Breast cancer and breast self-examination awareness among undergraduate students of the University of Bamenda, Cameroon

INTRODUCTION

Breast cancer is the most frequent malignancy among women and the second most diagnosed in the entire world population. In 2018, breast cancer represented the second most common cancer worldwide in term of incidence, just behind lung cancer.¹ In developing countries including Cameroon, the majority of women diagnosed with breast cancer do not survive because of late diagnosis of the disease.² With regards to other types of cancers, breast cancer is characterized by its occurrence in a visible organ.³ The 5-year survival rate reached to 85% with early detection whereas later detection decreased the survival rate to 56%.⁴ In addition to the inadequate diagnosis and treatment facilities, the low survival rates in less developed countries can be attributed to late detection. Clinical breast examination, mammography and breast self-examination (BSE) are the commonly recommended screening methods for breast cancer detection.⁵ However, yearly mammography and clinical breast examination are always not done by women in developing countries as these examinations require hospital visit and specialized equipment and expertise).⁶ Many national and international studies are recommending new tools or strategies for an early detection of breast cancer. Breast self-examination (BSE) has been considered as one of the best tool for the early detection of cancer.⁷ BSE is a simple, quick, suitable and cost-free screening method whereby women examine their breasts regularly to detect any abnormal swelling or lumps in order to seek prompt medical attention.⁸ Practically, women aged 20 and above should practice BSE monthly, 5 to 7 days after the end of their menstruation. Many women, however, practice BSE either irregularly or not at all.^9,10 Besides women, breast cancer is also prevalent in men, though little attention is shown on the latter sex. A longitudinal study from 2004-2006 and 2010-2011 in Yaounde (Cameroon), showed that breast cancer was the first type of cancer diagnosed among female (32%) with some cases diagnosed in men.¹¹ Another study on 5 regions in Cameroon (Center, Littoral, West, Northwest and South West) within a period of 10 years showed 2.40% of breast cancer diagnosed in men.¹² Moreover, a recent report also showed high prevalence of new cases breast cancer in both sexes in Cameroon.¹³

Though the university is considered as the place of higher learning, knowledge and practices of BSE have been shown to be low among university students. In a study conducted among female undergraduate students of Ahmadu Bello University Zaria (Nigeria) only 19.0% of them were performing BSE examination monthly.¹⁴ With female students of the University of Buea (Cameroon), though 9.0% knew how to perform BSE, only 3% were carrying out this examination regularly.¹⁵ Therefore, the appropriate knowledge and practice of BSE not only vary within universities, but are still far low to help promote early screening of breast cancer. Moreover, more extensive evaluations of the knowledge and practice of BSE in the higher learning institutes could help create more awareness within this subset of populations who could subsequently positively influence the communities or larger population in the early diagnosis of breast cancer. This study thus aimed at assessing the knowledge on breast cancer and BSE and the practice of BSE among male and female undergraduate students of the University Bamenda, Cameroon.

METHODS

This cross-sectional study was conducted among the students of the Faculty of Science of the University of Bamenda, Northwest Region, Cameroon. It was carried out from the June 2nd to July 31st 2018. The study population was made up of female and male undergraduate students regularly present on campus for their academic activities. The participation to the study was based on the free consent of the student and those refusing to take part were not compelled in anyway. The participants were assured of confidentiality of their information and those who doubted were assured of anonymity of their identity. What’s more, the study received an authorization from the public health authorities in the North West region of Cameroon (Reference Nº: 204/ATT/NWR/RDPH). A total 260 participants were recruited in the study according to a random sampling technique.

Questionnaire administration

After signing the informed consent, the purpose and importance of the study were explained to the participants. Then, they were asked to fill a questionnaire set on the aspects such as knowledge on female and male breast cancer, signs and symptoms of breast cancer, possible risk factors and treatments of breast cancers, knowledge of breast self-examination (BSE), method/procedure for performing BSE, age at which it should be carried out, the frequency in which it should be carried out. Independent variables notably the socio-demographic factors (age, marital status) were recorded.

Statistical analysis

The data analysis mainly consisted in descriptive statistics and a few statistical tests for qualitative variable, we used frequency tabulations for unvariate analysis and cross-tabulations with Chi-square test for bivariate analysis. The age range below 20 years old was considered as a reference population in comparative analysis.

RESULTS

Socio-demographic characteristics

Out of the 260 initially recruited participants, 255 gave complete answers to questionnaire, which gives a response rate of 98.07%.

The majority of the study population (61.96 %, 158 participants) was made up of females while 38.04% (97 out of 255) were males. Regarding the marital status, 87.45% (223 participants) were single while 11.76% (30 subjects) were married. The socio-demographic data of the respondents is summarized in Table 1.

