The practice and efficacy of breast self-examination: a critical review

A Community-Based Assessment of Knowledge and Practice of Breast Self-Examination and Prevalence of Breast Disease in Southwest Cameroon

INTRODUCTION

Despite the rising trend in breast cancer incidence and mortality across Sub-Saharan Africa, there remains a critical knowledge gap about the burden and patterns of breast disease and breast cancer screening practices at the population level. This study aimed to identify socioeconomic factors associated with knowledge and practice of breast self-examination (BSE) as well as assess the prevalence of breast disease symptoms among a mixed urban-rural population of women in the Southwest region of Cameroon.

METHODS

We conducted a household-level community-based study in Southwest Cameroon between January and March 2017, using a three-stage cluster sampling framework. We surveyed 1287 households and collected self-reported data on 4208 female subjects, 790 of whom were household representatives. Each household representative provided information on behalf of all female household members about any ongoing breast disease symptoms. Moreover, female household representatives were questioned about their own knowledge and practice of BSE.

RESULTS

Women demonstrated low frequency of knowledge of BSE, as 25% (n=201) of household representatives reported any knowledge of BSE; and among these only 15% (n=30) practiced BSE on a monthly basis. Age (aOR: 1.04), usage of Liquid Petroleum Gas fuel, a marker of higher socioeconomic status (aOR: 1.86), and speaking English as a primary language in the household (aOR: 1.59) were significant predictors of knowledge of BSE. Eleven women reported ongoing breast disease symptoms resulting in an overall prevalence of 2.3 cases of breast disease symptoms per 1000 women.

CONCLUSIONS

Socioeconomic disparities in access to health education may be a determinant of knowledge of BSE. Community-based strategies are needed to improve dissemination of breast cancer screening methods, particularly for women who face barriers to accessing care.

Variables Related to Breast Self-Examination: Model Generation

Using a prospective design, variables from several relevant social psychological theories that would predict breast self-examination were identified. The participants included a probability sample of 362 women who were 35 or older. Instruments were tested for validity and reliability. Data were collected from each participant twice, 1 year apart, using an in-person interview for Time 1 and a telephone interview for Time 2. Results of standardized path coefficients (beta) indicated that breast self-examination (BSE) at Time 2 was directly related to BSE at Time 1 (.76). Indirect paths for susceptibility (.40), health motivation (.46), and barriers (- .54) were identified. All paths mentioned were significant ( p ≤ .01). Findings have implications for interventions to increase BSE in women 35 and older.

Knowledge, attitudes, and practices surrounding breast cancer screening in educated Appalachian women

PURPOSE/OBJECTIVES

To determine how and what women learn about breast cancer and screening practices and which factors influence women's breast cancer screening practices.

DESIGN

Descriptive analysis of questionnaire data collected at the time of enrollment in a clinical trial.

SETTING

Breast care center of a mid-Atlantic academic health sciences center.

SAMPLE

185 women in a predominantly Appalachian, entirely rural state.

METHODS

Participants completed the Modified Toronto Breast Self-Examination Inventory and questions related to personal mammography practices at the time of enrollment before randomization in a longitudinal clinical intervention study.

MAIN RESEARCH VARIABLES

Women's demographics, knowledge of breast cancer screening practices, adherence to breast cancer screening guidelines, and motivation, knowledge, and practice proficiency surrounding breast cancer screening.

FINDINGS

These educated women had knowledge deficits about breast cancer, breast cancer risk factors, and screening guidelines, particularly the timing and practice behaviors of breast self-examination. Women who had received healthcare and cancer-screening instruction by healthcare providers, including advanced practice nurses, had greater knowledge of breast cancer and detection practices.

CONCLUSIONS

Women still have knowledge deficits about breast cancer, breast cancer detection, and personal risk factors. In addition, some educated women in this study failed to practice breast cancer screening according to current guidelines.

IMPLICATIONS FOR NURSING

Practitioners must continue to remind and update women about breast disease, and women's cancer-screening practices must be reinforced. All levels of providers should improve their rates of performing clinical breast examinations with physical examinations. Nurses, who greatly influence women's health care, must remain current in their knowledge of breast disease, screening, and treatment.

