies

carried out on breast cancer percentage in the Gezira state in the National Cancer Institute in the state in the years 2005, 2006, 2007 and 2008 were 18%, 29%, 25% and 28% respectively compared to all other cancers (National Cancer Institute of Gezira, 2008). Apart from the highly increased risk of getting breast cancer related to rare mutations, for example BRCA1 and BRCA2 (Hofmann 2000; Yang 1999). Other Numerous risk factors are also associated with breast cancer. One major risk factor is increasing age. Among the factors that increase the risk of breast cancer the most important ones include either a personal or a family history of breast cancer and some specific genetic mutations and hyperplasia that have been confirmed on biopsy. Other factors that augment the risks of developing breast cancer are: an early menarche and late menopause, obesity after menopause, use of iatrogenic hormones (both oral contraceptives and postmenopausal hormone therapy have been implicated), nulliparity or 'having the first child after the age of
2

30', certain ethnic features, radiation, or intake of alcohol on a daily basis (Shiyam Kumar et al., 2009). Effective early detection of breast cancer requires both early diagnoses in symptomatic and asymptomatic patients at risk. In low-resource settings, any programme for early detection must be focused and sustainable. In Sudan, It is implemented early screening programmes for only three cancers, breast, cervical and oral cancer (Hussein M. A., 2006). Preventive behavior is essential for reducing cancer mortality.

Knowledge is a necessary predisposing factor for behavioral change. Knowledge also plays an important role in improvement of health seeking behavior. Not only that knowledge might dramatically improve the attitude, disbelieve, and misconception and consequently enhance screening practice (Soheil Mia, 2007). This study is to assess the Knowledge, attitudes and practices of women towards early detection of breast cancer in Wad Madani, Gezira state, Sudan. 1.2 Problem Statement Breast cancer is the most common cancer among women in Gezira State according to the report form National Cancer Institute in Gezira state in 2008 which breast cancer constituted about 28% of all cancers. The mortality rate can be reduced by early detection of the breast cancer. But
3

the lack of awareness among women about the Knowledge and positive attitudes towards the early detection of breast cancer lead to the rise of incidences of the disease mortality among women. In the light of all above, this study aims at determining the Knowledge, attitude, and practices of women towards early detection of breast cancer in Wad Madani, Gezira state, Sudan. Effort to reduce breast cancer mortality must focus on early detection primarily through the use of the following screening techniques as recommended by the American Cancer Society: a. Monthly breast self-examination (BSE) beginning at age 20; b. Clinical breast examination (CBE) every three years for women 20 to 39 years of age and annually after 40 years of age; c. Annual mammography beginning at age 40 years (American Cancer Society, 2003). 1.3 Justification Since the prevalence of breast cancer among women in Gezira state is high compared to other cancers (the last study in NCI, 28% in 2008), it is important to detect the breast cancer early because Breast cancer is most treatable when it is found early when it is small and has not spread. There is no way to predict who will develop breast cancer and who will

not. For these reasons, routine early detection tests (checking for breast cancer when there are no symptoms present) are recommended. 1.4 Research Questions The following research questions were examined in this study: 1. What is the womens knowledge regarding breast cancer (risk factors, symptoms)? 2. What is the womens awareness about breast self examination (BSE)? 3. Is there any association between the level of education and the knowledge of practice of breast self-examination (BSE)?

1.5 Objectives of the study 1.5.1 General Objective To determine the Knowledge, attitudes and practices of women towards early detection of breast cancer. 1.5.2 Specific objectives To determine the knowledge of the women towards the most important factors that enhances the development of breast cancer. To identify the percentage of women who have correct knowledge about early detection by BSE. To measure the percentage of women who perform regular BSE.
5

 To determine the different types of breast cancer among patients. To determine the most important factors those enhance the development of breast cancer.

CHAPTER TWO
LITERATURE REVIEW

2.1 Anatomy and physiology of the breast

The breasts lie between the skin and the pectoral fascia to which they are loosely attached. Apparently the adult female breast overlies the area from the second to the sixth ribs and from the lateral border of the sternum to the anterior axillary line. 2.2.0 Components of the breast The adult female breast has two components: The epithelial elements- these are responsible for milk secretion and transport. Each breast consists of 15-20 radially arranged and each is drained by a lactiferous duct, the ducts converge at the nipple. A lobe is made up of 20-40 lobules, each of which consists of 10-100 alveoli. The alveoli and ducts are lined by a single layer of epithelium and the ducts are surrounded by contractile myoepithelial cells which are stimulated by oxytocin and move milk towards the nipple. The supporting tissues- fibrous septa (coopers ligaments) extend from the pictoral fascial to the skin and are responsible for the division of the parenchyma into lobes (Galal and Korashi, 2011).
7

2.3 Hormonal control Breast development is under the control of the following hormone: Oestrogen, Adenocortical steroids and growth hormone promote development of ducts Progesterone stimulates the growth of lobules Prolactin is essential for alveolar formation (Galal and Korashi, 2011). 2.3.1 Physiological changes At puberty: the breast remains dormant until puberty. The onset of cyclical hormonal activity stimulates growth, branching of ducts and formation of ductules. Menstrual changes: during the menstrual years the breast undergoes cyclical changes which can cause heaviness, discomfort and increasing nodularity during the latter part of menstrual cycle. During pregnancy: there is marked lobular development. Lactation: following delivery, reduction of estrogens increases sensitivity of mammary epithelium to the lactational complex.

After menopause: the lobules gradually disappear (Galal and Korashi, 2011).

Figure (2.1). Anatomy of female breast showing ducts and lobules. 2.4 Cancer overview
The body is made up of trillions of living cells. Normal body cells grow, divide, and die in an orderly fashion. During the early years of a person's life, normal cells divide faster to allow the person to grow. After the person becomes an adult, most cells divide only to replace worn-out or dying cells or to repair injuries. Cancer begins when cells in a part of the
9

body start to grow out of control. There are many kinds of cancer, but they all start because of out-of-control growth of abnormal cells. Cancer cell growth is different from normal cell growth. Instead of dying, cancer cells continue to grow and form new, abnormal cells. Cancer cells can also invade (grow into) other tissues, something that normal cells cannot do. Growing out of control and invading other tissues are what makes a cell a cancer cell. In most cases, the cancer cells form a tumor. Some cancers, like leukemia, rarely form tumors. Instead, these cancer cells involve the blood and blood-forming organs and circulate through other tissues where they grow. Cancer cells often travel to other parts of the body, where they begin to grow and form new tumors that replace normal tissue. This process is called metastasis. It happens when the cancer cells get into the bloodstream or lymph vessels of our body. Not all tumors are cancerous. Tumors that arent cancer are called benign. Benign tumors can cause problems they can grow very large and press on healthy organs and tissues. But they cannot grow into (invade) other tissues. Because they cant invade, they also cant spread to other parts of the body (metastasize). These tumors are almost never life threatening (American Cancer Society, 2011).
10

