A cross-sectional study was conducted to examine the knowledge and practice toward
breast self-examination (BSE), among a sample of female nursing student in University Sultan Zainal Abidin Terengganu. Using a purposed questionnaire, a total of 40 nursing student years 2 from Nursing Department completed the questionnaire. The mean age of the respondents was 20 years (SD = 3.7). All of respondent (100%) were single. The percentages of nursing student toward breast cancer and breast self examination were high (95%) seventy seven percent (77.5%) of respondent were practice the breast self examination and only twenty two were not perform breast self examination. most of respondent are not regularly perform breast self examination, only 7.5% do it regularly. the obstacle to perform BSE is not sure how to perform BSE
. The study findings suggest that the knowledge is but the practise is must be done regularly because the nurse should teach their client the right way to perform BSE. If the nurse cannot do it in right step how can they will teach their client
Background of study
1. Prevalence and incidence
Breast cancer is the most common cancer in women in most parts of the world. There is a marked geographical variation in incidence rate. In 2000, there were 1,050,346 cases reported with 372,969 deaths from breast cancer world-wide. The incidence ranged from an average of 95 per 100,000 in more developed countries to 20 per 100,000 in less developed countries.
The incidence (number of new cancers) is steadily increasing. The statistics are more frightening in countries like the USA where about 184,000 new cases of breast cancer are detected annually. The National Cancer Institute estimates that by age 50, one out of every 50 women will develop breast cancer. By age 80, it will rise to one in 10. If this risk is calculated over their lifetime, one in 8 women will suffer from breast cancer. One in 28 will die of the disease. One in 3000 women develop breast cancer during pregnancy and pregnant women tend to develop them usually in their 30s. (Only 2% of breast cancers are diagnosed in pregnant women.)
Presented in another way:
Every 3 minutes, one woman is diagnosed with breast cancer (USA)
Every 11 minutes, one woman dies from breast cancer (USA)
Every year, 30,000 women and 200 men are diagnosed with breast cancer (UK)
In countries where rates have been low, especially in Asia, the rate of increase has been the greatest with steep increases in the incidence as well as death rate (mortality).
Adapted from American Cancer Society (2003).
Breast Cancer in Malaysia
Breast cancer was the commonest overall cancer as well as the commonest cancer in women amongst all races from the age of 20 years in Malaysia for 2003 to 2005. Breast cancer is most common in the Chinese, followed by the Indians and then, Malays and breast cancer formed 31.1% of newly diagnosed cancer cases in women in 2003-2005.
Source from the National Cancer Registry
The Age Standardized Rate (ASR) of female breast cancer is 47.4 per 100,000 population (National Cancer Registry Report 2003-2005). Amongst the Chinese, it is higher at 59.9 per 100,000 population, for the Indians, the ASR is 54.2 per 100,000 and it is lowest in the Malays at 34.9 per 100,000 population. A woman in Malaysia has a 1 in 20 chance of getting breast cancer in her lifetime The cumulative life time risk of developing breast cancer for Chinese women, Indian women and Malay women were 1 in 16, 1 in 17 and 1 in 28 respectively. The peak incidence appeared to be 50-59 years old. In comparison, the next (2nd) commonest cancer in Malaysian women in 2002 & 2003 was cancer of the cervix, which only formed 12% and 12.9% respectively of total female cancers. The statistics for Malaysia was sourced from the National Cancer Registry Reports 2002 and 2003. Over time, the pattern of cancers, including breast cancer will be better established. It is only with continued reliable data that important decisions on planning and policy management can be made for Malaysia.
Estimates by the International Agency for Research in Cancers reported that in 2000, there were 3825 cases reported and 1707 deaths from breast cancer in Malaysia.
Breast cancer is the commonest female malignancy in Malaysia and all over the world. Its incidence in Malaysia in 2000 was 41.9 cases per 100,000. In 2002, 4337 cases of breast cancer were reported to the National Cancer Registry with an incidence rate of 52.8 per 100,000 and accounting for 30.4% of all diagnosed malignancies in Malaysian women. One in 9 Malaysian women has a chance of developing breast cancer. Breast cancer incidence in Malaysia is intermediate between rates of industrialized countries like the US 91/100,000 and developing countries like India 19/100,000. This situation is not permanent since the rate in developing countries is rising as women adopt lifestyles of the developed countries. Disease risk varies by ethnicity. Lifetime risk is 1 in 24 for Malays, 1 in 14 for the Chinese, and 1 in 15 for Indians. The age at diagnosis shows an opposite pattern being highest in the Indians and lowest in the Malays. The differences among ethnic groups reflect different age structures and lifestyle choices (parity, breast feeding practice, diet). Genetic risk factors have not been studies thoroughly in Malaysia. The risk of the disease increases with age being maximal at age 50-59. Women in Malaysia present with larger tumors and at later stages than women in the US. Certain health beliefs, lack of correct information, and inadequate health care facilities are a barrier to routine early detection and treatment of the disease
Breast Cancer is easier to treat the earlier it is found. For that reason, some experts recommend that women over age 20 perform a monthly breast self examination to look for new lumps and other changes.
