A STUDY TO “ASSESS THE KNOWLEDGE AND PRACTICES ON BREAST

SELF EXAMINATION, BREAST CANCER AND ITS TREATMENT

MODALITIES AMONG ADULT WOMEN, AGE BETWEEN
25-55 YEARS” AT MADHUGIRI TALUK, TUMKUR
DIST, IN A VIEW TO DEVELOP A SELF
INSTRUCTIONAL MODULE.

PROFORMA FOR REGISTRATION OF SUBJECTS

FOR DESSERTATION

Ms. USHA.H.
OBSTETRICS AND GYNAECOLOGICAL NURSING

MADHUGIRI SRI RAGHAVENDRA COLLEGE OF NURSING

MADHUGIRI – 572132 TUMKUR DISTRICT
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1. NAME OF THE CANDIDATE Ms. USHA.H.

AND ADDRESS M.Sc., Nursing 1st Year

Madhugiri Sri.Raghavendra College of
Nursing , Shankar Matt Road,
Raghavendra Extension,
Madhugiri- 572132, Tumkur district.

2. NAME OF THE INSTITUTION Madhugiri Sri.Raghavendra College Of

Nursing, Madhugiri.

3. COURSE OF STUDY AND M.Sc., NURSING 1st Year

SUBJECTS Obstetrics and Gynaecological Nursing

4. DATE OF ADMISSION TO
30-10-2009.
COURSE

5. TITLE OF THE TOPIC A study to assess the knowledge and

practices on breast self examination, breast
cancer and its treatment modalities among
adult women, age between 25-55 years at
Madhugiri Taluk, Tumkur Dist, in a view to
develop a self instructional module.

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA.
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

6. BRIEF RESUME OF INTENDED WORK:

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INTRODUCTION:

“ Attitude is a little thing that makes a big difference”

- Winston Churchill

Breast Cancer is the most common malignancy in women in United States.

Breast Cancer is a leading cancer among the women worldwide, with more than
5,40,000 new cases each year. Over 40% of these cases are in the developing
countries8. The lifetime risk of women for developing Breast cancer was 9.5%
among whites and 6.9% among blacks in the United States 6. Mean age of
occurrence of breast cancer is about 42 years in India as compared to 53 years in
white women of the United States of America12. There is rapid increase in the
incidence between the age 35 to 50 years and secondary rise in frequency after 65
years of age1.

Patients diagnosed with localized Breast cancer with no axillary node

involvement have a five year survival rate of 98%. Conversely, only 6% of
patients diagnosed with advanced stage breast cancer with metastases to distant
sites will survive five years or more21. Breast cancer is the second leading cause
for the death in worldwide and fifth most common cancer in India. According to
the population based tumor registry cell of the Indian council of Medical Research
in New Delhi, breast cancer constitutes about 12% of all cancers detected in Delhi
and about 24% of all cancer in women5.

Survival from breast cancer decreases rapidly with increasing stage of

disease. Typical population based figures for five year relative survival are 86%,
58%, 46% and 12% for stage I, II, III and IV respectively. There is considerable
potential for reducing population mortality from breast cancer by a systematic
approach to improving the stage at presentation by early detection3. Professional
 4

organizations recommended monthly breast self examination and every month

women should get her breast examined by a trained health care provider every
three years, up to the age of 40 years and annually there after. It is not practiced in
the developing countries, due to ignorance of people and lack of trained health
manpower18. Examination of the breast has been advocated for many years as the
first screening modalities for detection of the breast cancer. A World health
organization expert committee has also recommended breast self examination for
the early detection of the breast cancer18.

The extent of the surgical intervention is determined by the clinical

presentation and by the possibility of resecting the tumor with clean margins. The
goal is to preserve the breast, because there is no evidence that a mastectomy is
more beneficial than a lumpectomy plus radiation therapy. However because of
size or the multifocal or multicentric extent of disease, a mastectomy may be
necessary to provide adequate tumor removal20.

Common signs and symptoms of breast cancer include a lump in the breast
that feel distinctly different from other breast tissue or that does not go away,
swelling and thickening of the breast tissue, dimpling or pulling of the skin on the
breast which may then resemble the skin of an orange, any change in the breast
shape or contour, nipple discharge, retraction and scaliness of the nipple, pain or
tenderness of the breast and swollen bumps or puss-filled sores. If the women find
out these characteristics to be reported to the health care providers for the prompt
treatment30.