2.5 History of breast cancer The origin of the word cancer is credited to the Greek physician Hippocrates (460-370 B.C.), the "Father of Medicine." Hippocrates used the terms carcinos and carcinoma to describe non-ulcer forming and ulcer-forming tumors. In Greek these words refer to a crab, most likely applied to the disease because the finger-like spreading projections from a cancer called to mind the shape of a crab. Carcinoma is the most common type of cancer. Thus breast cancer is a malignant neoplasm of the breast. A cancer cell has characteristics that differentiates it from normal tissue cells with respect to: the cell outline, shape, structure of nucleus and most importantly, its ability to metastasize and infiltrate. When this happens in the breast, it is commonly termed as Breast Cancer. Cancer is confirmed after a biopsy (surgically extracting a tissue sample) and pathological evaluation. During the mid 1800s, surgeons first began to keep detailed records of breast cancer. Those statistics indicate that, even those treated by mastectomy had a high rate of recurrence within eight years especially when the glands or lymph nodes were affected. Nevertheless, the

11

common treatment was to remove the breast and the surrounding glands in an effort to stave off any further tumor development. In 1949 Raul Leborgne (Uruguay) emphasized breast compression for identification of calcifications. In 1940s-1950s breast self-examinations were advocated (Anna H. Israyelyan, 2003). It is a common cancer in women, a disease in which cancer cells are found in the tissues of the breast. Each breast has 15 to 20 sections called lobes. Lobes have many smaller sections called lobules. The lobes and lobules are connected by thin tubes called ducts. The most common type of breast cancer is ductal cancer. It is found in the cells of the ducts. Cancer that begins in the lobes or lobules is called lobular carcinoma. Lobular carcinoma is found in both breasts more often than other types of breast cancer. Inflammatory breast cancer is an uncommon type of breast cancer. In this disease, the breast is warm, red, and swollen. (East African Breast Cancer, 2009). 2.6 Breast cancer in Sudan Breast cancer is a public health problem in Sudan; According to the latest WHO data published in April 2011 Breast Cancer deaths in Sudan reached 1,968 or 0.53% of total deaths. The age adjusted death rate is 16.31 per 100,000 of population (WHO, 2011).

12

The breast cancer incidence in Gezira state exceeds 260 cases annually and the number of cases of women younger than 40 years of age reaches about 67.3% of all cases (National Cancer Institute of Gezira, 2008). Therefore, it is critical that efforts in prevention and early diagnosis of breast cancer are implemented everywhere. One of the main problems concerning breast cancer relates to the lack of patients awareness about the disease. Limitations in implementing breast self-examination and mammography screening programs are the other important issues. Overall survival and mortality due to this disease are influenced strongly by the stage of the disease at diagnosis. The optimal chances for surviving breast cancer in woman is by detecting it early; either by breast self examination (BSE) conducted by a woman herself, clinical breast examination by health staff or by mammography (Ahmed HG. et al., 2010). Knowledge of risk factors, as well as, rising of the awareness is momentous, particularly in a country like the Sudan, where many patients present from remote areas with poor health services. For that reason, the incidence and mortality of breast cancer are high, remarkably constant and the frequency is increasing particularly amongst younger women. Exposure to endogenous estrogens increases the risk of breast cancer. Women who start menstruating before age 12 or begin menopause after
13

age 55 generally have more monthly cycles and therefore a longer lifetime exposure to estrogen. This tends to increase their risk of breast cancer. (Hussein G. Ahmed et al., 2010). The incidence of breast cancer is lowest in women who have given birth to babies at an early age and have had multiple pregnancies. In communities where the custom is for women to marry early and have their first babies whilst still in their teens, the incidence of breast cancer is low, whilst in Westernized societies where first babies are commonly born to women over the age of 30 years, the incidence of breast cancer is higher. There may also be some protection against breast cancer by prolonged breast feeding as is common in most developing countries, although the evidence for this is less clear. Women who have never had a child, such as nuns, have the highest incidence of breast cancer (Stephens & Aigner, 2009). 2.7 Breast cancer early detection Breast cancers that are found because they are causing symptoms tend to be larger and are more likely to have already spread beyond the breast. In contrast, breast cancers found during screening exams are more likely to be smaller and still confined to the breast. The size of a breast cancer and how far it has spread are some of the most important factors in predicting the prognosis (outlook) of a woman with this disease. Most doctors feel
14

that early detection of breast cancer save thousands of lives each year, and that many more lives could be saved if even more women and their health care providers took advantage of these tests. Following the American Cancer Society's guidelines for the early detection of breast cancer improves the chances that breast cancer can be diagnosed at an early stage and treated successfully (American Cancer Society, 2010). 2.7.1 Breast-Self Examination Breast self-examination is one of the vital screening techniques for early detection of breast lumps, most especially cancer of the breast. The procedure, though simple, non-invasive, requiring little time, can only be practiced with the right attitude to sustain it and achieve the desired goal (Kayode F. O. et al., 2005). Breast self examination consists of two basic steps: tactile and visual examination: 2.7.1.1 Tactile examination An effective breast self examination is one that is conducted at the same time each month, uses the techniques properly and covers the whole area of each breast, including the lymph nodes, underarms, and upper chest, from the collarbone to below the breasts and from the armpits to the breast bone. The breast self examination can be done using vertical strip, wedge section and concentric circle detection methods. The breasts
15

should not be compressed between fingers as it may cause the woman to feel a lump that does not really exist. 2.7.1.2 Visual examination The visual examination of the breast is another tool in identifying possible breast disease. In preparing for the visual examination, the woman should stand in front of a mirror. When looking into the mirror, the woman must look for any changes in the contour or placement of the breasts, changes in the color and shape, discharge from nipples and discoloration of the skin (Khatib, 2006). The recent fall of death from breast cancer in western nations is particularly explained by earlier diagnosis as a result of early presentation. In most of the developing countries patient comes for treatment in an advance stage when little or no benefit can be derived from any sorts of therapy. Early diagnosis can be successfully achieved by mass screening either by Mammography, Clinical Breast Examination (CBE) and Breast self examination (BSE) or by the combination of three. Though it is well documented that mammography is the best choice for screening, breast self examination is also equally important and beneficial for mass awareness especially in country with limited recourses (Soheil Mia., 2007).

16

If cancer awareness among the general public is limited then people are ill equipped to make informed decisions about their health, which may consequently lead to delayed presentation and poorer survival (Ramirez et al, 1999; Richards et al, 1999; Coleman et al, 2003; MacDonald et al, 2006). 2.7.2 Clinical Breast Examination: Clinical Breast Examination (CBE) is a standardized procedure whereby a health care provider examines a womens breast, chest wall, and axillae. The examination consist of 1) Visual inspection of the breast while the women in upright position and her arms relaxes and then raised above her head. 2) Palpation of the axillae and supraclavicular fossae when the women in the upright position and 3) palpation of the breasts while the women both in upright and supine positions. The examiner inspects the breast visually for symmetry, skin of the breast, areola, and nipple for oedema, erythema, puckering, dimpling, or ulceration, all of which can be evidence of underlying masses. The provider palpates the regional axillary nodes. Enlarged hard, matted or fixed nodes can indicate cancer (Benjamin O. Anderson et al., 2003). 2.7.3 Mammography A mammogram is a special X-ray of the breast that may show the presence of cysts, dense fibrous tissue, or a cancer in the less-dense fatty
17

tissue of the breast. Small amounts of X-rays only are needed so this examination is safe if not used excessively. Although mammograms produce some false negatives and some false positives they are nevertheless very useful, safe and inexpensive in screening for breast cancer. However, even the small doses of X-rays needed for mammography are better avoided in women who may be pregnant or wish to have further pregnancies as even this exposure to irradiation can cause genetic mutation of fetal cells or of actively functioning ovarian tissue. This usually means that mammography is not routinely recommended in women younger than 40 (Stephens & Aigner, 2009). 2.8 Risk factors of breast cancer Although the causes and natural history of breast cancer remain unclear, epidemiological research has uncovered genetic, biological,

environmental, and lifestyle risk factors for the disease. A risk factor is anything that affects your chance of getting a disease, such as cancer. Different cancers have different risk factors. Having a risk factor, or even several, does not mean that you will get the disease. Most women who have one or more breast cancer risk factors never develop the disease, while many women with breast cancer have no apparent risk factors (other than being a woman and growing older). Even when a

