Breast cancer is the second most common cancer in the world and the deadliest cancer in women worldwide by far, it has become a real public health concern and challenge as it is the leading cause of cancer-related deaths amongst women, particularly in developing countries where the situation is seriously increasing  . About 2.1 million women were diagnosed with breast cancer in 2018, and 626,679 breast cancer-related deaths were reported. These represented increases of 19% in the incidence and 17% in the mortality rates as compared to 2012    . In Africa, breast cancer represented 16% of cancer incidence and 18.3% of cancer-related mortality in 2018. In Cameroon, the situation is becoming alarming as breast cancer-related mortality rate displayed an increase of 34% between 2012 and 2018. 3273 new cases were diagnosed and 1780 women died of breast cancer in 2018, ranking the cancer with the highest incidence and highest death toll in Cameroon  . Also alarming, the number of women younger than 35 diagnosed with severe high-grade breast cancer has been increasing   . The five-year median survival rate is 22%, and most patients die within 12 months after diagnosis    .
Early detection of breast cancer in asymptomatic women through screening is aimed at detecting the disease when it is less invasive, reducing advanced stage-associated morbidity and its rate of mortality  . Tools like the widely recognized Breast Cancer Risk Assessment Tool (BCRAT or Gail model) that were developed and adapted for the disparity in racial and ethnic groups in developed countries, in particular in the United States, has been proving challenging to adapt to developing countries  , including in Cameroon, where information about the epidemiology and diversity of dominant risk factors of breast cancer in female populations is often scarce  .
Few women in Cameroonian cities attend national screening programs when available, partly due to the lack of awareness about breast awareness and screening methods  . Unfortunately, mammography is still inaccessible to the majority of the population due to high costs. Thus, cases with breast lumps are detected most often accidentally and more than 80% of cases are diagnosed in late stages (stages III and IV) where the disease usually has a poor prognosis  , explaining why in most African countries, the breast cancer survival rate of Cameroon is low. Thus, breast cancer screening population should be a priority in this country, particularly in rural areas where healthcare centers are lacking   , considering that due to environmental differences, breast cancer incidence is expected to be different as compared to cities   . The present study was undertaken to assess the awareness of breast cancer warning signs and screening methods in the North Region of Cameroon. We hypothesized that poor awareness about breast cancer, its screening methods and signs by the general population are the major drivers of late diagnosis of breast cancer in Cameroonian rural areas.
2. Materials and Methods
2.1. Study Procedures and Ethical Considerations
From August 1st to December 28 2019, a cross-sectional and descriptive study was conducted in six health facilities of the North Region of Cameroon. Participants were recruited in the health facilities using simple random sampling. After being presented individually with the study rationale and detailed information on procedures, each participant willing to join the study had to sign an informed consent form. Afterward, she was submitted to a questionnaire that aimed to assess awareness about breast cancer and screening practice, breast cancer risk factors, and to collect some sociodemographic data. Then, a physical breast examination was performed. Women previously diagnosed with breast cancer and women undergoing unilateral or bilateral mastectomy were not included.
Our study participants were 475 women randomly selected among the residents of the rural areas around the city of Garoua, North region, Cameroon. Signed informed consent was obtained from each participant at recruitment. Before analysis, the data collected were anonymized to protect the privacy of participants. All the procedures of the study were approved by the North Regional Delegation of the Ministry of Health (Ref. No. 01832NS/D/DRSP/N/SAG).
2.2. Data Collection
Awareness about breast cancer amongst Health professionals was assessed using a questionnaire included questions aimed at assessing the awareness about the recommended screening methods for early detection of breast cancer and knowledge about commonly reported breast cancer symptoms. Amongst the general population, the questionnaire aimed at assessing awareness on breast cancer, its screening methods and practice. Also, it was used to collect some sociodemographic data such as age and educational level of participants.
2.3. Breast Physical Examination
During physical breast examination performed in the gynecology service of the health facility, Fine Needle Aspiration (FNA) was performed with the consent of the participant, using recommended standard clinical procedures, when a nodule was identified as well as its characteristics (site, number, consistency, size, mobility relative to deep skin and plans, painful or not). Each sample collected was mounted on a slide, processed for May-Grünwald Giemsa staining, and analyzed using bright-field microscopy (magnifications 4x to 40x) at the Laboratory of Anatomo-Cytopathology of the University Hospital Center of Yaoundé. In case of cancer, Fisher’s simplification of Black’s nuclear grading scheme was used to determine the grade.
Instead, when nipple discharge occurred during the examination, characteristics were determined and recorded as well (aspect, uni- or bilateral, uni- or multi-orifice). Moreover, palpation of armpits was also performed to assess eventual axillary lymph node inflammation. The following characteristics of inflamed axillary lymph nodes were determined and recorded: number, size, and mobility relative to surrounding tissue.
