Breast cancer is originated from breast tissues, and it may occur in women and men but it’s far more common in women [1]. Like other cancers, breast cancer may progress and invade surrounding and distant tissues and organs.
The exact causes of breast cancer are still unknown but several endocrine, environmental, genetic, and lifestyle risk factors are linked breast cancer development. A woman who has a family history of breast cancer, for example, has two fold increased risk for breast cancer. Scientist discovered two tumor suppressor genes known as BRCA1 and BRCA2 that are correlated with increased risk for breast and ovarian cancer development [2]. Breast cancer risk for 70 years old women who has BRCA1 or BRCA2 mutation is found to be 57% and 49%, respectively [3].
Generally, women over 50 years old are more likely to develop breast cancer than younger women. The median age at diagnosis for breast cancer is between 60 and 65 [4]. Unfortunately, breast cancer is the major leading cause of cancer death in females between the ages 20 to 59 years [5].
As published by the Jordanian ministry of health in 2012, the median age at diagnosis for females was 51 years, ranging from 20 to 91 years. About 26% of the cases were in the age group between 50-59 years. While 30.9% were in the age group 40-49 years, 28.4 % of the cases are above 60 years, and only 14.7% of the cases are under 40 years old.[6].
Interestingly, early menarche (menstruation beginning before the age of 12 years) or late menopause (at the age of 55 or later) are associated with increased risk for breast cancer development [7]. Many other risk factors like contraceptive use, nulliparity and late age of the first birth are also correlated with increased breast cancer risk to varying degree.
Breast cancer is classified into four stages. Stage 0 represents carcinoma in situ or disease that has not invaded the basement membrane of the breast tissue. Stage I represents a small primary invasive tumor without lymph node involvement or with micrometastatic nodal involvement, and stage II disease usually involves regional lymph nodes. Stages I and II are often referred to as early breast cancer which can be cured. Stage III, also referred to as locally advanced disease, usually represents a large tumor with extensive nodal involvement in which either node or tumor is fixed to the chest wall. Stage IV disease is characterized by the presence of metastases to organs distant from the primary tumor and is often referred to as advanced or metastatic disease [2]. The 5 years survival rates is 99% for localized disease, 85% for regional disease and only 26 % for metastatic disease [8]
In Jordan, as a summary for breast cancer distribution in 2012, 37.9% of the diagnosed breast cancer cases are regional, 27.8% are localized, 11.7% are distant tumors and only 4.3% are in situ [6]. The highest rate of breast cancer was recorded to be in Amman city (51.5/100,000), while the lowest rate was in Tafela (6.8/100,000) [6].
2.3 Breast Cancer Screening Methods
The current guidelines for breast cancer screening and detection are a combination of breast self-examination (BSE), Clinical breast examination (CBE) and mammographic imagining[9]. Other technologies like breast ultrasound and magnetic resonance imaging (MRI) are being used as adjuncts to mammogram.
2.3.1 Breast self examination (BSE)
BSE is a painless method, free, and easy to practice but it has been compared with nonscreening activity and it showed no any add benefit in reducing breast cancer associated mortality [10]. Additionally, a review of eight studies did not report a benefit for BSE in the diagnosis, stage, tumor size or the death from breast cancer[11]. Although BSE is still recommended as it helps in detecting any abnormality in the breast [12], it may lead to increase false positive, more testing, biopsies and diagnosis of more benign breast diseases with no reduction in mortality [13].
2.3.2 Clinical breast examination (CBE)
CBE was not evaluated independently, so it is not possible to assess the efficacy of this method when it is used alone. In a study of 39,405 women of age between 50 to 59 years o, CBE alone was compared with CBE plus mammography, and after 13 years of follow-up, the mortality rate was the same in each group [14,15]. CBE may lead to false positive with more testing and anxiety or false negative and delaying in cancer diagnosis [16].
2.3.3 Mammogram
A mammogram is a low-dose X-ray procedure allow the visualization of internal breast structure. Mammogram is the most widely used breast cancer screening tool. It has been documented that mammographic imaging is correlated with 15% to 20 % reduction in mortality rate in females aged 40 to 74 years [17].
Mammography is recommended to be done annually after the age of 45 years and women should continue screening no matter the health status when they have life expectance more than or equal 10 years according to the updated recommendation for the American Cancer Society 2016 [18].