Breast self-examination is a simple, very low cost, non-invasive adjuvant screening method for the detection of early breast cancer in women. Its purpose is important in case of a prompt reporting of breast symptoms which are important early detection messages for women of all ages, and to make women familiar with both the appearance and the feel of their breasts as early as possible. There is evidence that women who correctly practice Breast self- examination monthly are more likely to detect a lump in the early stage of its development, and early diagnosis has been reported to influence early treatment and to yield a better survival rate
It was found that mortality had fallen by 31%after 6-years for women aged 40-70 at the beginning of the trial. Unfortunately despite the benefits of regular Breast self-examination, few women actually examine themselves; in fact, majority does not even know how to do Breast self examination. Although opinions conflict about the value of Breast Self Examination (BSE)
1.2 Problem statement
Breast cancer is the second leading cause of cancer deaths in women today and is the most common cancer among women. .Breast cancer is the most common cancer among Malaysian women. There is a marked geographical difference in the worldwide incidence of breast cancer, with a higher incidence in developed countries compared to developing countries.
According to Malaysia cancer statistic (data and figure – 2006) found that the incidence of breast cancer case according to age between 0-9 years is 1 case, for to age 10-19 years – 6 cases and 20-29 years is 78 cases. It is show increase in cases and it happening to all groups. Because of that, it is very important for someone to detect early sign and symptom of breast cancer. All groups should know how to perform Breast self examination
Breast self-examination (BSE) is a screening method used in an attempt to detect early breast cancer. The method involves the woman herself looking at and feeling each breast for possible lumps, distortions or swelling.
Breast self-examination (BSE) is a low-cost, low risk procedure that can be repeated at frequent intervals, and has been advocated as a self-performed screening procedure.
1.3 Researcher experience
Trough author experience as a staff nurse in hospital and community health author found that many younger women at age 15-24 came to clinic to check the lumps because they don’t know how to perform the right technique of breast self examination . Usually at this age they feel shy to expose their breast to be palpable. End of the result the condition becoming worse. And for author experience as a clinical instructor at Nursing department, a few of the student always came with complain of they have a lump at their breast but not sure it is a lump or anything else
It is for this reason that the author chose to study student’s knowledge and practice of breast cancer examination. Having the knowledge of breast cancer could result in seeking medical attention early before complications develop.
1.4 Risk factors and symptoms of Breast cancer
1.4.1 Risk factors and sign symptoms:
A risk factor is anything that increases your chance of getting a disease, For example
Smoking is a risk factor for cancers of the lung, mouth, larynx, bladder, kidney, and
ischemic heart diseases. But having risk factor does not mean than the disease is certain.
Risk factors also can be divided into risk determinants and risk modulators. Determinants cannot be changed or influenced on the other hand risk modulators can be changed or influenced.
A. Determinant risk factors:
Gender: Being a woman is risk factors for breast cancer. Incidence of breast cancer in male is very low. Men account for approximately 1% of all breast cancer cases.
Growing age: Incidence of breast cancer is low before 40. In absolute term advancing age is the greatest risk for developing breast cancer. About 17% of the invasive breast cancer diagnoses are women in their 40s.while, 78% of the women diagnoses the same invasive breast cancer when they are in 50s or older
Genetic predisposition: Recent studies have shown that about 5% to 10% of breast cancer cases are hereditary as a result of gene changes (called mutations). The most common mutations are those of the BRCA1 and BRCA2 genes
Family history of breast cancer: Research has shown that women with a family history of breast cancer have a higher risk for developing the disease. Having 1 first-degree relative (mother, sister, or daughter) with breast cancer approximately doubles a woman’s risk. Having 2, a first-degree relative increases her risk 5-fold.
Personal history of breast cancer: A woman with cancer in one breast has a 3- to 4-fold increased risk of developing a new cancer in the other breast or in another part of the same breast.
Early age at menarche and late menopause: Early menarche and late menopause both increase the risk of developing breast cancer.
B. Risk modulators (Lifestyle-Related Breast Cancer Risk factors)
First birth at late age and low parity: Delaying childbirth or remaining childless
increase the risk of developing breast cancer. The higher parities and earlier age
at first pregnancy of women in many developing countries might account for
lower incidence of breast cancer in relation to developed countries.
