|Ahead of print publication
Knowledge, attitude, and practice towards breast cancer and its screening among women in India: A systematic review
Akanksha Pal1, Neha Taneja2, Neha Malhotra1, Rajashree Shankar1, Bhavika Chawla2, Aanchal Anant Awasthi2, Rajiv Janardhanan2
1 Laboratory of Disease Dynamics and Molecular Epidemiology, Amity Institute of Public Health, Amity University, Noida, Uttar Pradesh, India
2 Laboratory of Disease Dynamics and Molecular Epidemiology and Laboratory of Health Data Analytics and Visualization Environment, Amity Institute of Public Health, Amity University, Noida, Uttar Pradesh, India
|Date of Submission||11-Jul-2020|
|Date of Decision||19-Sep-2020|
|Date of Acceptance||07-Oct-2020|
|Date of Web Publication||27-Apr-2021|
Amity Institute of Public Health, Amity University, Noida, Uttar Pradesh. 201304, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Breast cancer is the most common cancer among women in India causing increased mortality. Lack of awareness leads to detection of breast cancer in advanced stages and is difficult to cure then.
Objective: A systematic review was conducted to evaluate the knowledge, attitude, and practice of breast cancer and its screening among women in India.
Methodology: Literature search was done on electronic databases including PubMed and Google Scholar. Specific keywords related to breast cancer were used such as breast cancer or breast carcinoma AND awareness or knowledge or attitude or education or practice AND women or females AND India. Searches were limited to articles published in English language in the last 10 years.
Results: Fifteen studies were selected with a total of 7545 women between the age of 14 and 75 years. Study population varied from health-care professionals, rural and urban women to general population. Majority of the women were married with illiteracy levels ranging from 5.6% to 42.8%. The knowledge of breast cancer was seen to be 62.99%. Knowledge and attitude toward breast cancer screening were 78.67% and 71.10%, respectively. Most reviewed studies showed a significant association of the knowledge of breast cancer with the education level, marital status, and age of study participants.
Conclusion: Majority of the population knew about breast cancer and had low percentage for practice of screening methods. Programs on information about breast cancer are required. Women from all populations need to be motivated for positive change toward proper screening, early detection, and treatment of breast cancer.
Keywords: Awareness, breast cancer, breast cancer screening, breast health, breast self-examination, knowledge, attitude, practice
|How to cite this URL:|
Pal A, Taneja N, Malhotra N, Shankar R, Chawla B, Awasthi AA, Janardhanan R. Knowledge, attitude, and practice towards breast cancer and its screening among women in India: A systematic review. J Can Res Ther [Epub ahead of print] [cited 2021 Jun 22]. Available from: https://www.cancerjournal.net/preprintarticle.asp?id=314513
| > Introduction|| |
The global burden of cancer is increasing largely because of the aging and growth of the world population with an increase in practice of cancer-causing behaviors, particularly smoking, in economically developing countries. Breast cancer is the most commonly diagnosed cancer and the prime cause of death due to cancer among females, accounting for 23% of the total cancer cases and 14% of deaths due to cancer. In many low-income and middle-income countries, the incidence of breast cancer is now rising rapidly due to alterations in reproductive factors, lifestyle, and increased life expectancy.
Breast cancer has crossed cervical cancer and has become the most commonly occurring cancer among Indian women residing in urban areas. Indian women mostly present with breast cancer when it has already reached at advanced stage which reduces the rate of survival. Early-stage diagnosis has a better chance of survival and good prognosis. The whole scenario of the advanced stage presentation moves around the two major factors: nonexistent of breast cancer screening program and nonparticipation of women if any such program does exist. Undoubtedly, breast cancer will become an epidemic in India in another 10 years, if the current status of detection continues. As there is no exact etiological agent for breast cancer, early diagnosis and treatment is of paramount importance in improving the morbidity and mortality status. Early detection plays a pivotal role in the prevention of breast cancer. The 5-year survival rate has reached approximately 85% with early detection, whereas later detection has decreased the survival rate to 56%.
There is an urgent need for proper awareness programs in developing countries as their awareness and health-seeking practices have been shown to be very low. One of the biggest barriers to early detection and screening of breast cancer is lack of awareness. There is an urgent need to develop community-based, well-organized screening programs for breast cancer instead of coincidental screening of women. Breast self-examination (BSE), clinical breast examination (CBE), and mammography are some of the methods recommended for early detection and screening of breast cancer.