However, mammogram also may lead to false positive and biopsies [19,20], false negative 6% to 46% of women with invasive cancer will have negative mammograms, especially if they are young, have dense breasts [ 21,22] or have mucinous, lobular, or rapidly growing cancers [23].
One the other hand, mammogram still the most effective method for early detection of breast cancer as it can detect the disease before physical symptoms appear.
2.2 Breast Cancer Awareness
Breast cancer has an emotional and psychological impact on the patient affected with it and with his/ her family member, and further, it affects the community socioeconomic status. Thus, many strategies and interventions should be implemented to increase the public knowledge and awareness about breast cancer and breast cancer screening tools to help detecting this disease early [24].
The most common symptoms of breast cancer are the presence of fixed, painless, hard mass in the breast area. Moreover, breast cancer may be detected in asymptomatic patients at diagnosis by routine screening mammogram [2]. Meta-analysis of 87 studies reported that the survival rate between women begin the therapy in less than 3 months of the appearance of breast cancer symptoms is better than the survival rate of women treated after 3-6 months[25].
In a study to determine who and what influence the delay in breast cancer presentation, 185 cancer patients were interviewed. Delay in presentation within patients was documented in 19% of the interviewed patients and was correlated with increased tumor size (4cm or more), and a higher incidence of locally advanced or metastatic diseases [26].
A cross sectional study conducted among postgraduate students of the University of Ibdan, Nigeria to assess awareness, knowledge and practice of breast cancer screening. This study included 278 women, mean age was 27 ± 5.1 Std. 58.4% of the respondents claimed to practice BSE occasionally and only 11.4% had a good knowledge about BSE, out of 53 had CBE, 33.7% had good knowledge about breast cancer risk factors[43]. However, the percentage of CBE in this study is very small compared to another study conducted in Malaysia among female university students 70% of the respondent had had CBE [44]. This difference may be due to shortage in educational programs in the developing countries[45]. Moreover, in southern Punjab, Pakistan, cross sectional descriptive study conducted also among university students[46]. A total of 566 students including 240 medical students responded to a self administered questionnaire, the mean age was 23 ± 2.1Std and 22 ± 1.3 Std. this study indicated a sinful result since less than 50% of the students could give correct answer for all question. For example, only 22% of non medical students and 28% of medical students knew that breast cancer can affect men.
In Smsun, Turkey another cross sectional study was conducted among university femal students to investigate awareness and knowledge about breast and cervical cancer [47]. A total of 301 female students with a mean age 22 ± 5.91 years filled a self administered questionnaire. 65.4% had a knowledge about BSE but only 52.2% only practiced BSE. The result of this study indicated gap in knowledge among the university student in Samsun,Turkey about breast cancer.
A study among three universities in Ajman,United Arab Emirates (UAE) recuted 392 females student aged 18 to 22 years old to explore the knowledge about breast cancer and it’s prevention [48]. Out of 40.6% had low/below average knowledge about risk factors, 45.9% had knew had low or below the average knowledge score about warring signs and 86.5% had low or below the average knowledge score about the methods of early detection.
In Ain Shams university, Egypt a total of 543 female students participated in a cross sectional study aimed to determine the overall knowledge about breast cancer risk factors, symptoms and early detection methods [49]. The most commonly known risk factors were smoking (66.9%), genetic (63.7%) and radiation to th chest (63.7%). Out of 81.6% of the students know that breast lump is symptom for breast cancer. Among the respondant only 1.3% practice BSE monthly, 47.7% had not know how to do BSE and 35% were not interested in BSE. These findings are correlated with insufficient knowledge about breast cancer risk factors, symptoms and early detection methods.
In Jordanian study aimed to assess the knowledge of jordanian female students about breast cancer and their practice of BSE [50]. A total of 900 female students age between 18 to 37 years old were included form the University of Jordan in Amman. 22.7% of the respondents believed that breast cancer is caused by medical condition, 16.4% knew that old age is risk factor and only 12.8% knew that breast cancer is genetic disease. Unfortunately, 34.9% of the students aware of BSE and only 11% practice BSE. According to the Ministry of Higher Education in Jordan, there are more than 27 university [http://www.mohe.gov.jo/ar/pages/Statistics.aspx}], but this study included females students from only the University of Jordan that cannot be used to give interpretation about the whole Jordanian university students.