Hormone Replacement Therapy (HRT): It has become clear that long-term use
(several years or more) of postmenopausal hormone therapy (PHT), particularly
estrogen and progesterone combined, increases risk of breast cancer.
Alcohol consumption: Recent studies have shown alcohol consumption increase the risk of breast cancer. In a summary analysis of epidemiologic studies, breast cancer risk increased between 40 and 70 percent with about two drinks daily.
Obesity and high-fat diets: The relation between the obesity, high fat intake and breast cancer is complex. Most of the studies found obesity and high fat intake is the risk factors for developing breast cancer. But the relation seems to be not strong or consistent.
1.4.2 Warning symptoms 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 are 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:
aˆ? Lump or mass in the armpit
aˆ? A change in the size or shape of the breast
aˆ? Abnormal nipple discharge
Usually bloody or clear-to-yellow or green fluid
May look like pus (purulent)
aˆ? Change in the color or feel of the skin of the breast, nipple, or areola
Dimpled, puckered, or scaly
Retraction, “orange peel” appearance
Accentuated veins on breast surface
Change in appearance or sensation of the nipple
Pulled in (retraction), enlargement, or itching
aˆ? Breast pain, enlargement, or discomfort on one side only
aˆ? Any breast lump, pain, tenderness, or other change in a man
aˆ? Symptoms of advanced disease are bone pain, weight loss, swelling of one arm,
and skin ulceration
(Source: Medline plus Medical Encyclopedia: Breast Cancer.)
1.5 Research Objective
1.5.1 General Objective:
To determine the level of the knowledge and practice toward breast self examination among year 2 female nursing student of University Sultan Zainal Abidin Terengganu
1.5.2 Specific objectives:
1. To determine the level of knowledge regarding breast cancer examination
2. To determine the practice of student on breast self examination.
1.5.3 Expected Benefit
The result of this study will identify level of knowledge and practice towards Breast Self Examination among nursing student and how frequent they practice the right steps. This study also will deliver the knowledge about right BSE to the student for them to apply on themselves and to expose the knowledge to the community.
1.5.4 Significance of project
Breast cancer is easier to threat the earlier it is found. There is evidence that women who correctly practice Breast Self Examination (BSE) monthly can detect a lump in the early stage of its development, and early stage of its development, and early diagnosis has been reported to influence early treatment and to yield a better survival rate. Unfortunately , despite the benefit of regular BSE ,a few women actually examine themselves , in fact , majority does not even know how to do BSE and opinion conflict about the value of BSEmen who correctly practice Breast Self Examination (BSE) montly can detect a
The aim of this study was to investigate the level of knowledge and practice towards Breast Self Examination among nursing student and how frequent they practice the right steps. This study also will deliver the knowledge about right BSE to the student for them to apply on themselves and to expose the knowledge to the community.
1.5.5 Scope of the project
Reference population : Student Nursing attending Medical and Health Science Faculty in UnisZA, Kuala Terengganu
Study subject : Year 2 Nursing student in nursing Department at Medicine and Health Science in UnisZA during study period (1st January to 31 March )
1.5.6 Definition of term
Student – anyone who is learning or someone who attends an educational institution (Wikipedia and free encyclopedia )
Nurse – is a healthcare professional, who along with other health care professionals, is responsible for the treatment, safety, and recovery of acutely or chronically ill or injured people, health maintenance of the healthy, and treatment of life-threatening emergencies in a wide range of health care settings (Wikipedia and free encyclopedia )
Knowledge – expertise, and skills acquired by a person through experience or education; the theoretical or practical understanding of a subject
Practice – a method of learning by repetition
Breast Self Examination – is a method of finding abnormalities of the breast, for early detection of breast cancer. The method involves the woman herself looking at and feeling each breast for possible lumps, distortions or swelling.
According to Israa M. Alkhasawneh et al (2008) It is therefore important for nurses as educators to have appropriate information and positive attitude toward early detection of breast cancer. The provision of cancer screening behaviour can be complicated by the fear and uncertainty associated with cancer. Nurses’ knowledge and awareness of breast cancer screening behaviour would impact patients’ behaviour by increasing their awareness.
