311J Contemp Med Sci | Vol. 8, No. 5, September-October 2022: 311–316 Original Breast Cancer Knowledge and Screening Practice among Women in Makkah, Saudi Arabia Arwa F Flemban1, Saeed M Kabrah2, Suhail S Alfaifi3, Ahmed S Alsubhi3, Ayoub S Alzahrani3, Khalid A Alhazmi3, Samah Alharbi4* 1Pathology Department, Faculty of Medicine, Umm Al-Qura University, Makkah, Kingdom of Saudi Arabia. 2Laboratory Medicine Department, Faculty of Applied Medical Sciences, Umm Al-Qura University, Makkah, Kingdom of Saudi Arabia. 3Faculty of Medicine, Umm Al-Qura University, Makkah, Kingdom of Saudi Arabia. 4Physiology Department, Faculty of Medicine, Umm Al-Qura University, Makkah, Kingdom of Saudi Arabia. *Correspondence to: Samah Alharbi (E-mail: saaharbi@uqu.edu.sa) (Submitted: 04 August 2022 – Revised version received: 22 August 2022 – Accepted: 06 September 2022 – Published Online: 26 October 2022) Abstract Objectives: This study aimed to estimate the level of current knowledge regarding breast cancer in Saudi Arabia. We assessed the knowledge of breast cancer risks, the knowledge regarding the BSE and mammogram in Saudi Arabian females using a survey-based study. Methods: A cross-sectional study was conducted using a self-administered survey to assess the knowledge and practice of Saudi women toward Brest cancer examination. Collected data were analyzed using SPSS program. Results: A total number of 499 surveys were collected. The data showed that there was general lack of practice of BSE in the sample only 186 (37%) reported that they practiced regular BSE and only 16 (3%) reported that they went to the clinic for breast examination. Among all participants around 54% had poor overall knowledge of breast cancer 65% had poor knowledge regarding breast cancer risk and 93% had poor knowledge regarding clinical examination. Surprisingly, 56% had good knowledge regarding the clinical picture of breast cancer. Conclusion: This clearly showed that the lack of breast self-examination, mammogram and clinical examination is not a result of total lack of knowledge but due to lack of knowledge regarding risks and examination. This set of data provide a guideline for the focus and planning of future breast cancer awareness campaigns. Keywords: Breast cancer, mass screening, awareness ISSN 2413-0516 Introduction Worldwide, breast cancer is the most common type of cancer among women.1 It is ranked as the first cause of death, in the case of women, compared with other types of cancer, consti- tuting 15% of cancer death.2-4 Breast cancer incidence rates are increasing globally especially in developing countries, this may be due to lower screening rates and incomplete reporting.2 In Saudi Arabia, breast cancer considered as a major source of death in females.5 According to ministry of health in Saudi Arabia, more cases are detected at late stage compared to developed countries, 50% and 20% respectively, causing higher mortality rate, lower prognosis rate, and higher cost for treat- ment.6 Regretfully, according to the latest statistics in Saudi Arabia 15.5% of newly diagnosed breast cancer cases have dis- tant metastasis and 40% of cases are diagnosed with regional spread at diagnosis.6 This figure illustrates that there remains lack of awareness regarding breast cancer that resulted in the delay in early detection. The 40% of patients with regional spread would have been detected earlier if there was a success in recognizing the early signs by breast self-examination (BSE). Additionally, the 15.5% of patients with distance metas- tasis would have benefited from treatment by earlier detection through BSE and mammogram. The chance of developing a disease increases as the risk factors increase, and breast cancer isn’t an exception. Risk fac- tors for breast cancer include age, as the disease peaks around age 60 with a sharp incline beginning at age 40.7,8 In fact, One of the most recognized risk factors for breast cancer is the duration of exposure to the hormones that regulate the female menstrual cycle including estrogen (ER) and progesterone (PR). Thus, there is no surprise that early menarche and late menopause is one of the most important risk factors.9 Also, race is considered as a risk factor, and it is found that there is lower risk in black women.10 Another important risk factor if the family history and previous history of the breast cancer and any other cancer.7 Also, prolonged use of hormonal con- traceptive is of the known risk factors as well as menopausal hormone therapy.9 Other risks include; delayed childbearing, decreased duration of breastfeeding, smoking, alcohol con- sumption, and sedentary lifestyle.11 Early detection of breast cancer by screening tests leads to more success in treatment and therefore better prognosis.12 