Development of a competency-based curriculum for training women in breast self-examination skills

It is expected that there will be 178,700 new cases of breast cancer diagnosed in American women during 1998. This corresponds to a new breast cancer diagnosis every 3 minutes. In the absence of any preventive measures at this time, control of breast cancer morbidity and mortality must be sought through early detection and treatment. A competency-based training curriculum in breast self-examination was developed that incorporated three specific skill components: a systematic pattern of search; palpation topography discrimination training; and use of appropriate finger pressure for examination. A computer-assisted breast model was built and piloted for use in this study. The design, implementation, and validation of this program as a platform to train women and advanced practice nurses in breast self-examination is described.

Improving breast self-examination compliance: a Southwest Oncology Group randomized trial of three interventions

BACKGROUND

Only 20-40% of U.S. women conduct breast self-examination (BSE). This Southwest Oncology Group experimental study compared the impact of three interventions on BSE compliance.

METHODS

Subjects were randomly assigned to one of three arms: (1) physician message; (2) physician message and BSE class; or (3) physician message, BSE class, and reinforcement (phone and postcard). Compliance (frequency and accuracy) was measured by interview at intake and at 6 months and by phone contact at 1 year. Logistic and multiple regression were employed.

RESULTS

This analysis included 2,233 subjects from six institutions. At 1 year the percentages of women doing BSE were 59, 62, and 78% for Arms 1-3, respectively; gains over intake frequency (27% average) were significant within each arm (P < or = 0.0001). At both 6 months and 1 year the differences between Arm 1 and Arm 2 average accuracy scores and the differences between Arm 2 and Arm 3 in the percentage of women doing BSE were significant (P < or = 0.0001). Findings within institutions were consistent with the overall findings.

CONCLUSIONS

The addition of a BSE class increased accuracy over physician message alone; physician message, BSE class, and reinforcement gave the highest percentage of women doing BSE.

Predictive factors of enrollment and adherence in a breast cancer screening program in Barcelona (Spain)

This paper study the predictive factors associated to enrollment and adherence in a breast cancer screening program in Barcelona, Spain; the Program is targeted to women 50-70 years of age who are members of a Health Maintenance Organization. Data were collected by personal interview for the attending women and by telephone in the non-attending group. The questionnaire was focused on knowledge, attitudes and practices related to female cancer prevention and breast cancer risk factors. Data analysis consisted of bivariate and multivariate analysis. Enrolling in a breast cancer screening program was strongly associated with practices related to cancer prevention in the bivariate analysis. Having had a previous mammography was the only behavioral factor that showed an independent relationship with enrollment (OR = 6.45, 95% CI = 3.35-12.42) in the multivariate analysis together with being younger than 55 and having family history of cancer. Adherence was associated with having the best opinion of the program, knowing the preventive role of mammography and performing regular breast self-examination in the bivariate analysis; of these, knowing the preventive role of mammography (OR = 2.66, 95% CI = 1.14-6.18) and performing regular breast self-examination (OR = 1.99, 95% CI = 1.23-3.23) were independently associated in the multivariated analysis. Being a relative of a municipal worker and younger than 55 were also significantly associated with adherence. Getting women to participate in a breast cancer screening program is difficult--mailed invitation letters are not sufficient.(ABSTRACT TRUNCATED AT 250 WORDS)

Training breast self-examination: a research review and critique

Despite an increase in knowledge about breast cancer, a relatively low percentage of women practice breast self-examination (BSE) regularly and competently. This article reviews the BSE literature with a focus on training of BSE components, discrimination training, and the effectiveness of training procedures. Methodological issues such as the absence of control groups, lack of criteria for termination of training and reliance on self-reports of BSE frequency are identified weaknesses of BSE training studies. A theoretical analysis of BSE highlights potential difficulties in maintaining regular practice of BSE. Recommendations regarding training of proficient BSE skills and promoting regular practice of BSE are offered, and suggestions for further refinement of BSE training and directions for future research are discussed. Promising avenues of research in BSE training technology include discrimination training (on real or simulated breast tissue) together with computerized assessment of skill proficiency.