Despite cancer awareness campaigns, there is no proper program running in the country at present which is dedicated specifically to breast cancer. The studies show that women have a suboptimal level of knowledge regarding breast cancer and also have very enthusiastic attitude toward it but still have inadequate levels of practice toward screening methods for breast cancer. Therefore, there is a need to increase breast cancer literacy among women of Indian community. The present review was done to evaluate the knowledge, attitude, and practice toward breast cancer and its screening among Indian women.
| > Methodology|| |
Information sources and search strategy
An extensive search of qualitative literature published from 2010 to April 2020 was conducted in electronic databases of PubMed and Google Scholar with the following keywords: breast cancer or breast carcinoma AND awareness or knowledge or attitude or education or practice AND women or females AND India. All English language studies which included information on knowledge, awareness, attitude, and practice of breast cancer and its screening in India were retrieved. Gray literature and additional articles were also hand searched using the reference lists of different articles, along with forward citation searches.
The inclusion criteria for the selection of articles were as follows: (1) published articles in peer-reviewed journals with full text available online. (2) Articles which were published in the last 10 years. (3) Target population was women aged between 14 and75 years. (4) Studies from India. (5) Language was English. (6) Cross-sectional study design.
Exclusion criteria for the selection of articles were as follows: (1) Type of studies – case reports, case series, earlier reviews, and qualitative studies of breast cancer and its screening. (2) Studies conducted in countries other than India. (3) Articles published in languages other than English. (4) Articles which were published before 10 years. (5) Articles which were in preprint version or of which full text was not available online.
Study selection, collection process, and data items
All the articles were screened properly for any irrelevant study which did not follow the inclusion criteria, and duplicate articles were also removed. The Preferred Reporting Items for The Systematic Reviews and Meta-Analyses flow diagram was used as a guidance tool for the review process and results [Diagram 1].
Initial search yielded 1520 studies in English language. Study selection was performed independently, respecting the inclusion and exclusion criteria previously mentioned. Study selection was done seeing the relevant information available in articles according to the objective of the research. The primary objective was to seek information on knowledge about signs and symptoms, risk factors, early detection/screening methods of breast cancer, and attitude and practices toward breast cancer. Out of total 1520 studies, 1318 were excluded based on the title. Total 202 relevant studies were retrieved out of which 92 were on PubMed and 110 on Google Scholar. 182 studies were excluded as they were either closed access articles or duplicate studies or reviews which did not fit our eligibility criteria. Out of remaining 20 studies 5 of them had unclear or incomplete data so they had to be excluded. Therefore, 15 cross-sectional studies with relevant information published in the last 10 years in English language and which had diverse female population within targeted age group were finally included for the systematic review.,,,,,,,,,,,,,,
Data extraction and synthesis
We draw out the following key attributes of the studies: author, year published, study design, sample size, age group, place of study, knowledge of breast cancer, risk factors of breast cancer, signs and symptoms of breast cancer, knowledge of early detection and screening techniques, and attitude and practice toward screening. Articles were reviewed, and prime outcome data of all articles were indexed in Microsoft Excel. Later, interpretation of textual data was extracted to a Microsoft Word document. The author independently carried out the literature search and identified citations for knowledge, attitude, and practice of breast cancer and screening independently. Full-text articles were identified and assessed for eligibility after applying the inclusion and exclusion criteria. Critical appraisal of each study found eligible was done by the investigator.
| > Results|| |
The literature was searched on electronic databases, and initially, 1520 studies were found. By searching specific keywords, PubMed found 92 articles and Google Scholar found around 110 articles which were relevant to the topic. Out of these, 15 articles met the inclusion criteria and were included for the systematic review. The studies included were cross-sectional studies. The total sample size included 7545 women aged between 14 and75 years [Table 1].
Out of 15 studies, three studies were done among health-care professionals,,, two studies involved rural and urban areas,, two studies were done among college-going females, , and the rest were done on general population. Majority of the studies were conducted in urban cities such as Delhi, Bengaluru, Maharashtra, Rajasthan, and Lucknow while some of them were done on a rural neighborhood of Andhra Pradesh and Wardha (Maharashtra). Majority of the studies consisted of married women (41.4%–88.3%), with illiteracy rates ranging from 5.6% to 42.8%,[Table 1].