Commonly used screening methods for breast cancer include mammography, CBE (clinical breast examination), and BSE (breast self-examination). Performing mammography by skilled technologists and interpretation by experienced radi- ologists can result in 85% to 90% accuracy rate in identifying pre-clinical, non-palpable tumors <15 mm in size.13 This leads to reduction of mortality by 30% to 50%.14 ACOG (American College of Obstetricians and Gynecologists) rec- ommendations for average-risk women state that mammog- raphy should be offered at the age of 40, and to be started no later than the age of 50 annually or biennially. CBE may be offered every 1–3 years for women at the age of 29–39, and annually for women at the age of 40 and above.15 Regardless the low cost of CBE and BSE screening tests, the supporting evidence of their effectiveness on reducing mortality is still lacking.16 Early detection of breast cancer would be enhanced if women in Saudi Arabia had better knowledge about breast cancer and were aware of the importance of practicing the rec- ommended tests. Thus, this study aims to determine the level of basic knowledge regarding breast cancer risk factors and its mailto:saaharbi@uqu.edu.sa 312 J Contemp Med Sci | Vol. 8, No. 5, September-October 2022: 311–316 Breast Cancer KAP in KSA Original A.F. Flemban et al. clinical picture, to determine prevalence of breast cancer screening tests practice among women in Makkah, Saudi Arabia, and to determine the relationship between the mam- mogram practice and the knowledge of breast cancer risk fac- tors and clinical picture. Methodology Study Design and Study Population A cross-sectional survey-based study was conducted to assess the breast cancer related knowledge, attitudes and practice among females in Saudi Arabia. Data Collection The research goals were used to create a questionnaire. It asked for personal information as well as a history of linked health incidents. The survey also looked at women’s knowledge and attitudes about breast cancer, as well as their use of screening techniques. During the academic phase, data was collected by pre-trained microbiology students as part of their research projects. After a thorough examination of the literature, the ques- tionnaire was created based on prior research. A group of pro- fessionals in research technique validated the face validity of the questionnaire before it was administered to the study pop- ulation. The reliability was assessed using Cronbach’s alpha, which was determined to be >0.70. The questionnaire was accompanied by a survey cover page that explained the research and was signed and completed by the participants. To safeguard participants’ identities and preserve data confidenti- ality, complete anonymity was maintained. The numerous survey questions were designed after an exhaustive literature search, and the questionnaire was sepa- rated into many parts. Some of the questions were changed or removed based on the expert committee’s suggestions since they were either off-topic or inappropriate for the Saudi community. The questionnaire was divided into many sections. The first section elicited socio-demographic information about each study participant’s family income, education, mar- ital status, history of breast cancer, and family history of breast cancer. In the second section, there were questions on breast cancer knowledge. These questions were divided into three categories: possible risk factors, signs and symptoms, and methods of breast cancer screening and diagnosis, such as BSE and mammography. The respondents were requested to record their answers by choosing one of the three options: ‘Yes’, ‘No’, or ‘Don’t Know’. The scale was then dichotomized (Yes = 1 and No/Don’t Know = 0). Data Cleaning SPSS (Version 28) was used for initial data cleaning, variable coding, variable computation, assumption checking and anal- yses. Descriptive analyses identified any potential outliers, out of range values and missing data values. No out of range values were detected. Data Analysis Descriptive statistics were used to summarise the demographic and clinical characteristics of the participants. The descriptive statistics involved frequency and percentage analyses of cate- gorical variables. Validity of the Questionnaire Validity represents the degree to which any measuring instru- ment measures what it is proposed to measure.7 There are many aspects and methods for evaluating the questionnaire validity: 1. External (Content) Validity: Content validity refers to the degree to which the questionnaire delivers adequate coverage of the research questions.17 The content validity of the questionnaire is conducted through the supervisor review in order to assure that the content of the question- naire is consistent with the research objectives, and eval- uate whether the items reflect the research problem or not. Also, academicians from the ……… University reviewed the questionnaire and provided valuable notes to improve its validity that their comments are taken into consideration. 