18

woman with risk factors develops breast cancer, it is hard to know just how much these factors may have contributed to her cancer. There are different kinds of risk factors. Some factors, like a person's age or race, can't be changed. Some are related to personal behaviors such as smoking, drinking, and diet. 2.8.1 Gender Simply being a woman is the main risk factor for developing breast cancer. Although women have many more breast cells than men, the main reason they develop more breast cancer is because their breast cells are constantly exposed to the growth-promoting effects of the female hormones estrogen and progesterone. Men can develop breast cancer, but this disease is about 100 times more common among women than men. 2.8.2 Aging The risk of developing breast cancer increases as the women gets older. About 1 out of 8 invasive breast cancers are found in women younger than 45, while about 2 of 3 invasive breast cancers are found in women age 55 or older(American Cancer Society, 2010). 2.8.3 Genetic risk factors About 5% to 10% of breast cancer cases are thought to be hereditary, resulting directly from gene defects (called mutations) inherited from a parent.
19

BRCA1 and BRCA2: (which are abbreviated BR from breast and CA from cancer) the most common cause of hereditary breast cancer is an inherited mutation in the BRCA1 and BRCA2 genes. In normal cells, these genes help prevent cancer by making proteins that help keep the cells from growing abnormally. If a woman has inherited a mutated copy of either gene from a parent, she will have a high risk of developing breast cancer during your lifetime (Trunbull C. & Rahman N., 2008). 2.8.4 Family history of breast cancer Women whose close blood relatives have breast cancer have a higher risk for this disease. Having a first-degree relative (mother, sister, or daughter) with breast cancer almost doubles a woman's risk. Having 2 first-degree relatives increases her risk about 3-fold. Although the exact risk is not known, women with a family history of breast cancer in a father or brother also have an increased risk of breast cancer. 2.8.5 Lifestyle-related factors 2.8.5.1 Parity Women who have not had children or who had their first child after age 30 have a slightly higher breast cancer risk. Having many pregnancies and becoming pregnant at an early age reduces breast cancer risk. The higher parities and earlier age at first pregnancy of women in many

20

developing countries might account for lower incidence of breast cancer in relation to developed countries. 2.8.5.2 Oral contraceptives Studies have found that women using oral contraceptives (birth control pills) have a slightly greater risk of breast cancer than women who have never used them (American Cancer Society, 2010). 2.8.5.3 Breast-feeding Some studies suggest that, breast-feeding may slightly lower breast cancer risk, especially if it is continued for 1 to 2 years. For example, the US Cancer and Steroid Hormone Study found that breast feeding for a total of 25 months or more reduced the risk of cancer by 33% in over 4500 women studied. (Sherif O. Jarques et al., 2010). 2.8.5.4 Alcohol Consumption of alcohol is clearly linked to an increased risk of developing breast cancer. The risk increases with the amount of alcohol consumed. Compared with non-drinkers, women who consume 1 alcoholic drink a day have a very small increase in risk. Those who have 2 to 5 drinks daily have about 1 times the risk of women who drink no alcohol. (American Cancer Society, 2010).

21

2.9 warning signs of breast cancer Early breast cancer is usually symptom less. But there are some symptoms develop as the cancer advances. Breast lump or breast mass is the main symptoms of the breast cancer. Lump is usually painless, firm to hard and usually with irregular borders. Every lump is not cancerous, sometimes some lumps or swelling in the breast tissue may be due to hormonal changes or benign (not harmful) in nature. Beside these some others symptoms are important, like: Lump or mass in the armpit A change in the size or shape of the breast Abnormal nipple discharge - Usually bloody or clear-to-yellow or green fluid - May look like pus (purulent) Change in the color or feel of the skin of the breast, nipple, or areola - Dimpled, puckered, or scaly - Retraction, "orange peel" appearance - Redness - Accentuated veins on breast surface Change in appearance or sensation of the nipple - Pulled in (retraction), enlargement, or itching
22

 Breast pain, enlargement, or discomfort on one side only Any breast lump, pain, tenderness, or other change in a man Symptoms of advanced disease are bone pain, weight loss, swelling of one arm, and skin ulceration (Medline plus Encyclopedia, 2011). 2.10 Stages of breast cancer and survival rates The staging systems currently in use for breast cancer are based on the clinical size and extent of invasion of the primary tumor (T), the clinical absence or presence of palpable axillary lymph nodes and evidence of their local invasion (N), together with the clinical and imaging evidence of distant metastases (M). This is then translated into the TNM classification which has been subdivided into Stage 0 called carcinoma in situ (lobular carcinoma in situ (LCIS) and ductal carcinoma in situ (DCIS) and four broad categories by the Union Internationale Centre Cancer (UICC), which are the following. Stage 0 :( Carcinoma in Situ) Carcinoma in situ is very early breast cancer. In this stage cancer has not invaded into the normal breast tissue and is contained in either the breast duct (ductal carcinoma in situ) or the breast lobule (lobular carcinoma in situ). By definition, this type of cancer is not invasive and is not able to travel to the lymph nodes or other parts of the body.

23

Stage I early stage breast cancer where the tumor is less than 2 cm across and hasn't spread beyond the breast. Stage II early stage breast cancer where the tumor is either less than 2 cm across and has spread to the lymph nodes under the arm; or the tumor is between 2 and 5 cm (with or without spread to the lymph nodes under the arm); or the tumor is greater than 5 cm and hasn't spread outside the breast. Stage III locally advanced breast cancer where the tumor is greater than 5 cm across and has spread to the lymph nodes under the arm; or the cancer is extensive in the underarm lymph nodes; or the cancer has spread to lymph nodes near the breastbone or to other tissues near the breast. Stage IV metastatic breast cancer where the cancer has spread outside the breast to other organs in the body. (Anna H. Israyelyan, 2003). The five-year survival rate from breast cancer among women age 15 and older is 89% in the United States, 82% in Switzerland, and 80% in Spain. Breast cancer survival rates in developing countries are generally lower than in Europe and North America, with rates as low as 38.8% in Algeria , 36.6% in Brazil, and only 12% in Gambia. The stage at diagnosis is the most important prognostic variable. For instance, the overall five-year relative survival among US women diagnosed with breast cancer at early stage is 98%, compared to 84% and 23% when the disease is spread to
24

regional lymph nodes or distant organs, respectively (GLOBOCAN, 2008). 5-years Relative Survival Rate Table (2.1). 5-years Relative Survival Rate Stage Stage 0 Stage I Stage IIA Stage IIB Stage IIIA Stage IIIB Stage IV Survival rate% 100% 100% 92% 81% 67% 54% 20%

