Turkish Journal of Surgery
ISSN: 2564-6850
e-ISSN: 2564-7032

Evaluation of knowledge and practice regarding mammography among a group of Turkish women attending a tertiary hospital

Tuba Mert

Department of General Surgery, Pendik Medipol University Faculty of Medicine, İstanbul, Türkiye

Abstract

Objective: Early detection is the most important cornerstone of breast cancer in determining treatment outcome and survival. In this study, it was aimed to investigate the level of knowledge, attitude, and practice of mammography in the early diagnosis of breast cancer in a group of women.

Material and Methods: Data of this descriptive study were collected under observation with the help of a questionnaire. Female patients over 40 years of age or over 30 years of age with a family history of breast cancer admitted to our general surgery outpatient clinic for a health problem other than breast were included.

Results: A total of 300 female patients with a mean age of 48.7 ± 10.9 years (min-max, 33-83 years) were included. Median frequency of correct answers among the women participating in the study was 83.7% (76.0-92.0). Mean score obtained by the participants from the questionnaire was 75.7 ± 15.8 (the median score 80; 25th-75th centiles, 73.3-86.7). Slightly more than half of the patients (159 patients, 53%) had at least one mammography scan before. The level of mammography knowledge was negatively correlated with age and the number of previous mammographies, and positively correlated with education level (r= -0.700, p< 0.001; r= -0.419, p< 0.001 and r= 0.643, p< 0.001, respectively).

Conclusion: Although the level of knowledge about breast cancer and early diagnosis methods in women was at a satisfactory level, it is obvious that mammography screening practice of women without any breast symptoms is very low. Therefore, it should be aimed to increase women’s awareness of cancer prevention and compliance with early diagnosis methods and to promote participation in mammography screening.

Keywords: Breast cancer, mamography, screening, the level of knowledge

Introduction

Breast cancer is the most common type of cancer in women worldwide and is the second cause of cancer-related death after lung cancer (1). It has been reported that the incidence of breast cancer has increased in studies conducted since 1990 in all developing countries, including Türkiye (1,2). According to the cancer registry unit of the cancer control department’s cancer report 2015 data, it is reported that 17.183 women were diagnosed with breast cancer in 2015, and the incidence of breast cancer increased nearly twice (3). In a recent study evaluating 44 populations around the world between 1998 and 2012, it was reported that breast cancer increased in premenopausal women in high-income countries, whereas the increasing postmenopausal breast cancer burden was most notable in countries undergoing socioeconomic transitions (4). In addition, breast cancer death rates are reported to decrease over time in most high-income countries but continue to increase in many low-middle income and low-income countries (5).

It is known that the probability of a woman developing breast cancer in her lifetime is remarkable. In order to reduce cancer deaths in the community, cancer must be detected at an early stage. Therefore, early diagnosis is extremely important in facilitating the treatment of breast cancer and reducing mortality (6). Early diagnosis of breast cancer can be achieved by educating women well and applying screening programs. The aim of screening programs is to detect breast-related pathologies at an early stage in women with no complaints by various methods (clinical breast examination, mammography, and breast self-examination). According to the breast cancer early diagnosis guideline, after the age of 40, women should have annual or biennial mammography, clinical breast examination and regular monthly breast self-examination. Although breast self-examination is a very effective method for early detection of breast cancer by patients themselves, it is not used enough among women (7). Apart from this, mammography, which is an inexpensive, easily applicable and safe imaging method, is a very useful test in the screening of breast cancer. Many international studies have shown that mammography screening reduces breast cancer mortality by 15-20% (8,9).

It is well-known that sufficient levels of knowledge of breast cancer have a positive effective factor on having mammography screening. Studies conducted in recent years have reported that the level of knowledge of women about breast cancer and mammography screening has increased significantly compared to previous years, but it has not reached a satisfactory level (3,7). In addition, the knowledge level of breast cancer and mammography screening practice have been shown to be associated with age, education level, family history of breast cancer, and economic status (10-12).

Despite the nationwide organized screening programs carried out in our country in recent years to raise awareness, it has been reported that the frequency of mammography screening is not sufficient, and the delay in the diagnosis of breast cancer continues to be a problem (3,7,10). In this study, we aimed to investigate the level of knowledge, attitude, and practice of mammography in the early diagnosis of breast cancer in women who applied to the our general surgery outpatient clinic for a health problem other than the breast.