2. Internal Validity: Internal validity of the questionnaire is measured by the correlation coefficients between each item in one field and the whole field.7 Results Reliability and Internal Consistency of the Questionnaire Cronbach’s alpha was used to test for reliability and internal consistency of the questionnaire. As shown in Table 1, the two-section scale showed good to excellent reliability, as did the overall scale. Participants Characteristics A total of 499 Wemen participated in the current study and most of them were Saudi (85%). The sample was of high varia- bility to insure including all the possible layers of society and that included different educational levels, family income, mar- ital status, age groups, and region. Results (Table 1) indicated that the majority of the participants were married (49.3%), whereas 41.9% were single and only 8.8% were divorced or widowed. The mean age of the participants were 38.76 ± 12.71 years, nearly half of the respondents were below the age of 40. The study sample reflected a high educational level in which 69.5% of the participants held a bachelor’s degree. Only nine women (15.8%) reported a having a family member who was previously diagnosed with breast cancer. When asked about the source of their knowledge regarding breast cancer, it was found that the main source was internet/social media (54.7%). The frequency and percentage of participant demographic information are displayed in Table 2. Table 1. Reliability analyses for patient-centred communication scale Scale Number of items Cronbach’s alpha Breast cancer knowledge 22 0.848 Screening test practice and knowledge 14 0.615 Total 36 0.758 313J Contemp Med Sci | Vol. 8, No. 5, September-October 2022: 311–316 A.F. Flemban et al. Original Breast Cancer KAP in KSA Table 2. Frequency and percentage for participant characteristics (n = 499) Characteristic n % Nationality Saudi 424 85.0 Non-Saudi 75 15.0 Age group <40 243 48.7% 40–50 165 33.1% >50 91 18.2% Region Middle region 138 27.7 Western region 149 29.9 Eastern region 66 13.2 Southern region 98 19.6 Northern region 48 9.6 Marital status Single 209 41.9 Married 246 49.3 Divorced or widow 44 8.8 Educational level Undergraduate 105 21.0 Bachelor 347 69.5 Post-graduate 47 9.4 Total family income per month (Saudi Riyale) <5,000 138 27.7 5,000–9,999 159 31.9 10,000–15,000 111 22.2 >15,000 91 18.2 First degree relative diagnosed with breast cancer Yes 79 15.8 No 420 84.2 Breast cancer information source Reading 70 14.0 Lectures and seminars 67 13.4 Family and friends 46 9.2 Internet/social media 273 54.7 Your doctor 7 1.4 TV 36 7.2 Participant’s Level of Knowledge Regarding Breast Cancer Next the correct answers were analysed and presented in Table 3. The questions were categorised into three main sub- headings: knowledge regarding breast cancer risks, the clinical picture of breast cancer and the knowledge regarding the clin- ical breast examination (CBE). As seen in Table 3A, there were fair to poor overall knowledge regarding breast cancer. When subdivided into categories it is clearly seen that the knowledge regarding the clinical picture of breast cancer was higher from fair to good. On the other hand, there were poor knowledge regarding the risk factors and knowledge regarding the CBE. The highest recognised risk factor was the lack of physical exercise (sedentary lifestyle) (77%) followed by smoking (65.5%), oral contraceptives (60%), age (57%) and hormone Table 3A. Participant’s level of knowledge about breast cancer (n = 499) The question field n % Breast cancer overall knowledge Poor 268 53.7 Fair 205 41.1 Good 26 5.2 Breast cancer risk knowledge Poor 322 64.5 Fair 144 28.9 Good 33 6.6 Breast cancer clinical picture knowledge Poor 63 12.6 Fair 158 31.7 Good 278 55.7 Breast cancer clinical examination knowledge Poor 464 93.0 Fair 33 6.6 Good 2 0.4 Table 3B. Participants knowledge frequency and percentage for breast cancer (n = 499) The question field Correct answers n % Risk factors knowledge Early menarche (less than 12 years) 48 9.7 Late menopause (55 years and older) 94 18.8 No children 136 27.3 First child after 30 years 241 48.3 Breastfeeding total duration (2 years and more) 147 29.5 Obesity 236 47.3 Cigarette/Shisha smoking 327 65.5 Increase age (more than 40 years) 287 57.5 Sedentary lifestyle (no physical activity) 384 77.0 Oral contraceptives 303 60.7 Antibiotics 161 32.3 High dose of vitamins 123 24.6 Hormonal replacement therapy after menopause 273 54.7 Calcium