(American Cancer Society, 2005). 2.11 Previous studies A number of articles have been found on breast cancer knowledge, attitude and Practice. Samira H. AbdElrahman and Magda A. Ahmed conducted a longitudinal interventional study in 2003 in the University of Gezira; the study was the role of medical students in the Faculty of Medicine about self examination of the breast for early detection of breast cancer. The study was done in three phases.
25

Phase one: training of students, phase two: students intervention and phase three: evaluation of students intervention. Pre-test assessment and post-test assessment was done, it comprised 200 students and 340 women. In the pre-test assessment 66.5% of students have heard about BSE, 8.0% rated BSE as very important and only 7.2% used to practice it. After the intervention the last figures rose to 100% and 73.9% successively. Prior to study, only 12.0% of the women have heard about BSE. By the end of students intervention 60.5% of the women adhered to regular monthly BSE. No lump was detected by a student. Olumuyiwa O,Odusanya and Olufemi O.Tayo conducted a cross sectional survey in 2001 among nurses in general hospital in Lagos, Nigeria. 204 nurses were included in the study. Knowledge about symptoms methods of diagnosis, and Self breast Examination was above 60%. In response to question on 5 risk factors more than 50% identified positive family history and that bruising the breast is a potential risk factor for developing breast cancer. The nurses were well informed about frequency of Breast Self Examination (BSE). More than one third (39.7%) of the respondents knew that, BSE should be done monthly interval. Majority (78.4%) of the respondents agreed that breast cancer is a curable disease if diagnosed and treated early. Majority (90%)

26

considered that, the disease is serious and would see a doctor within one month. BSE was most frequently done (89%). Among them 39 % conducted the procedure at monthly interval. Use of all 3 methods of screening was more common among those who had a greater knowledge about breast cancer. Perceived cancer risk assessment was done, 61% claimed not at risk. Another cross-sectional study was conducted among one thousand community-dwelling women from a semi-urban neighborhood in Nigeria by Michael N Okobia and et al conducted a study in 2006 to elicit knowledge, attitude and practices towards breast cancer. The Study result showed poor knowledge on breast cancer. Mean knowledge score was 42.3% and only 214 participants (21.4%) knew that breast cancer present commonly as a painless breast lump. In response to questions about etiology of breast cancer, 40% believed that evil spirit causes breast cancer and 259 (25.9%) indicated that breast cancer result from an infection. In terms of methods of diagnosis 432(43.2%) were able to answer correctly identified that BSE is a method of diagnosis. There was an indication of positive health seeking behavior as a majority of the participants mentioned that visiting the doctors was the best approach for breast cancer treatment. In terms of practices, 34.9% participants practice BSE. Only 91participants (9.1%) had clinical breast examination (CBE)
27

in the past year and no one had the history of mammography examination. Majority of the respondents did not take part in BSE or clinical breast examination due to having no breast problem. Grunfeld E A et al conducted a survey in 2002 on 1830 general female population of UK to elicit knowledge and believe about breast cancer. In the study it was found that, women had limited knowledge on risk factors and breast cancer related symptoms. Only 23% correctly indicated that 1 in 10 have a chance to developed breast cancer. Less than one third recognized the role of advancing age as a potential risk factor. More than 70 % of the sample identified that painless breast lump, lump under armpit, nipple discharge are potential symptoms. Bener A et al conducted a cross sectional community base line survey in 2001 to explore the knowledge, attitude and practice related to breast cancer screening among women of United Arab Emirates. They found that only 30% of the women agreed that family history was a risk factor, and 45 % incorrectly stated that most of the breast lump would become cancerous. One third (33%) of the women knew that early breast cancer was painful. Most of the women (79%) agreed to have breast examination by a doctor but only 14% had experienced a clinical breast examination. Only 13% performed breast self examination regularly on monthly basis.

28

Pinar Erbay et al in their study of The knowledge and attitude of breast self examination and mammography in a group of women in a rural area in western Turkey found that majority (76.6%) had heard about breast cancer but only 56.1% of them had sufficient knowledge about breast cancer. TV and radio programs were identified as the main source (39.3%) for information. Most of the respondents (72.1%) had knowledge about Breast self Examination but only 40.9% of the women had practiced BSE in the previous 12 months. Phls U G et al conducted a study in 2004 on Awareness of breast cancer incidence and risk factors among healthy women in Dsseldorf, Germany found that78.8% were well aware of breast cancer in general terms. Most of the women (94.9%) considered that former history of breast cancer is a risk factor Interestingly 37.1% considered breast feeding 32.0% considered age at menopause and 23.7% considered childlessness as a potential risk factors. Two -third of the participant estimated their personal risk of developing breast cancer was low to average. Gynecologists were the main source of information (59.9%) on breast cancer. Jebbin NJ and Adotey JM conducted a study in 2004 on Attitude, knowledge and practice of breast self-examination (BSE) in port Harcourt, Nigeria and found that 85.5% of the respondent had heard of
29

Breast self examination but 39.0% practiced BSE only occasionally. The news media nurses and physicians were the commonest sources of information on BSE. WA Milaat conducted a cross sectional study in 2000 on 6380 female secondary-school student in Jeddah to identify their knowledge of breast cancer and attitude towards breast self-examination (BSE). Knowledge of risk factors was very low. Over 80% of students failed to answer 50% of the questions correctly. Only 47.1% of students reported that they had heard of or read some scientific information about breast cancer in various media and 39.1% reported that lump in the breast is the warning sign of breast cancer. Only15.2% agreed that use of contraceptive pill is a potential risk factor. Few (16.2%) knew that breast cancer could appear as a change of or bleeding from the nipple. Ahmed HG et al; Conducted a case control study in the Sudan in 2010, risk factors for breast cancer were evaluated among 150 women with breast cancer (ascertained as cases) and 100 apparently health women (ascertained as controls); their ages ranging from 20 to 65 years with a mean age of 40 years old. The majority of patients were at the age range 36 - 45 years constituting 60(40%); hence the distribution was similar in respect to the upper and lower limits from the mean. Results showed Out of the 150 patients with breast cancer (cases), and 100 apparently healthy
30

individuals (controls); 38 (25.3%) and 38(38%) were identified as having a previous history of oral contraceptives usage, respectively. Information concerning the type of oral contraceptives were available for only 35 patients, of whom 28 (80%) were using progesterone only pill and the remaining seven (20%) were using combined pill. Out of the 150 cases and 100 controls, 22 (14.7%) and 14(14%) were found with a family history of breast cancer (First degree mother side), as well as, 20 (13.3%) were detected as having a previous history of breast cancer, respectively. Furthermore, 11(7.3%) of the cases and 27 (27%) of the controls have claimed other cancers in their families.

