Awareness of Breast Cancer Warning Signs and Screening Methods among Female Residents of Pokhara Valley , Nepal

Breast cancer is the second most common cancer in the world and, by far, the most frequent cancer among women with an estimated 1.67 million new cancer cases diagnosed in 2012 (25% of all cancers). It is the most common cancer in women both in more and less developed regions with slightly more cases in less developed (883,000 cases) than in more developed (794,000) regions (Ferlay et al., 2014). Evidence suggests that early diagnosis and screening interventions might help to improve outcomes. In developing countries like Nepal with a lower number of women who are university graduates (UGs), education and beliefs have vital importance in the early diagnosis of breast cancer. Studies have shown that the majority of women in the developing countries do not


Introduction
Breast cancer is the second most common cancer in the world and, by far, the most frequent cancer among women with an estimated 1.67 million new cancer cases diagnosed in 2012 (25% of all cancers).It is the most common cancer in women both in more and less developed regions with slightly more cases in less developed (883,000 cases) than in more developed (794,000) regions (Ferlay et al., 2014).Evidence suggests that early diagnosis and screening interventions might help to improve outcomes.
In developing countries like Nepal with a lower number of women who are university graduates (UGs), education and beliefs have vital importance in the early diagnosis of breast cancer.Studies have shown that the majority of women in the developing countries do not
Early detection plays an important role in reducing mortality rates and improving prognosis.There are three recommended screening methods for early detection of breast cancer: mammography, clinical breast examination and breast self-examination (BSE).None of these methods are ideal for screening breast cancer; each has its own should be to make women aware of the various screening methods of breast cancer and to upgrade their knowledge about the warning signs of breast cancer.The present study was conducted to assess the awareness of breast cancer warning signs and screening methods in the women of Pokhara valley, Nepal.

Study design
It is a cross-sectional study conducted amongst female residents of Pokhara valley, Nepal through a semi-structured questionnaire.A questionnaire was administered during one to one interactions by trained research assistants.Convenient sampling methodology was adopted for the study.

Questionnaire design
Semi-structured questionnaire in English was developed after an extensive review of the literature and a pilot study.It encompassed the questions related to breast cancer warning signs and different screening methods.

Data collection
This study was conducted during July to December 2013.A total of 1420 female subjects were included in the study; The sample size calculation suggested that at 95% the following was considered for sample size calculation 2010).
The trained research assistants described the purpose and process of the interview to the subjects, the responses.For the purpose of this study an informed consent was taken from all subjects.

Data management and statistical analysis
The response to the questions was coded in 'yes' or 'no' format.The age, religion and ethnicity were included as demographic factors which may affect dependent variables.The data collected were entered in Excel 2003 and analysed using R 2.8.0 Statistical Package for the Social Sciences (SPSS) for Windows Version 16.0 (SPSS Inc; Chicago, IL, USA) and EPI Info 3.5.1 Windows Version.Descriptive statistics was used to interpret the data.

Ethics
Ethics

Characteristics of subjects
age ranged from 15 to 68 years.The age at menarche of the selected population ranged from 12 to 17 years.
The main religion of the subjects was Hindu, followed by Buddhist, Muslim and Christian.The main religion of the subjects were Hindu and Buddhist.The caste to which majority belonged were Dalit, Chettri and Brahmin.Education levels attained by most of them were class 12 and graduation.Majority of them were students, shopkeepers and housewives by occupation (Table 1).
The Nepalese women had poor awareness of warning signs viz.breast lump, lump under armpit, bleeding or discharge from the nipple, pulling of the nipple, changes in the position of the nipple, nipple rash, redness of the breast skin, changes in the size of breast or nipple, changes in the shape of breast or nipple, pain in the breast or armpit, dimpling of the breast skin (Table 2).
The women with nursing profession were completely aware about BSE, mammogram and warning signs of breast cancer.Graduates were more aware about BSE, mammogram and warning signs of breast cancer compared to other educational levels (Table 3).

Discussion
conducted in Nepal to assess the awareness of BSE among women.Majority, of the women were not aware about the recommended steps of BSE.Presumably, it is ideal for women to examine and feel their breasts for its shape, size and consistency.Any deviation from the normal should lead to a suspicion of breast related disorders or cancer.The best period for BSE is after the completion of menstrual period.
Our study supports the study done in Saudi Arabia which states awareness of breast cancer warning signs, of breast cancer by participants, also they were aware of other breast cancer warning signs such as bleeding or discharge from the nipple, dimpling of the breast skin, changes in the size of breast or nipple and pulling in the nipple.Knowledge of other warning signs of breast cancer was poor as only few females knew that nipple rash and redness of the breast skin are warning signs of breast cancer (Radi, 2013).
by Radi in Saudi Arabia, which revealed that females were aware of painless lump in the breast, bloody or any discharge from the nipple and changes in the skin of the breast as the most common warning signs of breast cancer (Radi, 2013).
A higher education showed an increase in the awareness level consistent with previous studies (Sreedharan et al., 2010;Norlaili et al., 2013;Sreedevi et al., 2014;Karadag et al., 2014).These women are exposed to health-related issues through mass media, internet and a better socioeconomic status enables support of screening services.
However, practice of mammography was 19.9% in comparison to other studies which was 19% among Malaysian women (Kanaga et al., 2011).Barriers to mammography as reported by previous studies were embracement, low income, non availability and lack of health insurance coverage (Kanaga et al., 2011).
The limitations of the study were number of respondents and sampling done in few areas.However, the results of of breast cancer warning signs and screening among Nepalese women.
The poor awareness of breast cancer warning signs, BSE and mammography among the Nepalese women in Pokhara are of concern and suggest that increased awareness and subsidised mammography be given to the population in general.
Breast cancer affects younger women in Nepal unlike in other developing countries where it is predominant in menopausal and post-menopausal women (Chauhan et al., 2011).A public health education program designed to focus on younger women is essential to generate awareness and reduce fear, denial, myths and misconceptions of breast cancer among Nepalese women.Immediate measures should be taken to increase the awareness through campaigns by non-governmental organizations focussed on rural areas and the family physician may be called upon to raise awareness and perform opportunistic screening.Findings from this study may be useful in helping the clinicians understand perceptions of patients regarding breast cancer and screening procedures.
In conclusion, the findings of the present study suggested that Nepalese women's level of awareness of breast cancer i.e. knowledge of breast cancer warning signs and BSE were sub-optimal.Immediate measures are needed to build the capacity of women towards BSE.
approval was obtained from the Institutional Research and Ethics Committee of Manipal College of Medical Sciences, Pokhara, Nepal (affiliated to Kathmandu University) which is authorized by Nepal Health Research Council (NHRC) (IEC Letter no./ Ref no.MEMG/NHRC/GA).