Forgetfulness is the most important reason for not performing BSE. Furthermore, the fear of finding a mass, not having self-confidence, not being knowledgeable about how to perform BSE, laziness, and the absence of breast cancer in the family were the other reasons students refrain from the procedure. The main reasons for not performing BSE in the current study also were not know how to perform the examination, not having any previous problems in the breast, forgetfulness, and laziness. Sakine Memis (2009)
Nursing profession is one of them, and it is very important for self carefulness to be able to recognize the signs of their own illness. Breast self-examination is an examination that should be perfect for nurses. They have the knowledge of the clinical signs of Breast Cancer and of the examination technique, and they can do it themselves without consulting a physician. Furthermore, they are especially aware of the importance of the early detection of breast cancer for a successful treatment. It has been shown that confidence in one’s BSE ability is strongly correlated to BSE practice in the general population.
For more emphasis of BSE occurs in the work place and in undergraduate and postgraduate courses, nurses, teaching of BSE to clients may be increased. Also, the provision of BSE educational programs is necessary to increase nurses’ knowledge, confidence, performance, and teaching of BSE.( Ali Abu-Salem 2007)
It is supported by Agghababai sodabeh et al (2006) the nurses have a role for health and nature of the nurse client relationship facilitates opportunities for health education. Breast awareness will not necessarily translate into women becoming more familiar with their own breast tissue, unless they are encouraged to look at and touch the breast as a normal part of self -care health behavior.
Regarding to G Ertem, A Kocer a positive correlation was found between nursing work experience and their practice alongside BSE medical professionals. Almost all the nurses knew how to conduct BSE, but did not prioritize practicing it. Nurses have knowledge about breast cancer screening behavior, such as BSE, the rates of performance are not adequate. It is therefore recommended that to increase rates of regular breast cancer screening behavior, mass health protective programs be conducted, especially for female health workers who undertake the responsibility of raising breast cancer prevention and awareness in society.. (2009)
Dr.Osama et al Positive correlations were found between nursing work experience and their practice in BSE as working nurses. Studies like these can enhance the knowledge regarding BSE among nurses and other medical professionals. (2007)
According to Roupa Z1., et al (2002) the majority of the subjects in student nurse acknowledged the usefulness and the convenience of BSE in the early detection of the breast cancer. The majority of the subjects fail to perform BSE regularly. Considerable percentages of the subjects in student groups have insufficient knowledge of BSE.
From Mehregen Hj Mahmoodi et al (2002) Seventy-five percent of the women knew about breast cancer prevalence, but only 27% knew that breast pain is not a symptom of breast cancer. Although 73% of women did know that contact with a relative with breast cancer could not lead to development of breast cancer, the respondents’ knowledge of risk factors of breast cancer was not satisfactory. With regard to women’s attitudes toward BSE, the majority believed that it is not difficult and time consuming or troublesome (63% and 72%, respectively). Sixty-three percent of the respondents claimed that they know how to examine their breasts, but only 6% performed BSE monthly.
From study Ozgul Karayurt (2008), 6.7% of the students were performing BSE monthly and 20.3% of the students were performing BSE irregularly. Students’ knowledge about BSE might have affected their monthly BSE performance. However, only a small number of students who had knowledge about the BSE procedure were performing BSE monthly. The most common reasons for not doing BSE were “not knowing how to perform BSE” (98.5%), “not expecting to get breast cancer” (45.6%) and “not having a close relative with breast cancer” (42.9%).Consistent with the results of this study, in many studies, students noted that they did not perform BSE because they did not know how to perform it [4,29], and that they did not have a family history of breast cancer
This chapter contains the research design adopted for the study, a description of the study site, study population, sampling and sample size, data collection tool and method, data analysis, inclusion and exclusion criteria; and ethical considerations.
3.2 Research design
A cross- sectional quantitative study was conducted to determine the knowledge and practice of breast self examination.
3,3 Sample size
40 student of year 2 nursing student in department of nursing are selected as a sample for this study
3.4 Sample criteria
age 18 years above
year 2 student
below 18 years
year 1 and 3 student
3.5 Data collection tool and method
Data collection was accomplished using administered questionnaire (See appendix A). The questionnaire was divided into 3 major parts.
Socio demographic data: age, education level, marital status, and number of children..