31

CHAPTER THREE
MATERIALS AND METHODS

Figure (3.1) Map showing Gezira State and Wad Madani, the capital city 3.1 Study Area Sudan is a country in North Africa that is often considered to be part of the Middle East as well. It is bordered by Egypt to the north, the Red Sea to the northeast, Eritrea and Ethiopia to the east, South Sudan to the south, the Central African Republic to the southwest, Chad to the west, and Libya to the northwest.
32

3.1.1 Location Gezira state is one of the 15 states of Sudan. It is located in the middle of Sudan, bordered in the north by Khartoum State, in the south by Sinnar state, in the west by White Nile State and in the east by Gedarif State. The State has an overall population of 3,575,280 people. The region has benefited from the Gezira Scheme, a program to foster cotton farming begun in 1925. At that time the Sennar Dam and numerous irrigation canals were built. Gezira became the Sudan's major agricultural region with more than 2.5 million acres (10,000 km) under cultivation. Wad Madani is the area of current study which is the capital city of the state; it has a population of 345,290 people according to the last national census in 2008. It is located on the west bank of the Blue Nile River, agriculture is the central economic activity, like wheat, peanuts, barely and livestock. It is the home of Gezira University, Wad Madani Ahlia college and other institutions. 3.2 Study Design Type of study: this analytical Case control hospital based study conducted at Madani teaching hospital and National Cancer institute for cancer treatment (NCI). Study period: The study was conducted from November, 2011February, 2012.
33

Study population: the population under study was women residing in Wad madani town from 20 years of age who attended to Madani Teaching Hospital and National Cancer Institute (NCI). 3.3 Inclusion Criteria: In this study women in Wad Madani Town were included to evaluate their knowledge attitudes and practices towards early detection of breast cancer. The reason why women of 20 years of age included the study is that screening methods especially the breast self examination is recommended after 20 years of age. The control women in the survey were female patients and co-patients who visit to Wad Madani Teaching Hospital, those patients were non breast cancer patients. The cases in the study were breast cancer female patients who attended in the National Cancer institute for cancer treatment in Gezira state in the period of January 2011 to December 2011. 3.4 Sample technique The overall women that are 20 years of age and above are about 71,000 women projected from 2008 Population and Housing Census.

34

And the annual breast cancer treated estimated in the NCI was 934 with an incidence rate of 34%. At 95% confidence level and 5 %( 0.05) margin error. So the sample size was calculated using the formula below: N0 = Z P Q / d When: N0: sample size Z: value of selected level of 0.25 in each tail (1.96) P: anticipated population proportion Q: 1 p (anticipated population proportion) D: absolute population required on either side of the population (incidence point) (Lewanga K. & Lemeshow S., 1991). n0 =

n0 = 345 So the finite population correction proportion can be calculated:

n=

= 252

35

Patients sample: The cases were incident, diagnosed with breast cancer patients and they were entered in the study because they had a confirmed pathological breast cancer and admitted to National Cancer Institute (NCI). The initial unit in this study was woman with breast cancer treated at National Cancer Institute by using the statistical formula of a sample size and a simple random sampling. The sample size calculated was 345. The patients of breast cancer treated at (NCI) in the year is 934. These were the new cases treated each year. After the correction formula used the final overall sample size n= 252. So the recorded data needed to survey in the patients sample is half of the overall sample which is 126 medical records. Control Sample: The control women needed to recruit the study of Knowledge, attitudes and practices of early detection of breast cancer was randomly selected among women without any history of breast cancer residing in Wad Madani Town and attended to Madani Teaching Hospital. They were also asked whether they have some risk factors of breast cancer.

36

The control sample equal to the remaining half of the sample which is 126 samples from women attending to Madani Teaching Hospital. 3.5 Data collection and analysis Data collection was accomplished using interviewer-administered

questionnaires manuscript in Arabic language. The questionnaire was developed by the researcher using information on breast cancer from the literature and from questionnaire conducted in the other studies. The questionnaire used was in three parts. The first part was to elicit socio-demographic data on age, occupation, and marital status of each study participant. The second part was about the knowledge of breast cancer and the risk factors that enhance the development of breast cancer. Participants awareness of breast cancer and early detection methods were assessed in the third section. The attitudes and practice of BSE, CBE and Mammography among participants were also assessed in the last section. In the case section of the study medical recorded data was collected from the National Cancer Institute of breast cancer patients attended to the institute for treatment in the year 2011, the data was collected in a master sheet. Obtained data is arranged and finally data analyzed by using SPSS 16.0 software (SPSS Inc., 2008). Demographic characteristics will be simply
37

present in frequency and chi-square test is be used to compare Cases with Control about the risk factors that enhance the development of breast cancer.

38

CHAPTER FOUR
RESULTS AND DISCUSSION 4.1 RESULTS 4.1.1 CONTROL

Table (4.1) Distribution of the respondents According to their Age

Age Valid 20-29 30-39 40-49 50+ Missing Total Total System

Frequency and Percent 60 (47.6%) 24 (19.0%) 19 (15.1%) 20 (15.9%) 123 (97.6%) 3 (2.4%) 126 (100.0%)

Table (4.1). Shows the respondents frequency and their percentage with age group (20-29) being the most age group participated the survey of about 47.6%.

39

Table (4.2) Distribution of Respondents according to their marital

status

Marital Status Valid Single Married Widowed Divorced Missing Total Total System

Frequency and Percent 36(28.6%) 80(63.5%) 6(4.8%) 3(2.4%) 125(99.2%) 1(.8%) 126(100.0%)

Table (4.2). shows that most married were about 80 (63.5%) and single were the second 36(28.6%).

40

Table (4.3). Distribution of respondents according to their occupation Occupation Valid Housewife Employed Student Retired Total Missing Total System Frequency and Percent 80(63.5%) 16(12.7%) 25(19.8%) 3(2.4%) 124(98.4%) 2(1.6%) 126(100%)

In this table (4.3) results show that most respondents were housewife 80 (63.5%), followed by students of 25 (19.8%).

41

Table (4.4). Association between Education level to the heard of Breast cancer Did you hear about breast cancer Education Level Education Khalwa Primary school Secondary school Graduate Illitrate Total Yes % No % Total 17(13.4%) 22(17.4%) 25(19.8%) 40(31.7%) 22(17.4%) 126(100%) 13(10.3%) 17(13.5%) 23(18.2%) 39(30.9%) 9(7.1%) 101(80.1%) 4(3.1%) 5(3.9%) 2(1.6%) 1(0.8%) 13(10.3%) 25(19.8%)

In table (4.4). Results show that most participants heard of breast cancer 101(80.1%) of them have heard the breast cancer whereas 25(19.8%) of them didnt hear of breast cancer. Graduates were the most participants heard the breast cancer 39 (30.9%) followed by the secondary school participants of 23 (18.2%) participants. There is a significance according to Chi-square test between the Educational level and hearing of Breast cancer with P-value = 0.000.

42

Table (4.5). Association between Level of Education and heard of breast self examination BSE.

Did you hear of breast self examination- BSE? Yes Education Khalwa Primary school Secondary school Graduate Illitrate Total 8(7%) 10(8.8%) 10(8.8%) 36(31.5%) 4(3.5%) 68(59.6%) No 7(6.1%) 9(7.8%) 14(12.2%) 4(3.5%) 12(10.5%) 46(40.4%) Total 15(13.1%) 19(16.6%) 24(21%) 40(35%) 16(14%) 114(100%)

In table(4.5). Results show that more than half of the participants heard of breast self examination 68(59.6%) respondents heard of BSE. Graduates were the highest group to hear about BSE 36(31.5%) participants, followed by secondary and primary of 10(8.8%) respondents each. We can also see here in this table a significance between the level of education and hearing of BSE according to Chi-square test with pvalue= 0.000.

43

Table (4.6). Association between the level of education and the knowledge of method of breast self examination BSE.

