Self Breast Examination: A Tool for Early Diagnosis of Breast Cancer

Abstract

Breast cancer is a global health concern and a leading cause of morbidity and mortality among women. It has been identified as a major public health problem in both developed and developing nations because of its high incidence-prevalence, over-burdened health system and direct medical expenditure. Studies have shown that in most of the developing nations breast cancer is diagnosed in advanced stages of the disease when compared with developed nations and thus has a poor outcome and high fatality rate. This paper aims to check the effectiveness of breast self-examination in early detection of the breast cancer. In addition, it plans to consider all the factors which hampers with the uptake of the technique and what all could be planned to improve the current scenario. An extensive search of all materials related to the topic was made using library sources including Pubmed, Medline and google scholar searches. Keywords used in the search include breast self-examination, barriers in breast self- examination and breast cancer. Breast self-examination (BSE) has been identified as the only realistic approach in early detection of breast cancer in developing nations. A wide knowledge-application gap has been observed across the globe between the knowledge and the actual practice of BSE. Multiple socio-demographic factors, myths, cultural beliefs, lack of accessibility to the health care services have been identified as the reasons for the poor uptake of BSE. Considering the potential of BSE, there is an immense need for a public health education program to inculcate the practice of breast self-examination among women to minimize the fear, denial, myths and misconceptions. This requires a sustained political commitment and further studies to recognize the perceived barriers which are interfering with the uptake of BSE so that the greatest challenge of late presentation can be curbed and the chances of survival improved.

Full text

American Journal of Public Health Research, 2013, Vol. 1, No. 6, 135-139
Available online at http://pubs.sciepub.com/ajphr/1/6/2
© Science and Education Publishing
DOI:10.12691/ajphr-1-6-2
Self Breast Examination: A Tool for Early Diagnosis of
Breast Cancer
Saurabh RamBihariLal Shrivastava*, Prateek Saurabh Shrivastava, Jegadeesh Ramasamy
Department of Community Medicine, Shri Sathya Sai Medical College & Research Institute, Kancheepuram, India
*Corresponding author: drshrishri2008@gmail.com
Received June 14, 2013; Revised June 20, 2013; Accepted June 22, 2013
Abstract Breast cancer is a global health concern and a leading cause of morbidity and mortality among women.
It has been identified as a major public health problem in both developed and developing nations because of its high
incidence-prevalence, over-burdened health system and direct medical expenditure. Studies have shown that in most
of the developing nations breast cancer is diagnosed in advanced stages of the disease when compared with
developed nations and thus has a poor outcome and high fatality rate. This paper aims to check the effectiveness of
breast self-examination in early detection of the breast cancer. In addition, it plans to consider all the factors which
hampers with the uptake of the technique and what all could be planned to improve the current scenario. An
extensive search of all materials related to the topic was made using library sources including Pubmed, Medline and
google scholar searches. Keywords used in the search include breast self-examination, barriers in breast self-
examination and breast cancer. Breast self-examination (BSE) has been identified as the only realistic approach in
early detection of breast cancer in developing nations. A wide knowledge-application gap has been observed across
the globe between the knowledge and the actual practice of BSE. Multiple socio-demographic factors, myths,
cultural beliefs, lack of accessibility to the health care services have been identified as the reasons for the poor
uptake of BSE. Considering the potential of BSE, there is an immense need for a public health education program to
inculcate the practice of breast self-examination among women to minimize the fear, denial, myths and
misconceptions. This requires a sustained political commitment and further studies to recognize the perceived
barriers which are interfering with the uptake of BSE so that the greatest challenge of late presentation can be curbed
and the chances of survival improved.
Keywords: breast cancer, breast self-examination, risk factors, screening, awareness
1. Introduction
Breast cancer is a global health concern and a leading
cause of morbidity and mortality among women [1,2,3,4].
It has been identified as a major public health problem in
both developed and developing nations because of its high
incidence-prevalence, over-burdened health system and
added direct medical expenditure [5,6,7,8]. Trend analysis
of breast cancer indicates a rise by 50-100% in the
incidence of breast cancer in last 20 years [9]. Breast
cancer in men is uncommon, accounting for less than 1%
of all breast cancers but rise in incidence of male breast
cancer has also been demonstrated [10,11]. Breast cancer
can be distinguished from other cancers by the fact that it
occurs at a site which can be easily noticed and thus liable
for early detection & treatment [12]. The incidence,
mortality and survival rates for breast cancer vary across
the globe because of underlying differences in known risk
factors, availability of organized screening programs and
access to effective and affordable treatment modalities [1].
However, fatality rates tend to be higher in low-resource
countries [13,14].
Breast cancer associated morbidity and mortality can be
reduced through early detection by means of screening
programs [15], as it not only increases the chances for
successful treatment and cure of the disease [16,17], but
also improves chances of survival and lessens the need of
invasive treatment [18]. Ensuring availability of early
diagnostic & screening services and taking immediate
steps have been regarded as the two main strategies for
warranting improvement in the prognostic outcome
[19,20,21].
Studies have shown that in contrast to the developed
nations most of the developing nations have recorded a
poor outcome and high fatality rate owing to diagnosis of
the breast cancer in advanced stages [22,23,24,25,26,27,28].
In-fact, in a study done in India, five-year survival rate
was 56% among patients diagnosed with breast cancer at a
later stage in comparison to 85% for cases diagnosed early
[29]. Implementation of the preventive measures has been
acknowledged as the main tool in the fight against breast
cancer worldwide. Globally, breast self-examination
(BSE), clinical breast examination (CBE) and
mammography are the recommended screening test for
early detection of breast cancer. Due to lack of access to
diagnostic facilities, especially for women in low resource
settings, it is essential to empower them with BSE as a
primary modality for screening [28,30]. This review
article aims to review the effectiveness of breast self-
examination in early detection of the breast cancer. In