6.1. NEED FOR STUDY:

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“My cancer scare changed my life. I’m grateful for every new,
healthy day I have. It has helped me prioritize my life”
- Olivia Newton-John

Breast self examination is a technique that all women can do examine to

their own breast. Thus it is a useful self care activity for all adult women. Regular
monthly breast self examination is an essential health maintenance activity.
Teaching skills of breast self examination can be life saving and with regular
breast self examination, malignancy may be discovered at an earlier stage, which
can save lives18.

A set of limitations has been negatively related to breast self examination

practice such as lack of confidence in one’s examination, fear of an abnormality,
forgetting and lack of time. Therefore instruction in breast self examination can be
used to increase the frequency and thoroughness of practice 18. The breast health
survey done revealed that about 80,000 new cases of breast cancer are diagnosed
every year out of which 30,000 of them have the disease. As prevention is not
usually possible, early detection is the only option left. Early detection and
treatment can increase 17% of five years survival16.

Throughout history, the female breast has been regarded as a symbol of

beauty, sexuality and motherhood. Any actual or suspected disease or injury
affecting breast tends to reflect the prevailing societal view of the breast. The
threat of mutilation or loss of a breast may be devastating for the women because
of psychosocial, sexual and body image implications significance associated with
it2. In absence of an enact etiological agent for breast cancer, the most appropriate
way of controlling it, will be early detection and treatment. Mammography is the
method of choice but its use is limited due to high cost and unavailability 7. Breast
self examination is an ideal, safe, effective and cost free method which can be
 6

done by every women at her leisure time with little training. Breast self
examination helps women to find their breast cancer early10.

Despite an increase in women literacy rate and knowledge about breast

cancer, there are certain barriers to practice breast self examination, like worry
about breast cancer, embrassment, lack of time, unpleasant of procedure, lack of
privacy, fear of discovering a lump and unfavorable attitude towards breast self
examination4.

The researcher feels that lack of knowledge and skills is a barrier to breast
self examination practice. Therefore the researcher feels that, women by
allowing women to talk about breast cancer, correcting their misconceptions and
supplying accurate facts, they can reduce associated fear, anxiety and create
awareness. Women may then seek earlier assessment, diagnosis and effective
16
treatment . So the researcher selected the study to assess knowledge and
practices regarding the breast self examination, breast cancer and its treatment
modalities, to provide a self instructional module to improve knowledge of
participants.

6.2.REVIEW OF LITERATURE:

6.2.1 A study was conducted to investigate the relationship between the

performance of breast self examination. The sample size of 694 (69.4%) women,
aged 25-80 were selected with the questionnaire. The step-wise logistic regression
analysis shows that, for the whole sample as well as for the interview group, age
was the only significant predictor of breast self examination. The study was
concluded that the importance of younger women performing the examination is
stressed. Due to nurses being strategically located in a wide range of geographical
locations, allowing them to meet women in different settings, they are a good
 7

choice for motivating women to practice breast self examination9.

6.2.2 A study was conducted to develop an effective strategy to inform

Mexican women between 12 and 47 years of age about breast cancer and train
them to perform breast self examination. The sample size of 149 women were
selected randomly to assess the strategies. The results shows with strategies, there
was an increase of approximately 30% in women's knowledge of breast cancer
and breast self examination as well as in their ability to detect lumps. The study
was concluded with appropriate and monthly practice of breast self examination11.

6.2.3 A study was conducted to identify the beliefs, knowledge, and practices of
breast self examination in adolescent girls. The sample size of 350 teenagers were
selected for descriptive study to determine whether a teaching program would
change believes knowledge and practices of breast self examination. The results
shows that a one-time intervention can be successful in increasing breast self
examination practice and the knowledge of breast self-examination and cancer in
adolescents. The study was concluded that in 1 month after teaching, these
percentages changed appreciably, with 32% of students reporting that they never
practiced breast self examination and 23% reporting that they practiced breast
self examination monthly13.