On the other hand, binational cross sectional study was conducted in United States-Mexico to assess the knowledge, attitudes, and breast cancer screening practicing [51]. the number of participants from Mexico was 128 and from US. Latina was 137 aged more than 40 years old. Higher knowledge level recorded among Mexican women than US. Latinas (54.8% compared to 45.2%). Although high knowledge level of BSE among Mexican females, out of 67% of Mexican females had never performed mammogram or ultrasound and 55% had never had CBE. In contrast, higher breast cancer screening levels seen in US. border Latinas comparing with Mexican. This is may be due to the shortage of breast cancer screening programs along the US.-Mexico border.
A total of 1162 Chinese women aged 35 to 69 years old were surveyed to investigate the knowledge, attitudes and behaviors regarding breast cancer screening[52]. Overall, 90.6% were interested in knowing the risk factors and 78.5% in prevention of breast cancer. the knowledge rate for clinical symptoms and screening was 27.8% with 49.4% did not know the early warning signs for breast cancer. Of the 1162 interviewed females only 31.2% were performed breast cancer screening, 47.9% practice breast cancer screening irregularly and 20.9% never screened.
In order to examin the knowledge, attitude and practice about breast cancer a community based cross sectional study was conducted in Central India[53]. A total of 1000 women aged 13 to 50 years were included in this study, 609 were from rural area. The study documented low level of knowledge in rural Central India about breast cancer and it’s risk factors and symptoms. Furthermore, among the 1000 women only less than 7% had heard about BSE and just 4.5% of women ever performed BSE out of which 3.45% only from the rural areas and 6.14% from urban areas. What is promising that the majority of respondents ( 95.4% of the urban and 96.4% of the rural) were interested to approach the doctor when they feel a mass in their breasts.
In a study conducted among 603 market women aged 30 to 39 years in Ibdan, Nigeria to estimate the knowledge and beliefs about BSE [54]. Although 61.7% of the recruited women agreed that BSE is a method for breast cancer screening, Only 29.2% had performed BSE. Another study of 508 women aged 18 to 55 years carried out in Bagdad, Iraq to assess knowledge and practice about breast cancer [55]. About 61.2% of respondents had poor knowledge, only 30.3% practiced BSE and 41.8% did not know how to do BSE. This study was reported poor knowledge and low practice level of BSE.
A descriptive, cross sectional study was conducted among 369 women aged 20to 30 years in Muscat, Oman to assess the knowledge of breast cancer symptoms [56]. Overall, 19% of the women had poor knowledge, 59% had average knowledge, 21% had good knowledge and only 1% had excellent knowledge. Therefore, this study concluded a lack of knowledge on breast cancer symptoms between Omani women.
A total of 370 female teachers aged 35 to 45 years selected from 24 governmental school in Gaza City were surveyed to assess the knowledge and behavior toward breast cancer screening [57]. Overall, 24.6% of the teachers did not know any screening methods, 62% practiced BSE and more than 75% had never undergone CBE. These findings indicates poor knowledge in breast cancer screening methods among Gaza women.
A study to assess the awareness about breast cancer and it’s risk factors and screening methods was conducted in Malaysia among 134 women considered in high risk group aged between 18 to 60 [58]. This study documented that 71% of the recruited had poor knowledge about breast cancer risk factors. However, majority of the respondents were aware about BSE (92.4%) and mammogram (87.8%), only 25 women had mammogram and only 15 women of those aged between 40 to 60 years which is suggested to be the recommended age for mammogram. Furthermore, 86.3% already knew that BSE and mammogram help in the early detection of breast cancer. As breast cancer screening is vital for this high risk group specific and targeted programs must be established to increase the knowledge and practice about breast cancer screening. This type of targeted research is few in Jordan and in our study we will assess the knowledge and attitude in the included high risk group about breast cancer and breast cancer screening.
Two studies were conducted in Malaysia targeting health care providers. The first one targeted the community pharmacists to analyze their knowledge about breast cancer and their involvement in breast cancer awareness programs [59]. This study included 35 pharmacists with the mean age 34.7 ± 5.9 Std years. only 11.3% of the pharmacist answered the questions about breast cancer knowledge correctly and the mean knowledge about breast cancer risk factors and screening was just 56%. No one of the respondent were involved in breast cancer health promotion program. The second study was conducted among medical students in public university in Terengganu, Malaysia to assess the knowledge about breast cancer, its related risk factors and chemotherapy [60]. A total of 239 students with mean age 19.8 ± 0.1 Std were included in this study. Overall, 20.9% had poor knowledge about breast cancer and chemotherapy, 71% had moderate knowledge and just 7.9% had high knowledge.