Health education for testicular cancer

The incidence of testicular cancer is rapidly increasing. It is highly curable when detected and treated early, yet 500 to 1,000 men die from this cancer each year. Most victims are young men whose deaths account for a large number of potential years of life lost. Risk factors for testicular cancer are known but they cannot account for the increase in incidence. Only one age group, men between 15 and 34 years, is currently exhibiting an increase in incidence and mortality and should therefore comprise the primary at-risk group. Health education for the at-risk group, including promotion of regular and accurate testicular self-examination (TSE), could lead to earlier tumor detection and treatment and thereby save lives.

Effect of knowledge, teaching method, confidence and social influence on breast self-examination behavior

A descriptive study was conducted to identify the relationship of knowledge, teaching methods, confidence and social influence to intent, frequency and proficiency of breast self-examination. A probability sample of 380 women aged 35 years and over served as subjects for in-home interviews conducted by trained graduate assistants. Knowledge correlated significantly with intent and proficiency of breast self-examination but not with frequency. Confidence correlated significantly with all three dependent variables, while social influence correlated only with intent. Being taught individually with a return demonstration increased proficiency and frequency. Implications for clinical application and future research are suggested.

Attitudinal variables related to intention, frequency and proficiency of breast self-examination in women 35 and over

A correlational study was conducted to identify attitudinal variables specified by the Health Belief Model that were related to intent, frequency, and proficiency of breast self-examination. The probability sample consisted of 380 women age 35 and over who were contacted via random digit dialing. Data were collected during in-home interviews. Results supported the combined ability of susceptibility, seriousness, barriers, health motivation, and control to predict intent to practice breast self-examination (R = .61, p. less than or equal to .001). In addition, frequency and total proficiency for breast self-examination were predicted by health motivations, susceptibility, and barriers using discriminant analysis. Results lend support to use of the Health Belief Model variables in predicting women's intention and actual behavior of breast self-examination.

Breast self-examination and survival from breast cancer

The relationship between breast self-examination (BSE) and survival was evaluated in 2093 women with breast cancer newly diagnosed between June 1975 and February 1979. In this population self-examiners were younger, more educated, and more likely to be white, premenopausal, and married than nonexaminers. Self-examiners also tended to seek medical care more rapidly and to have earlier stages of disease at diagnosis. Five years after diagnosis, the cumulative observed survival rates from breast cancer were 76.7% among self-examiners and 60.9% among nonexaminers (P less than 0.0001). In a multivariate analysis known sociodemographic and treatment confounders accounted for 25% of the excess of breast cancer deaths among nonexaminers. Approximately half of the remaining survival differential was attributable to the more limited disease among selfexaminers. The residual association between BSE and survival may be related to uncontrolled effects of stage or other unrecognized confounders.

The need and value of breast self-examination

The incidence of breast cancer is higher for black women aged less than 40 years than for white women aged less than 40; however, both black and white women aged less than 35 years have the lowest breast cancer survival rates of all age groups. The issue of breast self-examination (BSE) efficacy has special implications for these women because the BSE and the clinical breast examination (CBE) are the only early detection techniques recommended to them. Breast self-examination is even more important for black women because CBE might not be accessible to them for economic or other reasons.Studies relating BSE practice to tumor stage were reviewed. Most of the evidence was favorable, although it was not obtained with the most scientific methodologic approach. The negative evidence, on the other hand, came from studies with additional methodologic and conceptual problems, and should have little impact when evaluating BSE efficacy.Competence of performance has been shown to affect the efficacy of the self-examination. Most studies on BSE value, however, did not assess the examiner's competence. Because data obtained elsewhere show that most women performing BSE do not perform it competently, the significance of the positive evidence on BSE value is heightened. Most breast tumors are self-discovered, and encouraging competent BSE performance will give more women better means to discover tumors earlier.

Effectiveness of teaching breast self examination during office visits

In a randomized clinical trial a comparison was made of two BSE teaching interventions delivered by primary providers during office visits in a group nursing faculty practice. Patients who reported no regular BSE (n = 121) received either individualized teaching focused on reducing perceived barriers and reinforcing benefits of BSE, or routine teaching limited to usual instruction in BSE technique. Patients reporting frequent/monthly BSE during the past year were comparison subjects (n = 81). Self-reported data on BSE behavior were obtained in questionnaires administered before the interventions and via telephone interviews three months after the visit. Analysis using chi square showed that, contrary to expectation, individualized and routine teaching were equally effective: 61.4% of the individually taught and 63.5% of the routinely taught reported frequent or monthly practice at followup. Both groups were significantly more confident in technique and ability to detect change in the breast. The previously non-practicing women remained significantly less likely than comparison subjects to be performing BSE monthly at followup. The perceived benefit of BSE giving peace of mind predicted non-practicers most likely to change.