The age of the participants ranged between 16 to 48 years old. The highest proportion of the participants 61.57% (157 respondents) were between 20-24 years old, followed by 25-29 years old (19.22%, 49 participants), below 20 years old (10.98%, 28 participants) and those ≥30 years old (6.27%, 16 participants).

Knowledge on breast cancer

The majority of the participants (91.77%, 234 respondents) have heard about breast cancer while 8.23% (21 participants) had no knowledge of this health problem (Table 2). Within gender, 93.67% (148 people out of 158) of women and 88.66 % (86 individuals out of 97) had idea of the breast cancer. For male breast cancer, 14.12% (36 participants) respondents have heard about it.

The participants pointed alcohol consumption and smoking (19.22%, 49 subjects), the use of contraceptive (18.04%, 46 individuals), late menopause (11.76%, 30 individuals), pesticides (5.10%, 13 people) and obesity (4.31%, 11 people respondents) as causes and risk factors of breast cancer. The participants aged 20-24 years old (2.7-time chances, p=0.031) and those older than 30 (4.6-time chances, p=0.048) were more aware of the possible risk factors of breast cancer than those younger than 20 years.What’s more, only 38,43% (98 among which, 60 women and 38 men) respondents knew some signs and symptoms of breast cancer while 44.31% (113 participants among which 71 women and 42 men) had an idea about possible treatment measures (surgery, hormonal therapy, chemotherapy, radiation therapy) of cancer.

The various signs and symptoms of breast cancer acknowledged by participants are summarized in the table 3. Among the participants, only 38.43% (98 subjects out of 255) respondents had knowledge of signs and symptoms of breast cancer. The highly recorded signs and symptoms were lumps in breast (48.86%, 43 respondents out of 88 answers) and breast pains (26.14%, 23 individuals out of 88 answers). For knowledge of the locally used methods for the management of breast cancer, participants proposed plants and medicinal herbs such as pawpaw leaves, mushroom, corosol, carrot juice, Aloe vera, garlic, Cymbopogon citratus (localy called fever grass). Between gender, there was no significant difference between men (43.3%) and women (44.9%) regarding the knowledge of traditional treatment of breast cancer.

Knowledge of breast self-examination (BSE)

For breast self-examination, 56.08% (143 respondents) participants have heard about it among which 100 women and 43 men. Only 23.92% (61 subjects) participants were practicing it among which 57 women and 4 men. From this study, 38.61% women (61 of the total female population, 158) have been taught on how to carry out BSE (Table 4). Concerning the frequency, BSE should be practiced daily for 11.37% (29 participants), weekly for 10.20% (26 participants) and monthly for 20.39% (52 respondents) of our study population. 58.04% (148 respondents) participants have no idea of the frequency at which BSE should be carried out. Men were significantly less informed (p=0.002) about the practice of BSE than women (reference group). Concerning the knowledge of BSE according to the participant ages, the more participants were aged, the more they were likely to have heard about BSE. Particularly, those aged between 20 - 24 years old and 25-29 years had 4.7 and 5.6 times more chances, respectively to had heard about BSE than those younger than 20 years.

Regarding the frequency of the practice of BSE, the majority (58.04%, 148 people) of the respondents had no idea, but monthly check up standard frequency was known by 20.39% (52 subjects) of the participants. For the age from which BSE be carried out, good portions of the study population either mentioned from puberty (41.57%, 124 individuals) or had no idea (48.63%, 106 people). However, 7.06% (participants) of the respondents knew that it should be done from 20 years old.

Predictors of breast self-examination

The age of participants and the general knowledge about cancer were good indicators for doing BSE. According to the various age ranges, BSE is much more practiced by participant between 20 to 29 years old. More precisely, 26.11% (41 people out of 157) participants from 20 - 24 years, 20.41% (10 individuals out of 49) aged between 25-29 years, 17.86% (5 people younger than 20 years old) and 18.75% (3 people out of 16) respondents older than 30 have been practicing BSE (Table 5).

The awareness about breast cancer was moderately not significantly associated with practice of BSE with 24.79% (58) participants having heard of breast cancer were practicing BSE (Pearson chi2(1)=1.1675 Pr=0.280). Among the participants, 34.69% (34 out of 98) knew the signs and symptoms of cancer and practice BSE. The knowledge about signs and symptoms of breast cancer significantly increased the chances of practicing BSE (Pearson chi2 (1)=10.1492, Pr=0.001) (Table 6).