therapy 31 6.2 Vitamin D after menopause 277 55.5 Clinical picture knowledge Breast mass 469 94.0 Nipple discharge 390 78.2 Nipple ulcer 354 70.9 Changes in breast skin color 384 77.0 Breast pain 66 13.2 Clinical examination knowledge Best examination time 202 40.5 Best age for mammography 31 6.2 Interval of mammography 31 6.2 314 J Contemp Med Sci | Vol. 8, No. 5, September-October 2022: 311–316 Breast Cancer KAP in KSA Original A.F. Flemban et al. replacement therapy (54%). The most known warning sign was detecting a breast mass, as reported by 94% of partici- pants, as shown in Table 3. The only fair knowledge regarding CBE among the participants was regarding the best time for clinical examinations (40% correct answers). Only 6% of par- ticipants in the study know about the recommended age for mammography. Participants Attitude toward Self-Examination and Clinical Examination There were poor practise of BSE and CBE in the participants. Only 37% reported that they practised BSE regularly and only 3% reported that they visited clinician regularly to do clinical breast examination (CBE), Table 4. Analysis for the Association of Knowledge and Practice of Self-Examination and Clinical Examination of the Breast As seen in Table 5a, poor overall knowledge (knowledge about risk factors, clinical picture, and CBE) was associated Table 4. Participants breast self-examination and mammography practise (n = 499) Attitude toward Practice n % Regular breast self- examination (BSE) Yes 186 37.3 No 308 61.7 Regular clinical breast examination (CBE) Yes 16 3.2 No 483 96.8 Table 5. Level of knowledge of breast cancer among Saudi women association with their practice of screening via (a) self- examination (b) mammography (n = 499) Breast cancer knowledge type Knowledge level (a) Self-examination (BSE) Chi-square P-valueYes No. (%) No No. (%) Overall Poor 66 (13.2) 202 (40.5) 45.2 <0.001*Fair 101 (20.2) 104 (20.8) Good 19 (3.8) 7 (1.4) Risk Poor 93 (18.6) 229 (45.9) 29.5 <0.001*Fair 72 (14.4) 72 (14.4) Good 21 (4.2) 12 (2.4) Clinical picture Poor 18 (3.6) 45 (9.0) 13.0 0.001*Fair 45 (9.0) 113 (22.6) Good 123 (24.6) 155 (31.1) CBE Poor 168 (33.7) 296 (59.3) 3.2 0.199Fair 17 (3.4) 16 (3.2) Good 1 (0.2) 1 (0.2) Breast cancer knowledge type Knowledge level (b) Mammography Chi-square P-valueYes No. (%) No No. (%) Overall Poor 30 (6.0) 238 (47.7) 0.408 0.816Fair 24 (4.8) 181 (36.3) Good 4 (0.8) 22 (4.4) Risk Poor 40 (8.0) 282 (56.5) 0.715 0.700Fair 14 (2.8) 130 (26.1) Good 4 (0.8) 29 (5.8) Clinical picture Poor 4 (0.8) 59 (11.8) 1.970 0.373Fair 20 (4.0) 138 (27.7) Good 34 (6.8) 244 (48.9) Practice Poor 46 (9.2) 418 (83.8) 19.3 <0.001Fair 11 (2.2) 22 (4.4) Good 1 (0.2) 1 (0.2) significantly (P < 0.001) with no practice of BSE and that the maximum of those preformed regular BSE had fair knowledge regarding breast cancer. Next, we subdivided the knowledge into three categories (risk, clinical picture and CBE) and assessed for association between knowledge regarding these categories and BSE practice. Poor knowledge regarding the risk factors for breast cancer was significantly associated with lack of BSE practice (P < 0.001). There were fair to good 315J Contemp Med Sci | Vol. 8, No. 5, September-October 2022: 311–316 A.F. Flemban et al. Original Breast Cancer KAP in KSA knowledge regarding the clinical picture of breast cancer and was associated with increased practice of BSE (P = 0.001). There were poor CBE among the participants in this study. The only association with CBE was seen between poor knowledge regarding the CBE and the practice of CBE (P < 0.001). Discussion Early identification and treatment of breast cancer rely heavily on knowledge and awareness. Clear and correct knowledge of breast cancer risks, diagnosis, breast self-examination (BSE), clinical breast examination (CBE) and clinical picture are important for all females. Detailed information regarding these factors forms the focus of the awareness campaigns. As a result, this research was carried out to assess the knowledge, attitudes, and behaviours of breast cancer screening among Saudi Arabian women. Our population had very low under- standing of risk factors, and diagnostic procedures (CBE). Our cohort’s knowledge of breast cancer seems to be lower than that seen in several previous research, however, we assessed for the reliability of the survey and the population and as seen in table 1 the reliability score was high (Alshahrani et al; 2019, Jahan et al; 2007).18 Several studies are available in Saudi Arabia that are aimed to assess the knowledge of females regarding breast cancer.10,19-22 The major conclusion of these studies is that there is general lack of knowledge in females in Saudi Arabia. These studies had concluded that the lack of knowledge is reflected