Did you know the method of breast self examination Level of Education Education Khalwa Primary school Secondary school Graduate Illitrate Total Yes % 4(4.2%) 2(2.1%) 4(4.2%) 28(29.7%) 2(2.1%) 40(42.2%) No % 7(7.4%) 13(13.8%)) 12(12.7%) 11(11.7%) 11(11.7%) 54(57.4%) Total 11(11.6%) 15(15.9%) 16(16.9%) 39(41.4%) 13(13.8%) 94(100%)

In table (4.6) results show that 40(42.2%) knew the method of breast self examination whereas 54(57.4%) do not know the breast self examination. The graduate respondents have the highest knowledge of breast self examination of 28(29.7%) knew the method of BSE. There was a significance relationship between the two variables with a p-value of 0.000.

44

Table (4.7) Distribution of respondents according to their practice of BSE Do you practice breast self examination BSE? Once a month Sometimes Knew but never practice Dont know how to practice Total Frequency and Percent% 11 (8.7%) 19 (15%) 10 (7.9%) 86 (68.2%) 126 (100%)

The table (4.7) shows that the practice of BSE is very low among respondents only 11 (8.7%) practice monthly regular breast self examination while 19 (15%) practice it only sometimes but the most respondents dont know how to practice it 86 (68.2%).

45

Table (4.8). Association of level of education with the knowledge of early warning signs of breast cancer

What are the early warning signs of breast cancer Level of Education Khalwa Secondary school Graduate Illitrate Total Painless lump 2 skin Swelling changes 4 1 5 5 1 16 2 1 2 2 0 7 nipple retraction 0 0 0 1 0 1 I dont know 3 9 5 9 14 40 Total 11 17 19 33 15 95

Primary school 6 7 16 0 31

In table (4.8). Results showed that painless lamp is the most known sign among respondents of 31(32.6%) participants. Graduates have the highest awareness of early warning signs of breast cancer of 33 out of 95 participants knew at least one early warning sign. There was a significance p-value 0.009.

46

4.2 Cases
Table (4.9). Distribution of medical recorded cases of breast cancer according to their age Age Valid 20 29 30 - 39 40 - 49 50+ Total Frequency and Percent 2(1.58%) 28(22.22%) 38(30.15%) 58(46.03%) 126(100.0%)

In this table (4.9) results show that in Cases the most recorded age group was (50+) age group with 46.03%.

47

Table (4.10) Distribution of medical recorded cases of breast cancer according to their marital status Frequency and Percent Valid Married Single Widowed Divorced 96(76.2%) 14(11.1%) 9(7.1%) 7(5.6%)

Total 126(5.6%) The table (4.10) shows that the most recorded patients were married 76.2% followed by single patients with 11.1%.

48

Table (4.11) Association of age with the type of breast cancer

Age * type of Breast Crosstabulation Type of Breast Cancer Age Age DCIS 20-29 2 30-39 11 40-49 18 50+ Total 26 IDC 0 14 16 26 LCIS 0 0 3 1 ILC 0 1 0 1
2(1.58%)

Others 0 2 1 4
7(5.55%)

Total 2 28 38 58
126(100%)

57(45.2%) 56(44.4%) 4(3%)

In table (4.11) results show that age crosstabulated with type of breast cancer without any significance, the most type of breast cancer in the patients was ductal carcinoma in Situ DCIS of 57 patients(45.2%), followed by Invasive ductal carcinoma IDC of 56 patients (44.4%), and lobular carcinoma in situ LCIS, invasive lobular carcinoma ILC represent 6 patients only (4.58%) an lastly other rare types of breast cancer which constitute 7(5.55%).

49

4.3 Case control section Table (4.12) Association of Cases and Controls regarding breast cancer risk factors
Cases(n=126) Controls (n= 126) P-value Number % Number %

Parameter

Age groups (years)

0.000 2(1.58%) 60 (47.6%)

20-29

30-39

28(22.22%)

24 (19.0%)

40-49

38(30.15%)

19 (15.1%)

50+

58(46.03%)

20 (15.9%)

Missing system

0(0%)

3(2.4%)

Marital status

0.42

Single

14(11.1%)

36(28.6%)

Married

96(76.2%)

80(63.5%)

Widowed

9(7.1%)

6(4.8%)

50

Parameter

Cases(n=126) Controls (n= 126) P-value Number % Number % 7(5.6%) 3(2.4%)

Divorced

Missing system

0(0%)

1(0.7%)

Family history of breast cancer

0.12

No

105 (83.3%)

108 (85.7%)

Yes

21 (16.6%)

9 (7.1%)

Dont know

0(0%)

9(7.1%)

Onset of Menarche

0.000

14 and below

35 (27.7%)

40 (31.7%)

15 and above

21 (16.6%)

73 (57.9%)

Do not remember

70 (55.6%)

13 (10.3)

Parity

0.62

Parous

81 (64.2%)

72 (57.1%)

51

Parameter

Cases(n=126) Controls (n= 126) P-value Number % Number %

Nulliparous

45 (35.7%)

54 (42.9%)

Age at First Birth

0.000

<20

13 (10.3%)

28 (22.2%)

20-29

33 (26.1%)

35 (27.7%)

30-39

9 (7.1%)

5 (4%)

Nulliparous

45 (35.7%)

51 (40.4%)

Dont remember

26 (20.6%)

7 (5.5%)

Smoking

0.50

Yes

1 (0.8%)

3 (2.3%)

No

125 (99.2)

123 (97.7%)

Hypertension

0.14

Yes

18 (14.3%)

6 (4.7%)

52

Parameter

Cases(n=126) Controls (n= 126) P-value Number % Number % 108 (85.7%) 120 (95.2%)

No

53

4.4 Discussion The study carried out determines the knowledge attitude and practices of women about the early detection of breast cancer and also the risk factors that enhance the development of the disease, the study was done in Madani Teaching Hospital and National Cancer Institute for cancer treatment during the study period of November 2011 to February 2012. The study revealed that most control participants were married about 80 (63.5%) See table (4.2) and also in Cases the most recorded patients were also married 96 (76.2%) as explained in table (4.9). The study showed that the majority of control respondents were housewives 80 (63.5%), followed by students of 25 (19.8%) as shown in table (4.3). It is obvious that knowledge and awareness about the breast cancer can have an impact directly upon behavior leading to modify breast cancer risk. It also plays an important role in an improvement of health seeking behavior . (Soheil mia, 2007). The current study showed that majority of participants heard about breast cancer 101(80.1%).The percentage of those heard about breast cancer was more among graduates of about 39(30.9%) as shown in table (4.4). There is a significance according to Chi-square test between the Educational level and awareness of Breast cancer with (P-value = 0.000).