6.2.4 A study was conducted to develop an educational booklet about breast

self examination and test its effectiveness on University Nursing Students
knowledge and practices. A sample size of 212 nursing students at the Faculty of
Nursing, Alexandria University, were selected by a self - administered
questionnaire. The result shows the general lack of knowledge and practices
 8

related to breast self examination among nursing students, where poor total score
of knowledge and practices was obtained. The study was concluded by improving
the health behavior, especially breast self examination, among nursing students
is needed to help them assume their responsibility towards prevention14.

6.2.5 A study was conducted to assess knowledge, attitude, and practice of breast
self examination in health centers. The sample size of 663 women were selected
randomly for interview. In the data analysis, women's answers for knowledge,
attitude and practice regarding breast self examination. The results shows that
knowledge and practice of breast self examination were adequate in 7.4% and
58.1% of the women were have forgetfulness, was the main barrier for not
performing self-examination. The study was concluded by the women attending
the health centers sampled in this study had inadequate knowledge and
practice about breast self examination, but they had an adequate and favorable
attitude about it15.

6.2.6 A study was conducted to determine the knowledge, attitudes and practices
of women in Qassim region regarding breast self examination, and also to explore
their level of knowledge regarding breast cancer. The sample size of 300 females,
20-70 years of age, were selected by a 10 randomly selected primary health care
centers. The result shows the 70.7% of the participants were literate. Regarding
the knowledge of risk factors, 76% of the respondents had 3 or more correct
answers out of the total 7 questions. 26% of the respondents did not know the
presenting symptom of breast cancer. A study was concluded that the level of
awareness of the females of Qassim region regarding breast cancer and
breast self examination is not adequate17.
6.2.7 A study was conducted on knowledge, attitude and practice about breast
 9

cancer among civil servants in Benin city, Nigeria. A sample size of 400 females
civil servants were selected by a structured questionnaire. The result shows 277
(72.0%) respondents had tertiary level of education. 312 (81.0%) respondents
knew correctly that breast lump is usually the first symptom of presentation of
breast cancer. 144 (37.5%) respondents knew that a positive family history of
breast cancer is a risk factor. The study was concluded with the level of
awareness about breast cancer among civil servants in Benin City is low 19.

6.2.8 A study was conducted to assess knowledge, attitudes and practice

concerning early detection for breast cancer among Iranian health care providers.
The sample size of 318 Health Care Providers were selected by a stratified simple
random sampling and with given questionnaires. The result shows for six
knowledge questions, 71.8% participants had four or more correct responses,
80.5% agreed completely with women will accept the screening program if the
physicians advise it. 81.5% did not carry out breast examinations for the majority
of female outpatients and inpatients during last year. The study was concluded
with the Knowledge and attitudes are relatively appropriate, but practical measures
are not enough29.

6.2.9 A study was conducted to compare the clinical outcome of patients with
stage I breast cancer diagnosed during two time periods that differed with respect
to adjuvant systemic therapy. The sample size of 1407 women < 60 years of age,
who were diagnosed breast cancer stage I. The results shows that the most evident
reduction of distant recurrence risk was among hormone receptor-negative patients
and among patients with a high tumor s-phase fraction. The study was
concluded that the causes of the increase in distant recurrence free survival for
women with breast cancer stage I are complex22.

6.2.10 A study was conducted to describe the introduction, and trends in the use
 10

of adjuvant systemic therapy for breast cancer in 2 of 6 public health regions in

Sweden. The sample size of 328 patients were selected on Population-based data
for the use of adjuvant therapy. The result shows the use of systemic treatment
was infrequent before the late 1980s, but increased during the 1990s. In 2005, the
proportion of operable breast cancer patients treated with adjuvant endocrine
therapy in the ages 40-59 was around 60 to 80%. The study was concluded that the
trends in, and levels of the use of adjuvant systemic therapy for breast cancer
varied over time in the two study regions, particularly for endocrine therapy23.

6.2.11 A study was conducted on breast cancer knowledge and screening

practices. The sample size of 1,000 women were selected by a self-administered
questionnaire. A result shows the response rate was 100%. The mean score was
11.4 and the median was 12 (range 0-19). The scores were high for general
knowledge and disease progression, but poor for risk factors, screening, symptoms
and treatment. Only 53% did regular breast self examination. A study was
concluded with knowledge affects practice. Public education is required to correct
misconceptions and focus on women with poor knowledge24.