2.4. Statistical Analysis
Data was collected, organized, and presented as frequency distributions. Data analysis was performed using XLStat Version 2019. The χ2 test was used to compare proportions and correlations were determined between age, education, occupation, and breast cancer awareness and also with screening practice. Statistical significance was set at p < 0.05.
Out of 475 women interviewed in this study, 37 were health professionals and 438 were general population.
3.1. Sociodemographic Information
The Age range was 13 to 72 years old and the median was 42.5. Most participants were younger than 35 (84.6%), had attended at least secondary school (56.6%), and were not housewives (63.2%) (Table 1).
3.2. Awareness of Breast Cancer Risk Factors and Warning Signs
91.3% of participants had heard about breast cancer and their main sources of information were their entourage (64.8%), media (46.5%), and health professionals (42.7%) (Table 2). More than 50% of the population was not aware of breast cancer risk factors. Most of them had misconceptions and myth-based
Table 1. Sociodemographic characteristics of participants.
Table 2. Breast cancer awareness, and known risk factors and symptoms reported.
ideas such as traditional breast massage (10.1%) and extended wearing of bra (13.2%) as the origin of the disease (Table 2). Hereditary factors (12.8%), and consumption of alcohol and tobacco (12.4%) were the most known actual risk factors of breast cancer (Table 2). Breast lumps (43.7%), pain (36.2%), and wounds (24.4%) were the most known breast cancer symptoms (Table 2).
3.3. Awareness of Breast Cancer Screening
56.8% of participants were aware of breast cancer screening and named clinical examination of the breast (34.9%), BSE (27.7%) and mammography (21.2%) as screening tools (Table 3). However, only 4.6% already performed mammography and 24.0% practiced BSE, of which 31.5% (7.5% of the overall participants) do so regularly (Table 3).
Table 3. Breast cancer screening methods cited and personal screening frequency.
BSEa: Breast Self-Examination.
3.4. Factors Affecting Breast Cancer Awareness and Screening Practice Frequency
Highly educated women were more likely to identify breast cancer actual risk factors (Table 4). However, they also had misconceptions and myth-based ideas: of the 48 women who attended university, 14 (29.1%) and 13 (27.0%, respectively, mentioned traditional breast massage and extended wearing of tight bra as risk factors and 15 (31.2%) had no idea (Table 4). Similarly, employed women were more aware of the disease, its risk factors and symptoms as compared to other groups (p < 0.0001) for most of the risk factors and symptoms (Table 4). Health professionals displayed better knowledge about breast cancer, although a few also had erroneous ideas and misconceptions (Table 4). Participants with higher education and employed women were also more aware of breast cancer screening, including BSE, mammography, and ultrasound (p < 0.0001 vs. other groups) (Table 4).
Breast Self-Examination practice among the study participants are presented in Table 5. Breast cancer screening and BSE were mostly performed by women with higher education and employed women (p < 0.0001 vs. other groups) (Table 5).
3.5. Breast Examination Findings
Out of 475 participants, 329 agreed to undergo breast clinical examination as part of breast cancer screening. The following cases were detected: 23 with lumps, 3 with inflamed axillary lymph nodes, 2 with wounds on the breast, and 2 with wounds on the nipple (Table 6). Analyses of fine-needle aspirates of nodules and lesions revealed 5 cases with the following cytological findings: a benign breast tumor, a galactophoric cyst, a cystic abscess, an abscess markedly swollen, and low chronic inflammation.
Table 4. Associations between occupation, education, and breast cancer awareness.
BSEa: Breast Self-Examination; CBEb: Clinical Breast Examination; A1 = Housewife; A2 = Student; A3 = Officer; A4 = Health professional; A5 = Other informal sector; B1 = No formal education; B2 = Primary school; B3 = Secondary school; B4 = University; χ2: * = p < 0.05; ** = p < 0.005; *** ≤ 0.0001.
Table 5. Factors affecting BSE practice.
χ2: ***p < 0.0001; df = degree of freedom; BSE = Breast Self-Examination.
Table 6. Clinical examination findings.
3.6. Reasons for Not Practicing Screening
Participants mainly claimed: 1) that should it be breast cancer it could only result from witchcraft and thus, they would not need hospitals to deal with it; 2) a lack of awareness about breast cancer screening methods and fear of discovering that they are sick; 3) to lack time for screening; and 4) that they don’t have any complaint and no history of breast cancer in their family, so there is no need for any exam. Other astonishing reasons proposed to reject screening included: 1) This lump in my breast has always been there and never had a problem or any complaint with it, so there is no need for a test; 2) “Breast cancer results from keeping coins in bra and I never do so”; 3) “I do not want to know whether my lump is or is not cancer, because it could result in stress, and I will be rejected by my husband if my breast is removed”; 4) “I don’t know how to perform BSE, nobody ever taught me”; and 5) “No one in my family ever had breast cancer and I never had any complaint, that’s why I will not perform any screening”.