54

Here we can realize that the education plays a great role to the awareness of health related issues. The current study also revealed that most participants heard of breast self examination 68 (59.6%) respondents heard of BSE. Graduates were also among the highest group of awareness about BSE 36(31.5%) followed by secondary and primary of 10(8.8%) respondents each. We can also see here a significance between the level of education and hearing of BSE according to Chi-square test with (P-value= 0.000). The study also showed that 40(42.2%) knew the BSE whereas 54(57.4%) do not know the breast self examination. Also here the graduates were among the highest group of knowledge about BSE and the chi-square test showed significance (P-value 0.00). The practice of BSE was very low among respondents about 11(8.7%) only practice it monthly regular BSE while 19(15%) practice it sometimes whereas most respondents 86 (68.2) dont know how to practice BSE. So we can say that the practice of BSE was poor among respondents due to lack of knowledge about the method of practicing it. Also in the study respondents were asked whether they know about the early warning signs of breast cancer, 31 (32.6%) said they know that painless lump is a warning sign of breast cancer, followed by swelling of the breast as the second most known sign with 16 (16.8%) respondents
55

whereas 40 (42.6) said they do not know any sign. This shows that about one third of the respondents do not know any sign of breast cancer thereby making difficult to go for screening or doing clinical breast examination. The results also revealed that age crosstabulated with type of breast cancer has no any significance p-value=0.6, the most type of breast cancer in the patients studied was ductal carcinoma in Situ (DCIS) of 57 patients(45.2%), followed by Invasive ductal carcinoma (IDC) of 56 patients (44.4%) as shown in table (4.10). In a study conducted in central Sudan on breast cancer stages, on 1255 women results showed that infiltrating ductal carcinoma IDC constituted the majority of breast cancer diagnosed about 82% of the patients whereas other types of breast cancer, such as infiltrating lobular carcinoma, ductal carcinoma in situ and infiltrating medullary carcinoma represented a small fraction of the diagnosed breast cancer (Elgaili et al., 2010). In the section of case control study regarding to breast cancer risk factors 126 records of breast cancer patients in NCI were ascertained as cases whereas 126 others are ascertained as controls, the controls were patients and co-patients attended to Madani teaching hospital but not with breast cancer patients, many risk factors for breast cancer development have been described and some of them including age, family history of breast
56

cancer and reproductive factors are well established ( Henderson IC, 1993). The results of current study aimed to compare the risk factors that are present in controls with those of patients recorded, results showed that about half of the recorded cases were fifty years and above of age that is 58 (46.03%) of breast cancer patients, whereas in controls about half of them 60 (47.6%) belong to the age group (20-29) as summarized in table (13) with (P-value= 0.000), this showed a statistically significant differences between the two groups, being the advanced age as a risk factor for the development of the breast cancer. Also the age of Onset of menarche was different among cases and controls and showed statistically significant difference only 21 (16.6%) of cases their onset of menarche was between the ages 15-17 years of age and 35 (27.7%) their ages of menarche were between 11-14 years, but the remaining patients were uncertain of their age at onset of menarche, on the other hand about two third of controls' age of onset of menarche was 15-17 years. The age of first birth also showed significant difference among cases and controls, only 13 (10.3%) had their first babies before the age of twenty in patients of breast cancer whereas about double of that percentage 28(22.2%) of controls had their first child before the age of twenty. So according to this study giving birth at an early age gives some kind of prevention against
57

the breast cancer. There was no significant difference among cases and controls with regard to marital status, parity, smoking and hypertension and hence have no any influence on the risk. A university hospital based study conducted in turkey in 2009 about the breast cancer risk factors among Turkish women for the study period from 200-2006. It was found that increasing age >50 was a risk among the patients, also age at first birth >34 and positive family history were among the risks found (Vahit O. et al., 2009).

58

CHAPTER FIVE CONCLUSION AND RECOMMENDATION 5.1 CONCLUSION

The results of the study indicated that most participants have heard of breast cancer but with different knowledge among them, also they have heard about breast self examination but only small portion knew the method of breast self-examination and few of them practiced monthly. The study also revealed that one third of the respondents knew at least one warning sign of breast cancer while one third of them don't know any sign about the early warning signs of breast cancer. The study also showed that educated people had access to knowledge about breast cancer and breast self examination, while those non educated had poor knowledge about the disease and its signs. In the section of case control study of risk factors comparison between cases and controls, the study showed that advancing age was the main risk factor among breast cancer patients, other risk factors studied were age at first birth, age of onset of menarche all showed significance different while the rest such as marital status,
59

family history, parity, smoking and hypertension all showed no significance and hence have no influence on the risk of developing breast cancer. The most type of breast cancer suffered the patients recorded was infiltrating ductal carcinoma and ductal carcinoma in situ. Other types were rare.

60

5.2 RECOMMENDATION Promote early detection measures through breast cancer education and awareness to let the women seek medical help earlier. Educate women about the importance of screening practices especially breast self-examination and to practice it regularly every month. Improvement of medical records regarding breast cancer patients in the National Cancer Institute for cancer treatment.

61

REFRENCES 1. Ahmed A. M. Farghaly S. and Darwish E. Knowledge attitude and practices of breast cancer. The Egyptian Journal of Community Medicine 2010; Vol.28; 21-38. 2. Ahmed HG, Ali AS, Almobarak AO. Frequency of breast cancer among Sudanese Patients with breast palpable lumps. Indian J Cancer 2010; 47(1): 48-51. 3. American Cancer Society (ACS), 2003-2011. Cancer facts and figures. Breast cancer: Early detection. The importance of finding breast cancer early. 4. Anna H. Israyelyan. The development of molecular diagnostics for breast cancer: Master thesis, August 2003. p.1-5. 5. Bener A, Alwash R, Miller CJ, Denic S, Dunn EV Knowledge, attitudes, and practices related to breast cancer screening: a survey of Arabic women. J Cancer Educ. 2001 winter; 16(4):215-20. 6. Benjamin O. Anderson, Susan Braun, Susan Lim, Robert A. Smith, Stephen Taplin and et al.: Early detection of breast cancer in countries with limited resources. The breast Journal 2003, 9(suppl.):S51-S59.

62

7. Coleman MP, Gatta G, Verdecchia A, Esteve J, Sant M, Storm H, Allemani C, Ciccolallo L, Santaquilani M, Berrino F (2003) EUROCARE-3 summary: cancer survival in Europe at the end of the 20th century. Ann Oncol 14: 128149. 8. East African breast cancer. http://www.breastcancerafrica.com accessed on 29th December 2011. 9. Elgaili M. Elgaili, Dafalla O. Abuidris, Munazah R., Arthur M. Michalek, Sulma I. Mohamed. Breast cancer burden in central Sudan. International Journal of womens' Health. 2010;(2):77-82. 10. Galal S., Mohsen A. and Korashi E. Medical physiology. Vol.II, New Delhi. Al azhar press. Egypt. 2011. 11. GOLOBOCAN. Most recent estimates of cancer incidences. Global Cancer facts and figures 2nd Edition. 2008. http://www.cancer.org/acs/groups/content/@epidemiologysurveilla nce/documents/document/acspc-027766.pdf accessed on 13th December. 12. Grunfeld E A, Ramirez AJ, Hunter MS, Richards MA: Women's knowledge and beliefs regarding breast cancer. Br J Cancer 2002, 86(9):1373-1378.