Material and Methods

This study was conducted between November 2020 and September 2021. Informed consent was obtained from all participants included in the study. This study was approved by the local ethics committee. Data of this descriptive study were collected under observation with the help of a questionnaire between November 2020 and September 2021. The questionnaire form consisted of 15 questions compiled by the researchers after the literature review on the subject and was applied to women over 40 years of age or over 30 years of age with a family history of breast cancer who admitted to our general surgery outpatient clinic for a health problem other than the breast. Before the questionnaire, sociodemographic characteristics of the women, such as age, family history and education level, were noted. In addition, it was recorded whether the women had mammography screening before and if they did, how many times they underwent mammography. The questionnaire consisted of 15 questions measuring the level of knowledge of the participants about the mammography method used in the early diagnosis of breast cancer and are answered as true or false (dichotomous scale). A total of 100 points is obtained as a result of correctly answering all 15 questions related to mammography. The participant was scored 6.7 points for each correct answer (100/15) and zero points for each incorrect answer.

SPSS 27.0 (IBM Corporation, Armonk, New York, United States) program was used in the analysis of the variables. Distribution of the data was evaluated with Shapiro-Wilk francia test. Mann-Whitney U with Monte Carlo tests were used together in comparing quantitative data of two independent groups. While Jonckheere-Terpstra test and Monte Carlo test were used together to compare more than two groups with each other according to quantitative data, Dunn’s test was used for posthoc analysis. Spearman’s rho test was used to evaluate the correlations of the variables. Quantitative variables were expressed as mean (standard deviation), median (minimum/maximum or 25th percentile/75th percentile), while categorical variables were shown as number (n) and frequency (%). The variables were analyzed at 95% confidence level, and a p value less than 0.05 was considered as significant.

Results

A total of 300 women with a mean age of 48.7 ± 10.9 years (median age 44 years; min-max, 33-83 years) were included in the study. Of these women, 4.7% were illiterate, 16.0% were primary school graduates, 17.7% were secondary school graduates, 34.0% were high school graduates, and 27.7% were university graduates. Only 13.7% of the cases had a family history of breast cancer. One hundred and forty-one (47%) patients did not have mammography before. Slightly more than half of the patients (159 patients, 53%) had at least one mammography scan before (Table 1).

Table 1. Educational level, family history of breast cancer, mammography practice and age distribution characteristics of the women included in the study

More than 90% of the participants knew very well that mammography should be done in the week after the end of the menstruation, the breasts should be gently compressed between two plates during mammography, mammography reduces breast cancer deaths, and that a person with a breast mass should undergo mammography and/or ultrasonography after the examination. On the other hand, the questions with the lowest level of knowledge were as follows: Q1. Mammography screening is a life-saving method, Q7. Cosmetic materials such as deodorant, talcum powder and lotion should not be used before mammography, Q14. It is possible to detect all types of breast cancer with mammography. Median frequency of correct answers among women participating in the study was 83.7% (76.0-92.0) (Table 2). Mean score obtained by the participants from the questionnaire was 75.7 ± 15.8 (median score 80; 25th-75th centiles, 73.3-86.7).

Table 2. The questionnaire applied to the participants in the study and the frequency of correct/incorrect answers

It was determined that the level of knowledge about mammography was significantly higher in those with a high education level and a family history of breast cancer (p< 0.05) (Table 3). The level of mammography knowledge was negatively correlated with age and the number of previous mammographies, and positively correlated with education level (r= -0.700, p< 0.001; r= -0.419, p< 0.001 and r= 0.643, p< 0.001, respectively).

Table 3. Evaluation of the factors affecting the knowledge level of the participants in mammography screening

Mean age of the women who did not undergo a mammography before was 43.1 ± 9.7 years (median 40 years), and mean knowledge score was 80.4 ± 13.6 (median 80; 25th-75th centiles, 80-86.7). While the level of knowledge of women who did not undergo a mammography before was the lowest in the uneducated group, it was highest in women who were university graduates. In addition, women with a family history of breast cancer had a significantly higher level of knowledge about mammography (p< 0.05) (Table 4).