In a study among 158 health professionals (27 medical, 131 paramedical) in 17 hospital in Bangui, Central Africa to determine the level of knowledge in breast cancer among health professionals [61], the average knowledge about breast cancer was 47.6%, about risk factors 23.8%, about treatment 34.3% and about diagnosis 45.5%. Further, the level of knowledge about risk factors, diagnosis and treatment was lower in paramedical than medical health professional.
In this context, a cross sectional study conducted in primary health care centers in Jeddah, Saudi Arabia aimed to assess the knowledge of breast cancer and breast cancer screening practice among nurses [62]. A total of 210 nurses with mean age 36.9 ± 8.6 Std. generally, the percent scored less than 50% of the total knowledge about breast cancer was only 11% and about risk factors was 35% with 67% scored more than 75% of the total score in breast cancer warning signs. Among the respondents 62.8% of the nurses performed BSE but only 4% practice BSE monthly, 81% of the nurses had never undergone CBE and only 14% had mammogram. Again this study indicated the need for education programs about breast cancer and breast cancer screening among nurses. In our study we will analyze the knowledge and attitude about breast cancer and breast cancer screening among health science specialist and student and we will compare it with other specialty and non educated females.
2.5 Breast Cancer Screening participation Rates
Few studies established to view the participation rates in breast cancer screening tools, but their results were unfortunately low among Arab countries. Rachivandran et al.,2011 reported that among 719 women included only 23.1% practice BSE, 14.2% undergone CBE and 8.1% had mammogram [31].
In Palestine, among 397 respondent women aged over 50, 60% had never attend mammogram, 28% had ever undergone CBE [32]. Furthermore, in Iran, a study accomplished among 320 women aged more than 35 years only 28% had mammogram [33]. Another study in Iran included 1402 women only 17% were practicing regular BSE, 20% had irregular BSE and 63% had never performed BSE [34]. Jordan also has a low rate of regular BSE performance, as mentioned in a study included 519 women only 7% performed BSE regularly [35]. However, newer study included 507 of Jordanian females aged 40 to 69 years the BSE rate was 34.9% and 16.8% undergone CBE and only 8.1% had mammogram [28]. In this context, Breast cancer screening barriers and awareness need to be evaluated in Arabic countries and more research should take a place in this zone.
2.6 Breast Cancer Screening Barriers
The principle aim for health care provider in the field of breast cancer is to early detect and treat the patients. Therefore, determining, analyzing and targeting barriers for breast cancer screening may be helpful.
Many studies were conducted to assess breast cancer screening barrier. A systemic review for breast cancer screening barriers extraction accomplished among different scientific search engines such as pubmed and ovid scopus, 21 related articles were included [1]. Lack of knowledge, beliefs and wrong information’s about breast cancer screening [2,3,4], breast cancer screening cost and lack of time for attending screening [5,6,7], fears of positive results and fear of pain from some of screening methods [8,9] and embarrassment [10,11,12,13], all are reported as breast cancer screening barriers.
A cross sectional study among Urban Indian women accomplished to identify cancer screening and early detection barriers [14]. The most common reason for not undergoing breast cancer screening among respondent in this study was the lack of knowledge on how to screen.
Strikingly, several studies in Jordan and Iran reported that health care providers have a lack in knowledge also in breast cancer screening and risk factors which may lead to transporting wrong information to the public [15,16,17,18]. In addition, some of the health care providers failed to perform CBE on their patients [19] and others do not recommend BSE for their patients [20]. A cross sectional study was conducted in Kasr Al Ainy medical school at Cairo university in Egypt to explore the level of knowledge among medical student and postgraduate about cancer screening. Low to moderate level of knowledge was documented among the respondent [21].
In Israel Arab women, embarrassment was found but not strong enough to be recorded as a barrier [22], but the fear of losing traditional role as a women if diagnosed with breast cancer was a big barrier [23,24].