in low early detection in the country and that improving knowledge via breast cancer awareness programs will aid in decreasing late diagnosis and thus, improving the chances of treatment and improve prognosis of the disease. Here, we assessed and analyze specifically the relationship between knowledge of (risk factors, clinical picture, BSE and CBE) and the attitude toward the practice of BSE and CBE. This type of analysis allowed the stratification of the possible cause of lack of practice and provide an insight into the areas that require further improvement in future awareness campaigns. A poor to fair knowledge about breast cancer was seen in all the participants of this study 263 (53.7%). The practice of BSE and CBE is very poor in the participants as well. This gave us an opportunity to assess for the exact area of knowledge that is associated with the lack of practice. A. Alam (2006) concluded that there is lack of knowledge regarding breast cancer self-examination and that there is moderate knowledge regarding breast cancer risks.23 Here, we found that the lack of BSE was due to lack of knowledge regarding the risks of breast cancer including the risk age, factors that increase the risk of breast cancer including obesity and hormonal therapy and oral contraceptives. Another aspect that is highlighted here is the assessment of the sources of information regarding breast cancer in the participating female. Previously, a study in King Saud Univer- sity concluded that mass media is an important source of information to improve the breast cancer awareness regarding self-examination.7,8 In agreement, we found that the major source of information for the ladies in this study was the internet and social media (54.7%) followed by reading (14%), lectures and seminars (13.4%). The top two sources of infor- mation regarding breast cancer can lack validity. The most important source of information and probably the most accu- rate is from the physicians and surprisingly we found that this is the lowest source of information considered in our study population (1.4% only). Thus, efforts to educate the public regarding the most appropriate sources of information is nec- essary. Also, more effort is needed from all responsible author- ities to enrich the public media including social media, internet websites and other easily accessible portals with the correct knowledge. The information provided through these means should be planned according to studies such as this one. A recent study has shown that although there is good knowledge regarding breast self-examination, the practice of it remains poor.24 Two recent studies have contributed the lack of practice to lack of knowledge in sup-population of females depending on the level of education (Suleiman 2014)24 and to the lack of sources in Arabic language.25 This is in agreement with our study, as we found that there is good knowledge regarding the clinical presentation of the disease. We con- cluded here that the lack of practice is attributed to lack of knowledge regarding risk factors and lack of knowledge regarding the details of clinical examination including the location, proffered time and intervals between examinations. Altogether, most studies agree on the importance of contin- uing raising the population awareness regrading breast cancer, its risks, BSE, and mammography practice. Conclusion Overall, Saudi women’s knowledge, attitudes, and behaviours about breast cancer were found to be lower than predicted. Although screening techniques and resources are readily accessible and free in Saudi Arabia, robust teaching initiatives and campaigns aimed at the female population are lacking. We can conclude that these are all evidence of the impor- tance of planning carefully for the awareness campaigns and to include the recommendations from all these studies in the plan and execution of such campaigns. Using the data ana- lyzed here, it can be suggested to plan for the awareness cam- paigns and to include the details that needs improvement in the public knowledge. Also, to use the most accessible and usable sources of information for the dissemination of such important details. Guided campaigns based of evidence from research such are this one is the next step to improve breast cancer situation in Saudi Arabia. Conflict of Interest None.  References 1. Torre, L. A., F. Bray, R. L. Siegel, J. Ferlay, J. Lortet-Tieulent, and A. Jemal. 2015. ‘Global cancer statistics, 2012’, CA Cancer J Clin, 65: 87–108. 2. Ferlay, J., I. Soerjomataram, R. Dikshit, S. Eser, C. Mathers, M. Rebelo, D. M. Parkin, D. Forman, and F. Bray. 2015. ‘Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012’, Int J Cancer, 136: E359–86. 3. 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