Coding for part 1:
Question 1: Age
Question 2: primary = 1, secondary = 2, tertiary = 3, none = 4
Question 3: Single = 1, married = 2, divorced = 3, widowed = 4, separated = 5
Question 4: none = 1, 1-5 = 2, 6-10 = 3, >10 = 4
Part II : Knowledge of breast self examination:
Coding for part II
Question 5 : S 1- S 5 – True = 2 (correct answer )
– False = 0
Question 6: S 1 – S 10 – True -2(correct answer)
– False = 0
Question 7: S1 – true = 2 (correct answer) false = 0
S2 – S4 – False – 2 (correct answer ) , True – 0
Question 8 : S1- S3 – True =2 (correct answer),
false = 0
Question 9 : Yes = 0
No= 2 (correct answer)
Question 10 : Yes = 2 (correct answer)
Question 11 : Yes = 2 (correct answer)
Question 12 : Yes = 2 (correct answer)
Question 13 : Yes = 2 (correct answer)
Question 14 : Yes = 2 (correct answer)
Question 15 : Yes = 2 (correct answer)
Question 16: S 1 – S 3 – True -2(correct answer)
– False = 0
Question17: S 1 – S 2 – True -2(correct answer)
– False = 0
Part 111 : Practice
Question 18: Yes = (Practice), no – (not practice)
Question 27.1: monthly- 1 , every six month – 2, yearly- 3 , never practice- 4
Question 27.2: forgetting = 1, not sure how to do it = 2, difficult to perform = 3,
never taught how to do it = 4
Data collection was done by the researcher, from Feb. 2011 to Mac 2011 , which is a period of one months.
3.6 Data analysis
Questionnaires were coded to suit computer statistical package and data was imported into Statistical Package of Social Sciences (SPSS). Analysis was done using SPSS to calculate mean, standard deviation and frequency distribution according to knowledge and practice of breast cancer examination.
Questions to assess the knowledge of breast self examinations and the knowledge questions were and the scores were categorizes as follows:
<34 =low, >34 = high. The total marks for the knowledge are 70
3.7 Ethical considerations
The research was commenced only after receiving the approval of the Research Ethics Committee (MREC) of the Faculty of Health Sciences- University Technology Mara, and the local authority from Dean, Medicine and Health Science Faculty UniSZA, written informed consent was sought from the study participants at the commencement of the study. The aims and objectives of the research were introduced to the participants.. They were informed that their participation was voluntary and they were free to decline from the study at any stage. Participants were assured of their confidentiality while they participated in the study and privacy was maintained by not writing their names on the question
PRESENTATION OF RESULTS
4.1.1 Socio-demographic characteristics of the respondents
Forty female student nursing student are participate in this study .the table of the social demographic characterized are shown on table 1.
Majority of the female nursing student are same age, single and same educational level because they are join nursing course after Malaysian Certificated Education (SPM)
< 20 years
20 and above
Number of children
4.1.2 Level of knowledge
4.1.3 Symptoms of breast cancer
Very few of the respondents that only 5 (12.5% ) knew that pain is not a symptom of breast cancer. Majority of the respondents 37 (92.5%) knew that lump in the breast is a symptom of breast cancer. The commonest presentation of breast cancer which is a painless breast lump only a third 16(40%) of the respondents knew about it. A very of the respondents 4 (10%) knew about nipple discharge as a symptom of breast cancer, while more of the respondents 35(87.5%) had knowledge on skin changes as shown on table 2 below.
Pain in the breast
Lump in the breast
(Correct answer are highlighted in bold)
4.1.4 Risk factor of breast cancer
Only one of the respondents 1(2.5%) did not knew about family history of breast cancer as a risk factor. That is same with risk factor where only one of the respondents 1(2.5%) knew about never given birth as a risk factor for breast cancer. This also applied to having many children, only one third of the respondents 11(27.5%) knew that it was not a risk factor. More than half of the respondents 30 (75%) knew that advancing age is also a risk factor for breast cancer. More than a half of the respondents 37(92.5%) knew that breast feeding is not a risk factor for breast cancer. Very few of the respondents 5(12.5%) had knowledge that oral contraceptive is a risk factor for breast cancer.
Only one of the respondents 1(2.5%) knew that tobacco intake as well as excessive alcohol intake are risk factors for breast cancer respectively. One third of the respondents 12(30%) knew that high dietary intake is a risk factor. Being obese as one of the risk factor and more than half of the respondents 28(70%) knew about it. Thin women is not a risk factor for breast cancer only 19(47.5%) knew about it, as shown on the table 3.
Never giving birth
Having many children
Excessive alcohol intake
High dietary fat intake
(Correct answer are highlighted in bold)
4.1.5 Protective factor of breast cancer
Table 4 below shows the protective factors for breast cancer, All of the respondents 40(100%) and most of them knew that breast feeding is a protective factor for breast cancer and they also knew that not to be a breast feeding is not protective factor for breast cancer . The fact that you are young you are protected from the breast cancer, however half of the respondents 22(55%) knew about it. Having first child at older age almost half of the respondents 17(42.5%) knew that it is not a protective factor.
Not to breast feeding
(Correct answer are highlighted in bold)
4.1.6 Method can detect breast cancer
Majority of the respondents 39(97.5%), and 38(95%) knew that breast self-examination, clinical breast examination and mammogr