6.2.12 A study was conducted on Breast-conserving surgery with or

without
radiotherapy versus mastectomy for ductal carcinoma in situ: French Survey
experience. A sample size of 1289 ductal carcinoma in situ patients. Ductal
carcinoma in situ was diagnosed by mammography in 87.6% of patients. The
result shows that Mastectomy, conservative surgery alone and Conservative
surgery with radiotherapy were performed in 30.5, 7.8 and 61.7% of patients,
respectively. Median tumor size was 14.5 mm (6, 11 and 35 mm) for
Conservative Surgery, Conservative Surgery plus Radio therapy and mastectomy,
respectively. The study was concluded with the treatment modalities varied widely
according to region: mastectomy rate, 20-37%; adjuvant Radio Therapy, 84-96%;
 11

hormone treatment, 6-34%25.

6.2.13 A study was conducted to assess the level of awareness regarding breast
cancer and its screening amongst Indian teachers. The sample size of 441 women
teachers from 8 of the schools located in Delhi, India were collected for cross-
sectional study. The result shows only 11.8% were aware of the normal look of
the breast and 5.4% of the normal feel. The study was concluded that there is
clearly a need to increase the level of awareness regarding breast cancer and its
screening amongst teachers in India26.

6.2.14 A study was conducted to verify the practice and to identify the meaning of
the breast self examination among women with cancer and were submitted to the
chemotherapy. A sample size of 422 women in a qualitative research, using the
speech of the women who are breast cancer carriers, through semi-structured
interviews. The results of the study was concluded with interviewees owned
knowledge on the existence and importance of breast self examination, however,
many did not practice it correctly or ignored the periodicity and technic indicated.
The study was conducted to develop effective interventions to promote the
understanding of the feminine population concerning the importance in adopting
practices for the diagnosis of the mammary cancer27.

6.2.15 A study was conducted to assess and compare the knowledge and
perception of breast cancer among women of various ethnic groups in the state of
Penang. A sample size of 384 participants were conveniently selected and
interviewed, by using a validated questionnaire. The result shows the mean
total score of knowledge was 59.1%, with Indian women having
significantly less knowledge. Only 117 (32.3%) women were aware of the
recommended breast self examination guidelines. A study was concluded that
 12

women in the state of Penang have serious knowledge deficits about

breast cancer and poor awareness of breast self examination guidelines 28.

STATEMENT OF THE PROBLEM

A study to “assess the knowledge and practices on breast self examination, breast
cancer and its treatment modalities among adult women, age between 25 to 55
years” at Madhugiri Taluk, Tumkur Dist, in a view to develop a self instructional
module.

6.3 OBJECTIVES OF THE STUDY

1. To assess the knowledge regarding breast self examination

2. To assess the knowledge regarding causes, signs and symptoms of
breast cancer and its treatment modalities.
3. To assess the practices among adult women on breast self
examination.
4. To assess the practices among adult women on assessment of signs
and symptoms of breast cancer and treatment modalities.
5. To determine the association between the knowledge and practices
on the breast self examination, breast cancer and treatment
modalities among adult women in selected variables.
6. To provide a self instructional module about the breast self
examination, breast cancer and treatment modalities among adult
women.

6.4. VARIABLES UNDER STUDY:

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Age, Genetic influences, Obesity, Spacing methods (use of oral

contraceptives), Life style (smoking and alcohol), Nullipara, Education.

6.5. OPERATIONAL DEFINITIONS:

* ASSESS To evaluate the breast self examination, breast cancer

and its treatment modalities of reproductive age
group women.

* KNOWLEDGE In this study “Knowledge” refers to the correct

response from the respondent (reproductive age
group women) on breast self examination, breast
cancer and its treatment modalities.

* PRACTICE In this study “Practice” refers to the actual

application or use of a plan or method on breast self
examination, breast cancer and treatment modalities.

* BREAST SELF In this study it refers to the examination of the breast

EXAMINATION themselves to identify any changes in the breast.

* BREAST In this study “Breast cancer” refers to a

CANCER malignant tumor of the breast.