136 American Journal of Public Health Research
addition, it plans to consider all the factors which hampers
with the uptake of the technique and what all could be
planned to improve the current scenario.
2. Materials and Methods
An extensive search of all materials related to the topic
was made using library sources including Pubmed,
Medline, World Health Organization website and Google
scholar searches for one month. Relevant documents,
technical publications series, systematic reviews, research
articles focusing on practice of breast self-examination
published in the period 1980 – 2013 were included for the
review. The identified articles were then re-grouped into
different sections viz. risk factors and clinical features of
breast cancer; significance of breast self-examination;
practice of breast self-examination; impact of socio-
demographic factors on performance of breast self-
examination; role of nurses’ in advocating breast self-
examination; impediments in breast self-examination; and
implications for practice and research. Keywords used in
the search include breast self-examination, barriers in
breast self-examination and breast cancer.
3. Breast Cancer: Risk Factors and
Clinical Features
The etiology of breast cancer is multi-factorial and
studies have revealed significant interaction between
endogenous (hormonal / genetic) and exogenous (drugs /
radiation) factors [31]. Other factors like women’s age
[32,33]; parity [34]; practice of late initiation of
breastfeeding [34,35]; oral contraceptives & hormone
replacement therapy [31,33,36]; high dietary fat, excessive
alcohol consumption, positive family history [33]; age at
menarche, menopausal status, age at first live birth,
genetic mutations and benign breast disease have also
been cited [37,38,39,40]. With regards to symptoms of
breast cancer, bloody discharge from the nipple and
presence of lump in breast are well known [41].
4. Breast Self-examination: Background
Early diagnosis of breast cancer is of extreme
significance in improving the survival rates and quality of
life especially in low-income countries [42]. Although
awareness about breast cancer has long been advocated
across the world, unfortunately studies have revealed that
a major proportion of women are still not breast aware
[41,43]. As discussed earlier, techniques such as breast
self-examination (BSE), clinical breast examination (CBE)
and mammography have been advocated for bringing
about a marked reduction in breast cancer associated
morbidity and mortality [44,45,46,47,48]. As compared to
CBE and mammography which require hospital visit and
specialized equipment / technical expertise, BSE is helpful
in the regard that it is cost-free, simple, non-invasive
intervention carried out by women themselves [4,49,50].
Studies conducted in developing countries have
established BSE as one of the most reasonable and
feasible approach in early detection of breast cancer
[51,52,53]. BSE not only familiarize women with the
appearance/feel of their breast but also aids in early
detection of breast cancer [30]. Some of the studies have
reported that BSE is highly effective in increasing sense of
ownership about health, healthcare seeking behavior,
encouraging adoption of preventive health behaviors and
creating awareness about breast cancer among women
[54,55]. Multiple studies have concluded that women,
who regularly perform breast self-examination present
with smaller neoplasm and rare involvement of axillary
lymph nodes [29,30,56,57,58,59]. On the other hand,
some researchers have seriously questioned the usefulness
of BSE [60,61], while others have revealed no added
benefits of BSE in improvement of survival rates [62,63].
5. Practice of Breast Self-examination
With the rising incidence of breast cancer and absence
of any uniform breast screening strategy in most of the
nations, it is important to assess the knowledge and
practice of BSE in various age groups. Irrespective of the
multiple benefits of BSE, various studies identified a wide
knowledge application gap with regards to BSE, the
practice of BSE remaining low and variable in different
nations like 54% in England [59]; varying from 19% to
43.2% in Nigeria [50,64], and varying from 0 to 52% in
India [29,65]. In a study done in Korea, 27% of students
were engaged in BSE which was higher than what was
observed in students (10.1%) from Nigeria [66,67].
Among the health-care providers, around 90.3% women
performed BSE in Sao Paulo [68]; while in Turkey 28%
of the nurses and 32% of physicians did not practice BSE
[69]. Similarly, in a cross-sectional study conducted in
Iran it was revealed that most of the female health care
workers (63-72%) did not practice BSE [70]. Studies done
with an aim to assess the knowledge about BSE among
men have shown low level of knowledge [71,72]. This
was mainly because most of the pamphlets and
information-education-counseling materials usually deals
only with women’s breast cancer related issues [71,72].
6. Impact of Socio-Demographic
Parameters on Breast Self-examination
Studies have indicated that major proportion of the
women are not aware of what they need to do to protect
themselves from breast cancer or even how to check
themselves [73,74]. Further it has been reported that older
age (>45 years) and married women were more likely to
practice BSE than others [54,75]. In a study done in
Turkey, significant association was observed between
breast cancer knowledge and practice of BSE [54]. In
addition, women with a positive family history of breast
cancer had a better knowledge as well as higher frequency
of BSE than those with a negative family history [74,76].
The importance of education in the adoption of BSE
practice has been reported repeatedly [75,77,78].
Simultaneously the positive impact of educational
interventions on BSE and breast cancer awareness have
also been emphasized [79,80].