Most reviewed studies showed a significant association between the knowledge of breast cancer and the education level of study participants,,,,,, marital status, and age,,[Table 1].
Among reviewed studies, nine studies,,,,,,,, reported the knowledge of breast cancer where it was seen that women had 62.99% knowledge regarding breast cancer [Figure 1].
The general awareness level of women regarding risk factors of breast cancer was found to be adequate which was 59%.,,,, The most common risk factor reported by the women was diet and lifestyle which was 51.77%,,,,, followed by 46.55% of the women having knowledge about increased age as a risk factor.,,,,,,,, The lowest levels of knowledge were obtained for nulliparity (10.91%),,,, early menarche (16.30%),,,, and late menopause (17.65%),,,,, which are the strongest risk factors of breast cancer [Figure 2].
The studies reviewed showed knowledge regarding signs and symptoms of breast cancer also to be adequate. The highest awareness level among study participants was seen for breast lump (62.29%) which was reported by 10 studies,,,,,,,,,, followed by knowledge about changes in breast shape and size (50.30%).,,,,, The low level of knowledge was seen for nipple changes (26.61%),,,,, and discharge (28.66%),,,,,, [Figure 3].
12 studies reported knowledge about early detection/ screening methods, which showed 40.46% participants had knowledge about Breast Self Examination.
On observing the practice of screening methods in study participants, 14 studies,,,,,,,,,,,,, reported that only 27.37% of the women practiced BSE, while practice of CBE and mammography was even lower than that, i.e., 16.71%,,,,, and 7.12%,,,,, respectively [Figure 4].
|Figure 4: Shows comparison between knowledge and practice of screening of breast cancer|
Click here to view
Only 3 studies,, reported that 80.99% of the women had knowledge about treatment modalities of breast cancer.
Among studies reviewed, 78.67% of the study participants had knowledge about the early detection/screening methods for breast cancer. In this review, it was also observed that 71.10% of the study participants had positive attitude toward breast cancer screening. Despite having good knowledge and attitude toward breast cancer screening, the practice levels were still seen to be very low among study participants [Figure 5].
|Figure 5: Depicts knowledge and attitude toward breast cancer and practice of self-breast examination among women in India|
Click here to view
| > Discussion|| |
This systematic review was done to provide a complete picture of breast cancer literacy by studying knowledge, attitude, and practices of breast cancer and its screening among women in India. The review was suggestive of suboptimal level of knowledge about breast cancer among study participants which is 62.99%.Our results when compared to a study done in Central India by Siddharth et al. were found to be inconsistent as they reported 81.11% of females had no knowledge about breast cancer. Another study done among private school teachers showed similarity with our results, with knowledge about breast cancer being 55.2%.
Regarding risk factors of breast cancer, the low knowledge scores for nulliparity in our study, i.e., 10.91%, were consistent with a study done by Santhanakrishnan et al. on nursing staff which reported it as 11.6%. In the same study, increased age was seen as a risk factor in 10.6% of the participants, while in our study, it was 46.55%. Although more than half of the study participants in our review had heard about breast cancer, they had very low level of knowledge for the strongest risk factors associated with it which were early menarche (16.30%), late menopause (17.65%), and nulliparity (10.91%). This indicates that in spite of massive efforts done nationally for awareness of breast cancer, it has not reached at the community level. Furthermore, now due to globalization and adoption of western lifestyles, Indian women are marrying late, not having first childbirth at an early age, and also not breastfeeding till long which increases the risk factor for breast cancer.
A study done by Singh et al. among women in Chhattisgarh reported knowledge of pain 32.52% and discharge 25.45% as most commonly reported signs and symptoms which is consistent with our study wherein knowledge of pain and discharge was reported 38.54% and 28.66% participants, respectively. On comparison with another study done by Puri et al. among North Indian women, awareness of breast lump as a sign and symptom was seen in 47.2% of the participants which was again accordant to our result wherein 62.29% reported the same. In the same study, only 13.5% reported about change in breast size as a sign and symptom which was inconsistent with our study as 50.30% reported breast size as a sign and symptom of breast cancer.