* TREATMENT In this study it refers to the procedure or method of

MODALITY treating the breast cancer in a way of presentation or
discussion of a breast self examination, breast cancer
and therapies for the breast cancer.
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* ADULT In this study it adult refers to a person who grown

and developed.

* WOMEN In this study “Women” refers to the adult age group

person ( 25 – 55 Years ).

* SELF In this study “Self Instructional Module” refers to a

INSTRUCTIONAL scientific information is provided regarding breast
MODULE self examination, breast cancer and treatment
modalities to make breast to be healthy.

6.6. ASSUMPTIONS:

6.6.1. Adult women with or without breast cancer may have deficit knowledge
regarding breast self examination for early detection and to treat breast
cancer.

6.6.2. Adult women may have deficit practices regarding breast self examination,
breast caner and its therapy.

6.6.3. Self instructional module will enhance the knowledge regarding breast self
examination.

6.6.4. Self instructional module will guide knowledge regarding etiological

factors, signs and symptoms and treatment of the breast cancer.

7. MATERIALS AND METHODS:

The purpose of the study is to assess the knowledge and practices on breast
self examination, breast cancer and its treatment modalities.
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7.1 SOURCE OF DATA :

 Research approach : Descriptive approach

 Research design : Survey method
 Setting of the study : Raghavendra and K.R. Extension, Madhugiri
 Population : Adult women (25-55 years)
 Sampling Technique : Simple random sampling
 Sample Size : 150 adult age group women
 Sampling criteria
* Inclusion criteria
- The women who are residing at Raghavendra and K.R.Extension,
of Madhugiri.
- The women who are lies in the adult age group.
- The women who can able to understand Kannada with some
educational background.
- The women who are willing to participate in the study.

* Exclusive Criteria
- The women who are not residing at Raghavendra and K.R.
Extension of Madhugiri.
- The women who are not belongs to adult age group.
- The women who can’t able to understand Kannada with no
educational background.
- The women who are not willing to participate in the study.
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7.2 METHOD OF DATA COLLECTION

 Tools of data collection : Structured questionnaire

Part A : Proforma for collecting the
demographic data
Part B : Structured questionnaire to assess the
knowledge and practices on breast self
examination, breast cancer and its
treatment modalities.

 Data analysis and Interpretation :

Data will be analyzed through descriptive and inferential method and
statistics.

 Duration of the study – 6 weeks.

 Does the study requires any investigations or interventions

- No -
 Has ethical clearance has been obtained from your institution in
case of the above.
Yes, ethical clearance will be obtained from,
- The research committee of Madhugiri Sri Raghavendra
College of Nursing.
- The authorities of selected communities, Madhugiri.
- The informed consent from the reproductive age group
women who are willing to participate in the study.
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8. LIST OF REFERENCES :

1. Hislop T.G, “International journal of Epidemiology”, 1986, 15(4); 469.

2. Lewis, SM and Collier, “IC.Medical surgical nursing”. 2 nd edition, pub.

McDraw Hill Book Company, Newyork, 1987; P 1349-50.

3. Stowart HJ, Anderson TJ, “ Screening for breast cancer”, British medical
bulletin, 1991; 47(2), 400-415.

4. Pinto B, et al, “Training breast self examination, a research review and

critique”, Health Edu. Q 1991, winter; 18(14) : 495-516.

5. Anand A, Nagpal R, “ Breast Cancer “, social welfare, 1992, XXXVIII (9-10 );

43-44.

6. Wilcox SL, Mosher DW “ Factors associated with obtaining health screening

among women of reproductive age”, Public health reports,1993; 08(1) : 76-85.

7. Mitra I, et al, “Early detection of breast cancer in industrially developing

countries”, Gan to Kayaku Rysho, 1995, August; 22 suppl. 3:230-235.

8. Haas K.B. “ The effects of managed care on brest cancer detection, treatment
and research”, Nursing outlook, 1997; 45(4) : 167-72.

9. Persson K, et al, “Breast self examination : an analysis of self reported

practice”, J Adv. Nurs 1997, May; 25(5) : 886-892.

10. Singh MM, et al, “Breast self examination for early detection of breast cancer”,
Indian J. Med. Sci, 1999, March; 53(3) : 120-126.