Table 4. Characteristics of the participants (n= 141) who did not have a mammogram before

Discussion

Screening women for breast cancer with various methods and at regular intervals after a certain age is vital for early diagnosis and treatment. Determining the knowledge, attitudes and behaviors of women on this issue is indispensable for the success of the screening programs. In the current study, we evaluated the knowledge levels and attitudes about mammography screening in women over 40 years of age or over 30 years of age with a family history of breast cancer. In addition, the relationship of the knowledge level of the participants with age, education level, and numbers of previous mammographies were investigated. In studies conducted in our country 15-20 years ago, it was reported that women had insufficient or incorrect information about the importance of breast cancer screening and early diagnosis (11,12). However, in recent years, as a result of educational activities regarding breast cancer screening and early diagnosis (informative meetings, TV programs, brochure, and social media sharing, etc.) carried out by both the ministry of health and non-governmental organizations, a significant increase in the knowledge level of women about breast cancer and mammography screening has been reported in various studies (7,13-15) but still has not reached a satisfactory level. In our study, mean score of the participants in the questionnaire prepared about mammography, a method used in the early diagnosis of breast cancer, was 75.7 ± 15.8 and median score was 80 (25th-75th centiles, 73.3-86.7). Although this score seems far above the level of knowledge 15-20 years ago, it is clear that it is not sufficient and must be increased further. The women included in the study were well aware that mammography reduces breast cancer mortality rates, mammography is performed by gently compression of the breasts between two plates, and that it is more appropriate to apply mammography one week after menarche. However, the knowledge that some cosmetic products, which complicates the assessment of mammography, should not be used before the screening, was insufficient among the participants. Therefore, it is necessary to provide more effective educational program on early diagnosis and screening of breast cancer with various audio-visual tools, and in this way, the level of knowledge of women about mammography should be increased.

Mammography is an effective and reliable method that can show the masses that are too small to be detected on physical examination or ductal carcinoma in situ, which is a noninvasive form. Detection of breast cancers at an early stage positively affects the clinical course of the disease and has been shown to reduce mortality in various studies (16). In general, in our country and worldwide, women are recommended to have a mammography screening every one or two years after the age of 40. In addition, there is a prevailing opinion that this screening should be started at an earlier age in those with a family history of breast cancer. Most of the participants in our study had a good level of knowledge that mammography screening is reliable in the diagnosis of breast cancer and that it has a life-saving aspect by providing early diagnosis. In addition, most of the participants in our study were aware that mammography screening should be done after the age of 40. However, despite the high level of awareness, 53% of the participants in our study underwent a mammography at least once before, while the remaining 47% did not perform mammography. Mean age of the women who had no previous mammography practice was 43.1 ± 9.7 years (range, 35-82 years). The wide age range shows that although the women included in the study were aware of the importance of breast cancer screening such as mammography, they could not reflect it on their behavior and frequently ignored it. Similarly, in many studies conducted in different countries around the world, including our country, it has been reported that the frequency of regular mammography screening is very low (11,14,15,17-21). Interestingly, even in health care professionals, who are in the best position to provide health education, the rate of having a regular mammography screening is low (39.4%) as shown in the study of Akpınar et al. (22). Although it is known that early diagnosis of breast cancer is of vital importance, the rate of mammography screening remains low due to lack of time, ignoring, forgetting, economic reasons (cost), no complaints about the breast, fear of being diagnosed with cancer, and being young (7,23). In order to be successful in mammography screening program, it is necessary to promote knowledge and behavior change in both women and health professionals.

Knowledge about mammography is known to be affected by various factors. In many studies, it has been reported that the level of knowledge about breast cancer and mammography screening is associated with age, the level of education and economic status (14,19,23,24). In our study, in line, the level of knowledge of women regarding mammography was found to be associated with the level of education and age. As expected, the level of knowledge was positively associated with the level of education and family history of breast cancer, but, interestingly, it was negatively associated with age and the number of previous mammographies. This can be explained by the fact that women with lower education levels had higher age (or vice versa) in our study. On the other hand, in the study of Koçyiğit et al. (24), unlike our study, it has been reported that mean knowledge score of women about breast cancer and mammography increases with age. The authors tried to explain this by the fact that younger women thought that breast cancer occurred in older women and that they were not at risk for breast cancer. Moreover, in many studies, similar to our study, it has been reported that women with a family or friend’s history of breast cancer have a higher knowledge score than those without (24,25).