63

13. Henderson IC: Risk factors for breast cancer development. Cancer supp 71:2127-2140, 1993. 14. Hofmann W, Schlag PM. BRCA1 and BRCA2-breast cancer susceptibility genes. Journal of Cancer Research and Clinical Oncology 2000;126:487-96. 15. . Hussein G. Ahmed, Rehab M. Musa, Mohamed M. Eltayeb and Mohamed O. M. Hussein. Role of some risk factors in the etiology of breast cancer in Sudan. Open Journal of breast cancer 2010; Vol.2 ; 71-78. 16. Hussein M. A. Hammad. Cancer initiatives in Sudan. European Society for Medical Oncology 2006 : 17(8). 17. Jebbin NJ and Adotey JM.:Attitude to,knowledge and practice of breast-self examination(BSE) in port Harcourt.Niger J Med.2004;13(2).166-70. 18. Kayode F. O., Akande T. M., and Osagbemi G. K. Knowledge attitudes and practices of breast self examination among female secondary school teachers in Ilorin, Nigeria. European Journal of Scientific research. 2005, 10:3

64

19. Khatib, Oussama M. N. Guidelines for the early detection and screening of breast cancer. World Health Organization. Emro publications, 2006. 20. Lewanga K. S., and Lemeshow S. Sample size determination in Health studies: A practical manual. World Health Organization. Geneva. 1991. 21. MacDonald S, Macleod U, Campbell NC, Weller D, Mitchell E (2006) Systematic review of factors influencing patient and practitioner delay in diagnosis of upper gastrointestinal cancer. Br J Cancer 94: 1272 1280. 22. Medlineplus Encyclopedia. http://www.nlm.nih.gov/medlineplus/ency/article/000913.htm accessed on 19th December 2011. 23. Michael N Okobia, Clareann H Bunker,Friday E Okonofua and Usifo Osime:Knowledge attitude and practice of Nigerian women towards breast cancer : A cross sectional Study. World Journal of Surgical Oncology 2006; 4:11. 24. Nadia Y. Seif and Magda A.aziz. Effect of Breast self-examination training program on knowledge attitude and practice of a group of

65

working women. Journal of Egyptian National Cancer Institute., Vol. 12:(2) 2000: 105-115. 25. National Cancer Institute of Gezira Archives, Gezira state. 2008. 26. Odusanya O. O., Tayo O. O.: Breast cancer knowledge, attitudes and practice among nurses in Lagos, Nigeria. Acta Oncol 2001, 40:844-848. 27. Pinar Erbay D. and et al: the knowledge attitudes of breast self examination and mammography in a group of women in a rural area in western Turkey. BMC cancer 2006, 6:43 28. Phls UG, Renner SP, Fasching PA, Lux MD, et al. Awareness of breast cancer incidence and risk factors among healthy women. Eur J Cancer Prev. 2004;13(4):249-256. 29. Ramirez AJ, Westcombe AM, Burgess CC, Sutton S, Littlejohns P, Richards MA (1999) Factors predicting delayed presentation of symptomatic breast cancer: a systematic review. Lancet 353: 1127 1131. 30. Richards MA, Westcombe AM, Love SB, Littlejohns P, Ramirez AJ (1999) Influence of delay on survival in patients with breast cancer: a systematic review. Lancet 353: 1119 1126.

66

31. Samira H. AbdElrahman and Magda A. A. Yousif. Selfexamination of the breast for early detection of breast cancer: the role of medical students in the faculty of medicine University of Gezira Sudan. Sudanese Journal of public health: January 2006, Vol. 1 (1) : 36-42. 32. Sherif O., Jarques R. and Hussein K. Breast cancer: national Cancer Institute of Egypt. Fifth edition. 2010. 33. Shiyam kumar, Ayesha M. Imam, Nauman F. Manzoor and nehal Masood. Knowledge attitude and preventive practices for breast cancer among healthcare professionals at Aga khan hospital Karachi. JPMA 59(7) 2009:475-478. 34. Soheil Mia. Knowledge attitude and practices regarding breast cancer among medical students of Bangaladesh: A master thesis; 2006, p. 29-41. 35. SPSS Inc. (2008). SPSS Base 16.0 for Windows Users Guide. SPSS Inc., Chicago. IL. 36. Stephens O. Frederik and Aigner R. Karl. Basics of Oncology. New York: 2009.

67

37. Trunbull C. Rahman N. Genetic predisposition to breast cancer: past present and future. Annu Rev Genomic Hum Genet. 2008; 9: 321-45. 38. Vahit O., Beyza O., Hasan K., et al. Breast cancer risk factors in Turkish women: a university hospital based nested case control study. World Journal of Surgical Oncology: April 2009, Vol. 7 (37): 1-8. 39. W A. Milaat: Knowledge of secondary school female students on breast self examination in Jeddah, Saudi Arabia. Eastern Mediterranean Journal 2000, 6: 338-343. 40. WHO, 2011. World life expectancy. http://www.worldlifeexpectancy.com accessed on 2nd January 2012. 41. Yang X, Lippman M E. BRCA1 and BRCA2 in breast cancer. Breast Cancer Research Treaties 1999;54:1-10.

68

APPENDIX Knowledge, Attitudes and Practices among women towards early detection of breast cancer Questionnaire I am a postgraduate student in the University of Gezira preparing my master degree thesis in KAP study of women towards the early detection of breast cancer. Breast Cancer is a Global public health problem. To ensure primary prevention and treatment population based screening program as well as breast awareness is necessary. To assess the knowledge attitude and practice regarding breast cancer some information is required from you. Your response will contribute a big effort to conduct this study. Your participation would be kept confidential. Do you agree to share this scientific research ____ Section One: Socio-demographic data 1. Age:

20-29

30-39

40-49

50+

2. Marital status:

Single
If Married:

Married

Widowed

Divorced

69

a. At what Age you married? ____ b. Do you have children? If Yes, 3. How many children do you have?

Yes

No

One Child

2-5 Children

6-10 Children

More than 10

4. What was your age at first child birth? _____ 5. Occupation Housewife 6. Education: Illitrate Secondary School Khalwa Graduate Primary school Postgraduate

Employed

Student

Retired

7. Family size _____________ 8. Family history of breast cancer? If yes, mention relative degree : Yes No

Mother

Grandmother

Aunt Sister Other____

70

9. Which of the following do you have? Smoking Not breastfeeding Early onset of menarche Nulliparity Hypertension

Yes Yes Yes Yes Yes

No No No No No

Section Two: Knowledge about breast cancer 10. Did you hear about breast cancer? Yes If yes, a. What is breast cancer? A fatal disease A disease that cannot be prevented b. Where is the source of information? Radio Magazines TV Friends Posters A disease that can be prevented A common disease in women No

Other, __________

71

11. What are the factors that cause breast cancer? Hereditary Nulliparity Magic and evil spirits Smoking Not breastfeeding Other______ Obesity Age above 40

Section Three: attitudes and practice about breast cancer 12. Did you hear of breast self examination? If yes, 13. Do you know the method of breast self examination? Yes No If yes, frequency of application Once in a month Never Occasionally Other Yes No

14. Do you believe Breast cancer is common in women with big breasts? Yes No I dont know

15. Do you believe Lumps in the breast that are cancer are pain full? Yes No
72

I dont know

16. Did you hear clinical breast examination? If yes frequency of application? Once in a month Occasionally

Yes No

Never Yes No

17. Did you hear mammography? If yes, at what age mammography is done? 20 years above 40 years and above

Before 40 years I dont know

18. What are the early warning signs of breast cancer ? Painless lump Swelling Skin changes Discharge from nipple Nipple retraction I dont know

73

19. Have you ever been educated about breast cancer? Yes No If yes, what is the source of education? Doctor Healthcare provider Peers Radio programme TV programme Internet

Other ____

Thank you for your cooperation

74