11. Ortega-Altamirano D, et al, “Strategies for teaching self examination of the

breast to women in reproductive age”, Salud Publica Mex 2000, Jan-Feb;
42(1) : 17-25.
 18

12. Hanchard B, Blace G, Wolff C, et al “ Age specific incidents of cancer in

Kingston and st, Andrew, Jamaica”, West Indian Med. J 2001 ; 50(2) : 123-9.

13. Ludwick R, Gaczkowski T, “Breast self exams by teenagers : outcome of a

teaching programme”, Cancer Nurs. 2001, Aug; 24(4) : 315-319.

14. Sobhy SI, et al, “Developing and testing the effectiveness of an educational
booklet about breast self examination on university nursing students
knowledge and practices”, J Egypt public health Assoc. 2003; 78(3-4) :
341-359.

15.Marinho LA, et al, “Knowledge, attitude and practice of breast self

examination in health centers”, Rev Saude Publica 2003, Oct; 37(5) : 576-582.

16. Jacintha Jasmine VS, “Effect of a structured teaching programme on breast

cancer and breast self examination”, Nightingale nursing times, June’2005;
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17. Jahan S, et al, “Brest cancer : knowledge, attitudes and practices of breast self
examination among women in Qassin region of Soudi Arabia”, Soudi Med. J,
2006, Nov; 27(11) : 1737 – 1741.

18. Tara S, Agarwal “Validating breast self examination as screening modalities for
breast cancer in eastern region of Nepal : a population based study”,
Kathmandu university medical journal, 2008, Vol. 6, No.1, issue 21, 89-93.

19. Osime OC, et al, “Knowledge, attitude and practice about breast cancer among
civil servants in Binin City, Nigeria”, Ann Afr Med. 2008 Dec. 7(4) : 192-197.

20. Joyce M Black, et al “Medical surgical nursing”, Elsevier, Vol. 1, 2009, New
Delhi, India, 942-966.

21. Lewis, Heitkemper “ Medical Surgical Nursing”, 7 th edition, Elsevier, India,

2009; 1348-1361.
 19

22. Johansson P, et al, “Improved survival for women with stage I breast cancer in
south east Sweden : a comparison between two time periods before and after
increased use of adjuvant systemic therapy”, Acta Oncol 2009; 48(4) :
504-513.

23. Kemetli L, et al, “Temporal trends in the use of adjuvant systemic therapy in
breast cancer : a population based study in Sweden 1976-2005”, Acta Oncol
2009, 48(1) : 59-66.

24. Sim HL, et al, “Breast cancer knowledge and screening practices : a survey of
1000 Asian women”, Singapore Med. J 2009, Feb; 50(2) : 132-138.

25.Cutult B, et al, “Breast conserving surgery with or without radio therapy Vs

mastectomy for ductal carcinoma in situ : French survey experience”, Br J
cancer 2009 April 7; 100(7) : 1048-1054. Epub 2009 March 10.

26. Khokhar A, “Level of awareness regarding breast cancer and its screening
amongst Indian teachers”, Asian Pac J Cancer Prev. 2009, Apr-June; 10(2) :
247-250.

27. Nascimento TG, et al, “Breast self examination : meaning for patient in
chemotherapeutic treatment”, Rev. Bras, Enferm, 2009, Jul-Aug; 62(4) :
557-561.

28. Abdul Hadi M, et al, “Knowledg and perception of breast cancer among
women of various ethnic groups in the state of Penang : a cross sectional
survey”, Med. Princ prac. 2010; 19(1) : 61-67. Epub 2009 Decmber.

29. Harirchi I, et al, “Early detection for breast cancer in Iran”, Asian pac J Cancer
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30. www.wellness.com
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9. SIGNATURE OF THE CANDIDATE…………………………………

10. REMARKS OF THE GUIDE.

11. NAME AND DESIGNATION OF GUIDE

11.1 SIGNATURE………………………………………………………..

11.2 H.O.D. OF THE DEPERTMENT.

11.3 SIGNATURE .

12. REMARK OF THE CHAIRMAN/PRINCIPAL.

12.1 SIGNATURE …………………………………………………