DISCUSSION

Breast self-examination (BSE) is a checking up and screening technique used by an individual which aims at early detection of breast cancer. It is a simple, very low cost, noninvasive with no need of special equipment. It is an effective method for breast cancer screening which only takes few minutes.¹⁶

In the present study, breast cancer awareness was high among the study population as 91.76% have heard of breast cancer. The findings also showed a poor knowledge of the practice of BSE with more than half (56.08%) of the respondents though having heard of the practice of BSE had no idea of how often BSE should be carried out. This is comparable to the study carried out by Abay et al in North Ethiopia indicating that 44.5% of the participants to their study have heard about BSE. However, Adetule showed in a study carried out in Senior secondary in Ibadan North Local Government of Oyo State (Nigeria) that up to 97.3% of the study population had heard about BSE.^17,18 The discrepancy of having heard about BSE with the present study could be attributable to the higher implication of mass media in the sensitization of the population against cancer in Nigeria. In fact, Adetule showed that mass media were the actual source of information of their study population about cancer and BSE. Moreover, the nature of the studied population could also be considered in explaining the present findings as men have shown to be relatively less aware of cancer and BSE than female.¹⁸

In this study, 23.92% of participants were practicing BSE, a figure lower than those obtained among female undergraduates in Owerri, South Eastern (Nigeria) and women in Akatsi South district of Volta region (Ghana) where 32.5% and 27.5%, respectively of the study population were performing BSE.^19,20 In general, the practice of BSE have been shown to be low in African populations, and this illustrates certain negligence of our populations for this essential screening measure of the early detection of breast cancer. In the present study, the more the participants were aged, the more they were likely to have heard about BSE. Particularly, those aged between 20 - 24 years old and 25-29 years old had almost 5 times more chances to have heard about BSE than younger people. Similarly, respondents of the age range 20-24 years old and above 30 years old were significantly more aware than those younger than 20 years on the possible causes and risk factors and signs and symptoms of breast cancer. The practice of BSE as function of age in this study is consistent with the observations of Sani and Naab and Dadzi and Adam who supported than younger women (18 - 30 years) or below age 30 were more likely to have knowledge about BSE.^20,21 We could hypothesize that the highest awareness and practice of BSE could be due to a certain active sexual reproductive age of the females from 20 to 29 years old.

This study indicated a poor knowledge about the frequency and the period of life at which BSE should be practiced as more than half (58.05%) of the participants had no idea of frequency at which BSE should be carried out though 1/5 (20.39%) of the respondents indicated monthly standard checkup frequency. The percentage of the population that could practice BSE on a monthly frequency obtained in this study is higher than the 3% found in similar study carried out among female undergraduate students in the University of Buea in Cameroon.¹⁵ The present findings are however close to those of Tuyen et al who noted that 15.2% of the female textile workers in Vietnam were practicing BSE monthly.²² It is normally recommended that BSE should be carried out monthly 5 to 7 days after menstruation.¹⁰ Also, the study population showed little knowledge of age from which BSE should be performed with only 7.06% of the of them indicating that BSE should be done as from 20 years as indicated in the literature.¹⁰ Therefore, more education is still to be done to improve the knowledge of the studied population about BSE.

Though our population has relatively heard about breast cancer, only 38.43% and 45.1% of the respondents had knowledge of the signs and symptoms and the risk factors of this disease, respectively. Casmir et al found a quite low knowledge (19.9%) of the risk factors of breast cancer among female undergraduates in Owerri, south eastern Nigeria.¹⁹ On the other hand, Shrestha et al recorded higher frequency of answers about the signs and symptoms such as growth in breast (82%) and breast enlargement (80%) among reproductive age women from Pancheswor Mahila Jagaran Kendra in Nepal, as compared with the present study.²³ The discrepancies among the knowledge of the studied populations regarding the signs and symptoms of breast cancer could be due to different academic and socio-cultural backgrounds.

CONCLUSION

Summarily, the present study demonstrated that the general had poor knowledge of the signs and symptoms of breast cancer and the BSE practice, though the population aged 20-29 years old has relatively heard about breast cancer and BSE. There is therefore a necessity to develop more techniques and means to inform and educate the university students and the global population on breast cancer and BSE.