Our review reported that 78.67% of the women knew about early detection and screening methods or had heard about it. A study conducted among rural women by Veena et al. revealed that only 5% of the women had knowledge about mammography and 80% had heard about BSE which is contrary to our results wherein 40.46% and 46.19% of the women had knowledge about BSE and mammography, respectively.
In our review, it was observed that 71.10% of the study participants had positive attitude toward breast cancer screening. A similar study done by Sharma et al. showed that 56% of the women had a positive attitude toward breast cancer. Women having knowledge about breast cancer had positive attitude and were willing to participate in the screening programs. Community participation or community screening of breast cancer is important in which even women who are not sure about the screening procedure still go for seeing as majority of the women doing it or because it is being provided for low cost or free.
However, practice toward (early detection/screening methods) BSE was seen to be 27.37% and mammography was seen to be 7.12% of the study participants. Only 16.71% of the study participants in our study practiced CBE which is very low, and a similar low practice of screening methods was seen in a study done on Kashmiri females, in which only 5.6% and 4% had practiced BSE and CBE, respectively. Furthermore, in a study done on Indian teachers, it was seen that only 36% had heard about BSE and this dismal awareness level was reflected in practice as none had ever practiced BSE, CBE, and mammogram. Mammography is a very useful but expensive technique and for this reason difficult to adopt in a country like India as a routine public health measure.
These figures in our review show that even after having proper knowledge and attitude toward breast cancer, women still do not practice early detection/screening methods. Lower practice levels could be because of many hurdles such as absence of any medical problems, inconvenient screening timings, lack of awareness of screening tests and its benefits, negligence, embarrassment due to the procedures involving genital exposure, fear of pain, or detection of cancer and considering oneself as not to be at risk of developing cancer.,
Furthermore, on comparing knowledge, attitude, and practice in between our study populations, 83.05% of the health-care workers,, had good knowledge about breast cancer as compared to rural and peri-urban populations,, which was 60.61%. In the study population of college-going females,, the knowledge level regarding BSE was 18%; therefore, the practice levels of BSE were 28.19% which were higher than rural and peri-urban population (11.53%) but lower than health-care workers (48.2%).
Breast cancer mortality is common in India because women present it in very advanced stages which could be majorly reduced by early detection and screening. This review surely indicates lack of breast cancer literacy among women in India. Lack of awareness is one of the barriers which needs to be removed for proper detection and prevention of breast cancer. Social stigma attached to breast cancer also needs to be cleared out, and women should be encourages for self-examination of their breasts which could be the first step in reducing the incidence of breast cancer.
This review has certain limitations: only published articles were included which may lead to publication bias. Efforts were made to identify and include all relevant articles but due to our exclusion criteria including some was not possible. Studies included in the review include different populations from different areas, but findings may not be generalized across the country as India has different kind of populations with different social and economic backgrounds, various cultures, regions, and other factors which may give wider contrasting features than observed. Some data could be false due to language and illiteracy barriers, as taken from rural population. Furthermore, the data taken are secondary data, and some women due to social or cultural circumstances might have hesitated to speak openly about breast cancer to an unknown person or possibly given false data.
| > Conclusion and Recommendation|| |
This systematic review revealed that more than half of the study population have adequate knowledge and positive attitude toward breast cancer and its early detection and screening methods, but still, there is a huge void which needs to be filled in terms of its practice.
Indian women need to be aware of risk factors for breast cancer to adopt appropriate practices for prevention. Effective nation and statewide cancer literacy programs as well as engagements with community-level organizations and the health system are urgently required. Targeted government programs in India and other low-income countries on early detection methods of breast cancer should urgently be implemented at health centers and health posts, which would definitely reduce morbidity and mortality from breast cancer.
Increasing the practice toward early detection/screening methods such as BSE, CBE, and mammography could help in detection of breast cancer in early stages and therefore can help in proper and early treatment.
Women need to be motivated to examine their own breasts and to detect any changes at the earliest. Women all over must come together and help each other out. The way ahead is by sharing information about the importance and technique of BSE and setting an example for others to follow as health-care professionals, Indians, and women.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]