This study has some limitations that must be acknowledged. Since there is no internationally standardized questionnaire about breast cancer and mammography screening, we created a questionnaire measuring the level of knowledge about mammography in women as a result of the literature review, which is one of the most important limitations of our study. In this study, the knowledge level of women about mammography screening was questioned, but no evaluation was made in terms of the factors that caused the participants not to have regular mammography screening. In addition, this study was performed in the general surgery outpatient clinic of our tertiary hospital, so the findings of this study cannot be generalized to a particular region or to the whole of our country.

In conclusion, in this study, it was concluded that the majority of women had a fairly good level of knowledge about mammography screening; however, some topics need to be improved with various tools. In addition, it was shown that the level of knowledge related to mammography screening was positively correlated with education level and family history of breast cancer. As shown in our study and many studies conducted in different countries around the world, although the level of knowledge about breast cancer and early diagnosis methods in women is at a satisfactory level, it is obvious that the mammography screening practice of women is very low. For this reason, it should be aimed to increase women’s awareness of cancer prevention and compliance with early diagnosis methods and to promote participation in mammography screening.

Cite this article as: Mert T. Evaluation of knowledge and practice regarding mammography among a group of Turkish women attending a tertiary hospital. Turk J Surg 2022; 38 (3): 230-236.

Ethics Committee Approval

This study was approved by İstanbul Medipol University Non-invasive Clinical Research Ethics Committee (Decision number: 852, Date: 12.11.2020).

Peer Review

Externally peer-reviewed.

Author Contributions

Concept – T.M.; Design – T.M.; Supervision – T.M.; Materials – T.M.; Data Collection and/ or Processing – T.M.; Analysis and/or Interpretation – T.M.; Literature Search – T.M.; Writing Manuscript – T.M.; Critical Reviews – T.M.

Conflict of Interest

The authors have no conflicts of interest to declare.

Financial Disclosure

The authors declared that this study has received no financial support.