American Journal of Public Health Research 137
7. Role of Nurses’ in Breast Self-
examination
Health care providers, educational institutions and
mass-media are the important resources in dissemination
of any public health related information to masses. The
nursing staff can play a pivotal role in educating women
through specially designed learning programs in the health
care setting, as well as, through community outreach
approaches that suit the social and cultural settings [81]. A
study done in Turkey emphasized that nurses’ opinion
about breast cancer screening programs was crucial in
developing breast cancer educational programs [78]. It has
been reported that nurses who own adequate knowledge
about breast cancer can definitely contribute towards early
detection of breast cancer [82,83]. It has been realized that
nurses have an indispensible role in teaching women in
the community and in influencing their behavior,
especially those working in the rural healthcare set-up [12].
8. Barriers to Breast Self-examination
Though breast self-examination is considered an
important tool in early detection of breast cancer, multiple
barriers have been identified viz. awareness about breast
cancer [52,54,77,84]; lack of time, shortage of self-
confidence, fear of possible detection of a mass and
feeling of awkwardness about breast handling [85]; health
related assumptions [86]; anxiety and forgetfulness
[29,87]; low socioeconomic status and poor access to
health care facilities [88]; negative socio-cultural
perception about breast cancer and strong belief in
traditional medicine[89], and lack of motivational support
from parents, spouse or friends [90].
9. Implications for Practice
There is an immense need for a public health education
program to inculcate the practice of breast self-
examination among women to minimize the fear, denial,
myths and misconceptions. The messages and
recommendations about breast cancer screening must be
clear and the recognized barriers should be taken into
consideration for maximization of the outcome. Every
effort has to be taken to encourage the practice of BSE not
only among women but also among men as there is visible
increase in the incidence of male breast cancer. Healthcare
professionals including grass root level health workers
have to play a significant role in educating the public
especially the high risk men & women. The involvement
of community, family especially parents and spouse
should be facilitated to maximize the understanding of
BSE. Non-governmental organizations can be roped in
rural areas for this initiative. Concurrently, family
physicians should be encouraged to raise awareness; offer
clear and specific instructions on practice of breast self-
examination and promote referral as well.
10. Implications for Research
It is essential to plan and conduct community-based
studies to find the knowledge, attitude and practices of
BSE among both women and men as it will aid in
identification of the perceived barriers. Further studies are
needed to explore what customized interventions could be
implemented to improve the uptake and practice of BSE
and other methods for early breast cancer detection.
Results derived from these studies will help the program
managers and healthcare professionals to modify /
emphasize / strengthen the existing strategies so that the
greatest challenge of late presentation can be curbed and
the chances of survival improved.
11. Conclusion
Breast self-examination has been identified as the only
feasible and reasonable approach in early detection of
breast cancer especially in developing nations.
Considering the substantial role that can be played by BSE
in low resource settings, there is an urgent need for
interventions to implement and reinforce BSE in the
existing cancer awareness and screening programs. Also,
to bridge the wide knowledge - application gap, health
education and awareness campaigns should be organized
to empower the public on the causes, risk factors and
prevention of breast cancer.
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