February 2007 - Volume 1, Issue 1

BREAST SELF-EXAMINATION AMONG FEMALE NURSES

	Dr.Osama Abu Salem JBGS. MRCSI. (RMS) Montaha Abdulla Hassan S.N. (RMS)
	Dr .Osama Abu Salem, and Montaha Abdulla Hassan P.O.Box: 620033 Irbid - Jordan Email:osama65@gmail.com

ABSTRACT In the past 20 years, breast cancer incidence in the world has had a dramatic increase of 50-100%, which strongly supports the need for breast cancer prevention, and screening programs. The purpose of this study was to identify and investigate the knowledge and practice of breast self- examination (BSE) with the influencing factors on the compliance of (BSE) among female nurses. Methods: A study was conducted between January and December 2002. Female nurses (80) from Prince Rashid Military Hospital constituted the study population. The questionnaire contained items on the demographic characteristics of the respondents' knowledge of breast cancer, attitudes toward BSE and questions regarding the practice of BSE. The analysis included descriptive statistics to examine the association between BSE and medical history, knowledge of BSE and attitudes toward BSE. Results: The results of the study indicated that 52% of the sample performs BSE. Approximately 30% of those who perform BSE said they learned information regarding BSE during their work experience. A significant relationship was found between higher levels in work experience and BSE practice. Except for age, no significant relationship was found between the socio-demographic factors and BSE practice. The sample showed strong belief in breast lumps as a causing factor of breast cancer and had significant correlation with BSE practice. Conclusion: 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.

INTRODUCTION

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. The self exam has limitations, however, and is not a substitute for regular breast examinations from your doctor or screening mammogram.

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 the 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. (1) Evidence suggests that clinical breast examination detects most breast cancers found by mammograms, and also some that mammograms miss, particularly in younger women, If you do perform monthly examination, do it 3-5 days after your period, when your breasts are the least tender and lumpy. Recent estimates suggest that screening by breast examination has a sensitivity of about 54% and aspecifity of about 94%,, in some countries. The cost of screening mammography is considered to be high and policy makers are considering implementing screening programs based on clinical breast examination rather than mammography.(2) It is known that breast cancer in general affects up to one in 11 women during life.

It was found that mortality had fallen by 31% after 6 years for women aged 40-70 at the beginning of the trial (3). Unfortunately despite the benefits of regular Breast self-examination, few women actually examine themselves; in fact, the majority do not even know how to do Breast self-examination (4). Although opinions conflict about the value of BSE (5), there is no uniform agreement for breast screening methods. METHODS

A study was conducted between January and December 2002, of female nurses, (80) in number, working at Prince Rashid Military Hospital. The nurses who were conducting regular breast examination were 52%(42), and with non compliant or irregular breast self examiners were 48%(38).

The study was designed to provide a description of the knowledge and practice of performance of BSE. The socio-demographic factors, medical history and the interrelationships between these variables were studied, including knowledge of breast cancer, attitudes toward BSE and questions regarding the practice of BSE. RESULTS

Participants in this study ranged in age from 18-40 years, with mean age of 29 years and their average BMI was 24. Single women made up to 60%(48) of the sample and 40%(32) were married (Table 1). The results of the study indicated that 52% (42) of the sample performs BSE. Approximately 30% (13) of those perform BSE regularly. Only 5% (4) of the subjects had a positive family history of Breast Cancer and 85% (68) showed a regular menstrual cycle. Out of the total sample, 25 (31%) nurses reported pain in their breasts.

A significant relationship was found between higher levels in nursing work experience and BSE practice. 60-80% of subjects believe that presence of masses (breast lumps), family history of breast cancer (Table 2), nipple discharge, frequent mammograms and smoking are the causative factors for breast cancer. 10 % (8 nurses) of subjects believe that, usage of contraceptives, wearing of a Nylon bra, using breast creams; direct sun exposure, obesity and ovarian pain are breast cancer causing factors.

In this present study sample (Table 3), pregnancy at an early age and breast feeding are believed to be the least believed causative factors of breast cancer. The significant correlation was seen between large breast lumps and BSE.

The most frequently endorsed steps (Table 4) were examining breasts in front of a mirror, or during a bath, examining breasts while lying down, and feeling for a lump, hard knots, nipple discharge, or breast thickening. The least frequently endorsed steps were looking at breasts in the mirror with hands on thighs. Overall the majority of subjects knew most of the recommended steps.

In our study 52% perform BSE, which encompasses awareness of reporting breast symptoms as an early detection activity for all females in the study and in the population in general who will benefit from this study group. DISCUSSION

To date, the etiology of breast cancer is uncertain and adequate primary prevention is not possible. Thus early detection measures remain the first priority. More than 50% of the total breast cancers diagnosed annually is found in premenopausal patients, creating the need to initiate breast cancer screening programs in this population. These measures include BSE, which is a screening behaviour of relevance for women's health. METHOD

First, lie on your back. Place your right hand behind your head. With the middle fingers of your left hand, gently yet firmly press down using small circular motions to examine the entire right breast. Then, while sitting or standing, examine your armpit (commonly skipped) because breast tissue extends to that area. Gently squeeze the nipple, checking for discharge. Repeat the process on the left breast.