In Qatar, a study among pharmacist, although more than 60% of the included pharmacist interested to be involved in breast cancer screening education, 78% of the respondent never provide any educational material about breast cancer screening [25].
Descriptive study among Jordanian and Palestinian American women, documented four main barriers to breast cancer screening: 1) cultural barrier like embarrassment and shame views, 2) immigration related barriers like language and insurance status, 3)general barriers like lack of motivation and knowledge or fear of getting breast cancer, 4) irrelevant barriers like health professional delay and availability of service [26]. The same study suggested to create specific educational materials for Arab middle Eastern immigrate women to improve their involvement in breast cancer screening[26].
In a Turkish study, socioeconomic barriers to mammogram screening were evaluated by comparison between two population-based survey studies that investigated mammogram screening barriers in women aged 40-69 years and living in two different cities one with a lowest socioeconomic status (Mus) city and the second one is Istanbul which has the highest socioeconomic status in Turkey [27]. Mammogram screening rate was higher in Istanbul thane Mus (49% vs 35%). Additionally, Women younger than 50 years old and uninsured has very low level of mammogram screening. Hoever, knoledgable women about breast cancer and women how were being educated by her doctor about breast cancer have a high mmogram screening rate among females in both cities. On the other hand, false beliefs about mammogram radiation reduced mammogram screenin rate among females in both cities [27].
In Jordan, a cross sectional study was conducted in 6 governorates to assess mammogram screening barriers among women aged 40 to 69 years [28]. the most common barriers were the fear of result(63.8%), low support from surrounding (59.7%), financial barriers (53.4%) and fatalism took 51.1%. Although, 14.7% of the diagnosed breast cancer cases in Jordan their age is under 40 [6], this study does not included females under the age of 40 years. Jordan is an Islamic country with specific tradition, however, this study did not discuss embarrassment as a barrier for mammogram screening which is suspected to be the most common barrier. Additionally, this study used a leading questions that may lead the respondent to take wrong information about breast cancer screening like ” I do not have pain, this indicates I have no breast cancer, and therefore I there is no need for me to be screened” and “I have not noticed any change in my breast, this indicates I have no breast cancer, and therefore there is no need for screening” [28].
Interestingly, the most common breast cancer barriers are able to be broken. For example, increasing the education programs to increase public awareness, using internet and the social network sites like facebook, instegram, twitter, and snapchat all may help in spreeding the knowedge about breast cancer and breast cancer screening. Improving the health care provider involvement in breast cancer screening is also advocated [29,30]. On the other hand, providing free screening programs will encourage uninsured women to perform screening and visit the specialized doctor for CBE.
2.5 Breast Cancer Screening Cost
The cost effectiveness of breast cancer screening was evaluated and compared with the need for surgery or treatments. For example, zelle et al.,2012 reported that CBE is cost effective in Ghana [36]. Yearly mammogram after the age of 50 years and every two years in high-risk women ages 40–49 years was cost-effective in Mexico [37]. Mammogram for females aged 40to 69 years every two years in Hong Kong SAR, China, was cost-effective[38]. On the other hand, mammogram screening every three among women aged 45 to 65 years in the Republic of Korea was not cost-effective [39].
An economic evaluation study for the cost effectiveness of breast cancer screening program using mammogram in women aged 35 to 69 years old among south east Iran [40]. This study concluded that screening is more cost effective than non-screening, but they suggested that including screening programs in the insurance package is no longer recommended since the target women have a low participation rate [40].
Another study estimated the cost effectiveness of breast cancer screening in Canada reported that the benefit and the cost of breast cancer screening increased with the number of screen per women [41]. While the willingness and the recall for further examination is affecting the decision on how to screen in Canada [41].
A systemic review for 17 mammogram screening data set concluded that mammogram screening is cost effective in most of western countries but not in Asian countries. This result may be related to the incidence rate or to the racial characteristic like dense breast tissue [42].
In Jordan, no or little data available about the cost effectiveness of breast cancer screening comparing with no screening. Economic research are required in this area to modify and redirect breast cancer screening education programs.
Strikingly, in Jordan, no regular systemic screening program is available so that this service uptake is very low. It is recommended to create national programs focused on mammographic screening for breast cancer and to remove the current barrier prevent women from being screened for this awful disease.
In this cross-sectional study, we aimed to explore breast cancer screening tools practiced in Jordan and the barrier for mammographic screening.