Changes in breast self-examination behavior in a cohort of 8214 women in the Canadian National Breast Screening Study

A study cohort of 8214 women was formed from all participants in the Canadian National Breast Screening Study who attended their first three screens after the introduction of a structured evaluation protocol involving eight criteria for breast self-examination (BSE). Self-reported BSE frequency was collected by questionnaire at all three screens. Breast self-examination instruction preceded breast exam at each screen but BSE evaluation occurred only at the second and third screen. Reported monthly BSE frequency increased from 18% to 51% to 55% on first, second, and third screens, respectively. The proportion claiming to do no BSE fell correspondingly: 52%, 16%, and 11%. Compliance with each of the seven other BSE criteria was significantly greater at the third screen than at the second. The mean number of these criteria performed at screen 3 was 5.1 compared with 4.4 at screen 2; older women performed as well as younger. The mean number of criteria performed was associated with BSE frequency at screen 3. The authors conclude that women's BSE behavior can be altered, and that integration of BSE evaluation and instruction into routine medical exams seems feasible and potentially useful.

Innovations in behavioral medicine

The chapter begins with a brief history of the behavioral medicine movement along with an overview of contemporary activities in the field. Three subsequent sections review technical innovations in major areas of clinical behavioral medicine: treatment, health care delivery, and preventive health care. The final section describes the methodological characteristics of research in behavioral medicine, discusses the field in light of the psychosomatic medicine and behavior modification movements, and calls for a conceptual integration that is authentically behavioristic. Already the quality of research in behavioral medicine appears comparable to that of research in behavior therapy. Even so, when viewed in terms of contemporary methodological desiderata, most of the work is fairly unimpressive. Possibly needed are "hybrid" experimental approaches in which the inferential power of intrasubject phase manipulations and between-subject outcome comparisons are combined. There is good reason to believe that behavioral medicine will follow the historical course of behavior therapy/modification, not the course of psychosomatic medicine. Behaviorally knowledgeable psychologists can become major service providers in liaison with well-informed medical practitioners. Some potentially deleterious influences on the behavioral medicine movement are (inevitable) mentalistic and dualistic thinking and a retreat toward psychosomatic medicine. Field behaviorism as an organizing schema can, in principle, serve as a safeguard against such untoward influences.

Physicians and the teaching of breast self-examination: implications from a survey at a university teaching hospital

We surveyed 80 physicians from four specialties (Family Medicine, General Medicine, General Surgery, Ob-Gyn) to investigate how they taught breast self-examination (BSE). Only half reported personally teaching BSE. Few MDs reported routinely using techniques to assess BSE competency. Most (72 per cent) claimed no formal training in teaching BSE; 10 per cent claimed no training at all. Techniques used to teach BSE may vary, and physicians may lack the training to teach BSE.

Seeking an effective strategy for promoting breast self-examination among women

Breast self-examination (BSE) may be effective in the early detection of breast cancer, but women must be aware of both the benefit of the procedure and the need for regular practice. The purpose of this study was to ascertain the effects of modeling plus rehearsal with respect to knowledge, attitudes, and subsequent frequency of BSE among women. The sample for this study consisted of 292 college students randomly assigned to one of two groups and exposed to: a facilitator-conducted program using modeling plus rehearsal (treatment group); or pamphlets addressing breast cancer and BSE (comparison group). A posttest-only comparison-group design was used. At completion of the programs, subjects responded to knowledge and attitude inventories. Three months later, a questionnaire requesting information on BSE practice was mailed to all subjects. Performance on the knowledge inventory indicated no group differences (P = 0.05). However, there were significant differences between groups in practice frequency and in selected attitudes (P less than 0.05). At three-month follow-up, significantly more members of the treatment group indicated practicing BSE at least once since exposure to the educational program. Conclusions support those of earlier investigations and indicate that modeling with rehearsal can be a useful method for promoting the practice of BSE.