References

  1. Global Burden of Disease Cancer Collaboration, Fitzmaurice C, Dicker D, Pain A, Hamavid H, Moradi-Lakeh M, et al. The global burden of cancer 2013. Jama Oncol 2015; 1(4): 505-27.
  2. Ferlay J, Colombet M, Soerjomataram I, Mathers C, Parkin DM, Piñeros M, et al. Estimating the global cancer incidence and mortality in 2018: GLOBOCAN sources and methods. Int J Cancer 2019; 144(8): 1941-53. https://doi.org/10.1002/ijc.31937
  3. Ozmen V, Boylu S, Ok E, Canturk NZ, Celik V, Kapkac M, et al. Factors affecting breast cancer treatment delay in Turkey: A study from Turkish Federation of Breast Diseases Societies. Eur J Public Health 2015; 25(1): 9-14. https://doi.org/10.1093/eurpub/cku086
  4. Heer E, Harper A, Escandor N, Sung H, McCormack V, Fidler-Benaoudia MM. Global burden and trends in premenopausal and postmenopausal breast cancer: A population-based study. Lancet Glob Health 2020; 8(8): e1027-e1037. https://doi.org/10.1016/S2214-109X(20)30215-1
  5. Hashim D, Boffetta P, La Vecchia C, Rota M, Bertuccio P, Malvezzi M, et al. The global decrease in cancer mortality: Trends and disparities. Ann Oncol 2016; 27(5): 926-33. https://doi.org/10.1093/annonc/mdw027
  6. Shin DW, Cho J, Kim SY, Guallar E, Hwang SS, Cho B, et al. Delay to curative surgery greater than 12 weeks is associated with increased mortality in patients with colorectal and breast cancer but not lung or thyroid cancer. Ann Surg Oncol 2013; 20(8): 2468-76. https://doi. org/10.1245/s10434-013-2957-y
  7. Korkut Y. Assessment of knowledge, attitudes, and behaviors regarding breast and cervical cancer among women in western Turkey. J Int Med Res 2019; 47(4): 1660-6. https://doi.org/10.1177/0300060519830252
  8. Løberg M, Lousdal ML, Bretthauer M, Kalager M. Benefits and harms of mammography screening. Breast Cancer Res 2015; 17(1): 63. https:// doi.org/10.1186/s13058-015-0525-z
  9. Pace LE, Keating NL. A systematic assessment of benefits and risks to guide breast cancer screening decisions. Jama 2014; 311(13): 1327-35. https://doi.org/10.1001/jama.2014.1398
  10. Ozmen V, Nilufer Ozaydin A, Cabioglu N, Gulluoglu BM, Unalan PC, Gorpe S, et al. Survey on a mammographic screening program in Istanbul. Turkey Breast J 2011; 17(3): 260-7. https://doi.org/10.1111/ j.1524-4741.2011.01065.x
  11. Dündar PE, Ozmen D, Oztürk B, Haspolat G, Akyildiz F, Coban S, et al. The knowledge and attitudes of breast self-examination and mammography in a group of women in a rural area in western Turkey. BMC Cancer 2006; 6: 43. https://doi.org/10.1186/1471-2407-6-43
  12. Secginli S, Nahcivan NO. Factors associated with breast cancer screening behaviours in a sample of Turkish women: A questionnaire survey. Int J Nurs Stud 2006; 43(2): 161-71. https://doi.org/10.1016/j. ijnurstu.2005.02.004
  13. Sohbet R, Karasu F. Kadınların meme kanserine yönelik bilgi, davranış ve uygulamalarının incelenmesi. Gümüşhane Üniv Sağlık Bilim Derg 2017; 6(4): 113-21.
  14. Açıkgöz A, Çehreli R, Ellidokuz H. Women’s knowledge and attitude about cancer and the behaviour for early diagnosis procedures. Dokuz Eylül Üniv Tıp Fak Derg 2011; 25(3): 145-54.
  15. Nergiz-Eroglu U, Kilic D. Knowledge, attitude and beliefs women attending mammography units have regarding breast cancer and early diagnosis. Asian Pac J Cancer Prev 2011; 12(7): 1855-60.
  16. Fancellu A, Sanna V, Sedda ML, Delrio D, Cottu P, Spanu A, et al. Benefits of Organized Mammographic Screening Programs in Women Aged 50 to 69 years: A surgical perspective. Clin Breast Cancer 2019; 19(5): e637-e642. https://doi.org/10.1016/j.clbc.2019.04.013
  17. Fotedar V, Seam RK, Gupta MK, Gupta M, Vats S, Verma S. Knowledge of risk factors and early detection methods and practices towards breast cancer among nurses in Indira Gandhi Medical College, Shimla, Himachal Pradesh, India. Asian Pac J Cancer Prev 2013; 14(1): 117-20. https://doi.org/10.7314/APJCP.2013.14.1.117
  18. Sarma EA. Barriers to screening mammography. Health Psychol Rev 2015; 9(1): 42-62. https://doi.org/10.1080/17437199.2013.766831
  19. Al-Mousa DS, Alakhras M, Hossain SZ, Al-Sa’di AG, Al Hasan M, Al-Hayek Y, et al. Attitude and practice around breast cancer and mammography screening among Jordanian women. Breast Cancer (Dove Med Press) 2020; 12: 231-42. https://doi.org/10.2147/BCTT. S275445
  20. Raji MO, Adamu SP, Akinnibosun-Raji HO, Raji HO, Ango UM, et al. Knowledge, attitude and uptake of mammography among female health workers in two tertiary health facilities of Sokoto state, Nigeria. Int J Community Med Public Health 2021; 8(2): 511-7. https://doi. org/10.18203/2394-6040.ijcmph20210199
  21. Marinho LA, Cecatti JG, Osis MJ, Gurgel MS. Knowledge, attitude and practice of mammography among women users of public health services. Rev Saude Publica 2008; 42(2): 200-7. https://doi.org/10.1590/ S0034-89102008005000006
  22. Akpinar YY, Baykan Z, Naçar M, Gün I, Çetinkaya F. Knowledge, attitude about breast cancer and practice of breast cancer screening among female health care professionals: A study from Turkey. Asian Pac J Cancer Prev 2011; 12(11): 3063-8.
  23. Dinçel E, Kısmet K, Erel S, Sunay D, Şahin M, Taşova V, et al. Factors affecting the first mammography age. Meme Sağlığı Dergisi 2010; 6(3): 113-7.
  24. Koçyiğit O, Erel S, Kısmet K, Kılıçoğlu B, Sabuncuoğlu MZ, Akkuş MA. Knowledge about breast cancer, mammography and breast self examination in women who applied to outpatient clinics: A study conducted in the city center. Nobel Med 2011; 7(2): 19-25.
  25. Lippert MT, Eaker ED, Vierkant RA, Remington PL. Breast cancer screening and family history among rural women in Wisconsin. Cancer Detect Prev 1999; 23(3): 265-72. https://doi.org/10.1046/j.1525- 1500.1999.99023.x