Although, some women find it easier to do the examination in the shower, when the skin is soft and wet, you are more likely to examine all of the breast tissue if you are lying down. Breast self examination is a unique procedure in many ways:
it is in expensive, non -invasive, involves little time and physical energy,
it is simple and doesn't depend on professional help.

However, the effectiveness of BSE remains controversial. It is argued that significant numbers of women find masses when they are bathing or dressing, and BSE once a month may contribute to a women's heightened awareness of what is normal for her. (6) The justification for this position is laid out in the discussion with a call for additional research. Despite the demographic and economic challenges posed by the aging of the population and the increasing incidence of breast cancer with age, we have to continue screening in older women who have few competing causes of mortality, and who would be candidates for treatment, if breast cancer was identified. The chronological age alone may be a difficult way to determine the utility of screening procedures, and that competing causes of mortality, as well as other factors, should perhaps also influence future recommendations (7)

In one study, it was shown that 81%of women first noticed symptoms themselves(8).

The evidence of primary cancer prevention is slowly growing; its strategies cannot yet be implemented in clinical prevention programs, therefore, secondary prevention, early detection of cancer, remains the main focus for reducing breast cancer mortality. This is especially true because of the proven relationship between mortality, and size of the primary tumor, as well as the status of the axilla.

Thus one may argue that if women are finding most breast cancer themselves, as occurred in our study. About 36 nurses felt a sort of self awareness of breast etiology and abnormalities during their course of study, would assist. Normal breast tissue is present in both males and females of all ages. This tissue responds to hormonal changes and therefore, certain lumps can come and go. Breast lumps may appear at all ages: - nfants may have breast lumps related to estrogen from the mother -young girls often develop breast buds that appear just before the beginning of puberty -teen age boys may develop breast enlargement and lumps because of hormonal changes, which are considered a normal variation of breast tissue; fibro adenomas are non cancerous lumps. Like fibrocystic disease of the breast, they occur most often during the reproductive years and the only way for definitive diagnosis is by taking a biopsy. Other types of lumps might be milk cysts ,lipomas, papillomas. Breast cancer, treatment of a breast lump depends on the cause.

It is possible that by knowing how to do a more thorough BSE women could find breast cancers of smaller sizes, which in turn may lead to an improved prognosis. Medical professionals have knowledge of the causes of diseases and have learned to recognize the warning signs of the disease when present in their patients. It seems, however, that these professionals don't always recognize the signs of their own illness (9).

Nursing profession is one in which it is very important for self-awareness, 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; nurses can promote monthly BSE by supporting realistic beliefs about screening and cancer as well as demonstrating BSE, especially among married women. 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. PATIENT ADVICE SHEET

Call your doctor if:
-You find a new breast lump during your monthly self-examination.
-You have bruising on your breast but did not experience any injury.
-You have nipple discharge, especially if bloody or pinkish (blood tinged).
-The skin on the breast appearS dimpled or wrinkled (like the peel of an orange).
-Your nipple is inverted (turnED inward) but normally is not inverted.
-If you are over the age of 20, consider doing a monthly breast self examination
-If you are over 40, you have to complete breast self-examination in addition tothe examination by a doctor every year.
-If you are over the age of 50, get a yearly screening mammogram.

In one study, Budden (10) reported that.96% of nursing students performed BSE during a year but only 46% had practiced as regularly as once per month.

Haji-Mahmoodi et al (11), reported from a cross sectional study among female health care workers that, more than 70% of subjects had knowledge regarding BSE and also had strong belief in its beneficial affects, but only 6% of them was performed BSE regularly. It is well documented that beliefs and behavior surrounding breast cancer vary with several factors such as ethnicity, age, education and socioeconomic status (12). Initially, breast cancer screening programs depended on breast self-examination, however, marital status, family monthly income and family history of Breast cancer showed no significant association with BSE practice. Similar results were reported by Budden, that, no significant relationship was found between a family history of BC and regular BSE practice. Self-efficacy theory and behavioral self -regulation theory suggest that the most important predictor of a highly specific behavior (such as BSE) is the individual's own confidence in performing the behavior (13).

A more optimistic attitude would appear to increase the likelihood of greater self efficacy in performing BSE. In other words, women who anticipated favorable outcomes in general were more confident in their breasts. Our study showed that there is a strong belief that breast mass is a causative factor of breast cancer, which was reflected in its significant correlation with BSE practice.
CONCLUSIONS

1. Breast cancer mortality in the US has been increasing by O.6% per year since 1987. This increase in mortality is occurring despite screening. In a move to reduce the number of deaths from breast cancer, we have to emphasise breast awareness in addition to breast self-examination.
   
2. Initially, breast cancer screening programs depended on breast self-examination,
   
3. The prompt reporting of breast symptoms are important early detection messages for women of all ages.
   
4. Factors recommended for female patients regarding breast pathology are to do exercises regularly, reduce fat intake and to eat a lot of fruits, vegetables and other high fiber foods.
   
5. A Canadian breast mammographic screening study showed no difference between breast examination, BSE and five annual screenings with mammography compared with a single breast examination and BSE alone regarding the mortality in breast cancer. Nurses have a vital role to play in encouraging women to become more breast-aware. Their health promotion activities in this area can have an important impact on the uptake of breast screening initiatives.
   
6. Biopsy is the only way to determine if tissue is benign (non-cancerous) or malignant (cancerous).
   
7. The result of this study suggest that, for nurses, if 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

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