ACKNOWLEDGEMENTS

The authors hereby express their deep gratitude to the undergraduate students of the University of Bamenda for their participation to this study. They are also grateful to Dr. Kankeu T. Hyacinthe for the statistical analysis of data.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. WHO. WHO-Cancer report 2020 global profile, 2020. Available at https://www.paho.org/hq/index.php ? option=com _ docman & view=download&category_slug=4-cancer-country-profiles-2020&alias=51561-global-cancer-profile-2020 & Itemid=270 & lang=fr. Accessed on 24 November 2020.
2. 2. WHO. Awareness is the first step in battle against breast cancer. Bull World Health Organ 2012;90:164-5.
3. 3. Avcı İA, Altay B, Kocatürk B. Health beliefs of student mid-wives toward breast self-examination. J Breast Health. 2008;4:5-28.
4. 4. Hallal JC. The relationship of health beliefs, health locus of control, and self concept to the practice of breast self-examination in adult women. Nurs Res. 1982;31(3):137-42.
5. 5. Noreen M, Murad S, Furqan M, Sultan A, Bloodsworth P. Knowledge and awareness about breast cancer and its early symptoms among medical and non-medical students of Southern Punjab, Pakistan. Asian Pac J Cancer Prev. 2015;16:979-84.
6. 6. Vieira RA, Biller G, Uemura G, Ruiz CA, Curado MP. Breast cancer screening in developing countries. Clinics. 2017;72(4):244-53.
7. 7. Mahboobi HR, Khorgoei T, Eftekhar F. New recommendations about breast self-examination. Iran J Cancer Prev. 2010;3(4):155-6.
8. 8. Kayode OF, Akande GOMT. Knowledge, attitude and practice of breast self- examination among female secondary school teachers in Ilorin, Nigeria. European J Scientific Res. 2005;10(3):42-7.
9. 9. WHO. World Health Organization, International Agency for Cancer Research. Breast Cancer/Breast Self‑Examination (BSE), 2020. Available at https://screening.iarc.fr/breastselfexamination.php . Accessed on 24 November 2020.
10. 10. Koc G, Savas H, Ergol S, Cetinkaya M, Aydin N. Female university students’ knowledge and practice of breast self-examination in Turkey. Niger J Clin Pract. 2019;22:410-5.
11. 11. Orock GE, Ndom P, Doh AS. Current cancer incidence and trends in Yaounde, Cameroon. Oncol. Gastroenterol Hepatol Reports. 2012;1:1.
12. 12. Engbang NPJ, Essome H, Koh MV, Simo G, Essam SDJ, Mouelle SA, et al. Breast cancer in Cameroon, histo-epidemiological profile: about 3044 cases. Pan African Med J. 2015;21:242.
13. 13. Globocan. 120-cameroon-fact-sheets. The Global Cancer observatory, Cameroon, 2018. https://gco.iarc.fr/today/data/factsheets/populations/120-cameroon-fact-sheets.pdf. Accessed on 24 November 2020.
14. 14. Gwarzo DMU, Sabitu K, Idris HS. Knowledge and practice of breast-self-examination among female undergraduate students of Ahmadu Bello University Zaria, Northwestern Nigeria. Annals African Med. 2009;8(1):55-8.
15. 15. Nde PF, Assob NCJ, Kwenti ET, Njunda LA, Tainenbe GRT. Knowledge, attitude and practice of breast self-examination among female undergraduate students in the University of Buea. BMC Res Notes. 2015;8:43.
16. 16. Ayed AJ, Eqtait F, Harazneh L, Fashafsheh I, Nazzal S, Talahmeh B, et al. Breast self-examination in terms of knowledge, attitude, and practice among nursing students of Arab American University. J Edu Practice. 2015;6(4):37-47.
17. 17. Abay M, Tuke G, Zewdie E, Abraha TH, Grum T, Brhane E. Breast self-examination practice and associated factors among women aged 20-70 years attending public health institutions of Adwa town, North Ethiopia. BMC Res Notes. 2018;11:622.
18. 18. Adetule CY. Breast self-examination (BSE): a strategy for early detection of breast caancer in Nigeria. Annals Oncol. 2016;27(9):19-29.
19. 19. Casmir ECI, Anyalewechi NE, Onyeka ISN, Agwu ACO, Regina NC. Knowledge and practice of breast self-examination among female undergraduates in South-Eastern Nigeria. Health. 2015;7:1134-41.
20. 20. Dadzi R, Adam A. Assessment of knowledge and practice of breast self-examination among reproductive age women in Akatsi South district of Volta region of Ghana. PLoS ONE. 2019;14(12):e0226925.
21. 21. Sani MA, Naab F. Relationship between age and Breast Self-Examination among women in Nigeria. IOSR J Nur Health Sci. 2014;3(6):34-9.
22. 22. Tuyen QD, Dung VT, Dong VH, Kien TT, Huong TT. Breast self-examination: knowledge and practice among female textile workers in Vietnam. Cancer Controls. 2019;26:1-7.
23. 23. Shrestha S, Chhetri S, Napit J. Awareness on breast self-examination among reproductive age women. JCMS Nepal. 2017;13(4):425-9.