The results showed that most of the surveyed professionals had good awareness about the existence of breast cancer, but insufficient knowledge and misperceptions on its risk factors and causes, and screening methods as well as infrequent practices of it. More than 50% of the population was not informed about breast cancer risk factors. Most of them had misconceptions about traditional breast massage (10.1%) and took extended wearing of bra (13.2%) as risk factors. These results are surprising, given that most of the study participants had heard about breast cancer (91.6%) were young, and had the right education level to access more information (46.5% attended at least secondary school). This could be explained by the fact that many of them heard about the disease from those around them such as friends and family members (64.8%). Indeed, in traditional African public beliefs, breast cancer is a mystical disease due to supernatural causes, including witchcraft, curses, and divine punishment   .
Breast pain (34.0%) and skin ulceration on the breast (23.5%), presence of a lump in the breast (43.7%), were the clinical signs most known by women as reported in previous studies  . Indeed, in the North region of Cameroon, due to poverty, patients generally consult when breast ulceration is marked or breast lumps are painful, events that usually occur when the disease is already at late stages    , contributing to late detection of the disease and poor prognosis  .
Highly educated and employed women in the present study, identified breast cancer risk factors more accurately than uneducated and unemployed women (p < 0.0001). However, misconceptions on the origin of the disease were also found here. In the 48 women with university degrees, 14 (29.1%) and 13 (27.0%) respectively mentioned traditional breast massage and extended wearing of tight bra as risk factors, and 15 (31.2%) had no idea about disease risk factors. These women confessed their erroneous information came from their entourage, and they did not see the importance of verifying it before participating in the study. This further suggests a lack of public awareness about breast cancer and underlines the need for education for early diagnosis and a better prognosis of the disease. Media could help to disseminate the right information, as they were a source of information for 46.5% of the participants. Health facilities could help as well, as 28.7% of the participants reported health education sessions in local languages held during prenatal consultations and immunization days in Cameroonian healthcare centers as their major source of medical information. Studies in comparable contexts showed that presentations in local languages by qualified health professionals attract more auditors  . As expected, in this study most health professionals interviewed (and all those working with breast cancer patients) were aware of breast cancer risk factors and listed the clinical signs of the disease accurately. However, only 24.32% practiced BSE regularly and 10.81% had already undergone mammography screening as a medical prescription, and none had ever undergone mammography as routine screening. This observation corroborates reports in other African countries   and suggests that good knowledge does not imply better screening practices. This was explained by negligence or the high costs of mammography.
Several other participants reported that it is possible to detect breast cancer early and cite clinical breast examination (32.87%), BSE (22.60%), and mammography as screening tools. However, a low level of practice of mammography screening (4.11%) and BSE (6.16%) was also observed here, also due to the high cost of mammography, together with a lack of mastery of the BSE technique and the fear of actually discovering a disease sign, considered a harbinger of mastectomy and death   . Considering the alarming rates of disease also reported elsewhere in the country, the Cameroonian Government should make mammography, the current gold standard for breast cancer screening, available for free to rural populations, for instance, through screening campaigns. BSE, a low-cost screening option that proved to be effective in similar contexts   could be thought and recommended to women during these campaigns as done in various successful breast cancer screening programs worldwide    .
79 (16.63%) participants refused clinical examination in this study, as they feared discovering breast cancer or to show their breasts to the medical professionals performing the examinations due to religious reasons (to preserve their intimacy). This also justified the refusal of several participants to be sampled for cytopathological examination of the nodules, as they argued that they needed the consent of their husbands. Breast palpation coupled with fine-needle aspiration, a cost-effective cytopathological analytic technique efficient in this context , revealed nodules in 4.55% of participants , confirming the need for breast cancer screening campaigns in Cameroonian rural areas like the North Region.
There is a need to raise awareness among the public about the risk factors and clinical signs of breast cancer and the importance of screening practice by both mammography and regular practice of BSE and CBE in the diagnosis of breast cancer at early stage and management of the disease. The Cameroonian health authorities should organize campaigns for early detection of asymptomatic cases of breast cancer, considering the positive implications for treatment outcomes.
The authors thank the authorities and the health professionals of Garoua Regional Hospital and surrounding health facilities for their help in data collection and all the participants.
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