Attitude towards Breast Cancer and Breast Self-Examination in Middle Aged Females at a Tertiary care hospital in Lahore Pakistan

• Muhammad Waseem Riaz
• Muhammad Saad Azam
• Shiza Ashraf
• Nauman Ismat Butt
• Barak Waris
• Muhammad Sohail Ajmal Ghoauri

Vol. 6 No. 2: 2025 | Pages: 71–76

DOI: 10.47679/makein.2025254   Reader: 431 times PDF Download: 191 times

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Abstract

INTRODUCTION

Breast cancer, a worldwide public health concern, is a genetic disorder of cell growth that is triggered by acquired or less commonly inherited mutations affecting a single cell and its clonal progeny (Kumar et al., 2017). Breast carcinoma is the most common and fatal malignancy found in women, globally (Centers for Disease Control and Prevention, 2024). Each year 1.7 million women are diagnosed and one in three of those affected die of the disease. In 2020, there were 2.3 million women who were diagnosed with breast cancer and 685,000 deaths were recorded globally. By the end of 2020, there were 7.8 million women alive and diagnosed with breast cancer in the past 5 years, making it the world’s most prevalent cancer (Kumar et al., 2017). Early detection of breast cancer is crucial for improving prognosis and limit mortality. The disease if left undiagnosed and untreated can ultimately metastasize (spread) to the bones, lungs, brain and liver, reducing its overall prognosis. This necessity for early detection has spawned a number of screening initiatives aimed at reducing disease-related morbidity and mortality. Breast Self-Examination (BSE) is a common self-performed screening method to detect any possible changes in the breast. It is widely practiced around the world in developed and under developed countries for the earliest possible detection of the breast cancer. Thereby this cost effective and time saving method of Breast Self-Examination is encouraged after the age of 30 as there is an increase in the incidence of the disease after the mentioned age (Kumar et al., 2017). However, studies have shown that many women do not perform BSE regularly or correctly, leading to missed diagnoses and delayed treatment (Fortunato et al., 2025). It is therefore essential to assess BSE knowledge and behaviors in middle-aged women, as they are at higher risk for breast cancer and may have established beliefs that affect their practices. Identifying gaps in their knowledge can help develop targeted interventions to improve awareness and encourage proper BSE, ultimately leading to earlier detection and better outcomes.

In 2020 according to WHO there was an incidence of 34.4 percent and a mortality of 18.8 percent within Pakistani females due to the disease. The highest prevalence was seen in Karachi and Federal Capital (Khan et al., 2021). In Lahore from 2010-2019, 57.1 percent of the cancers in females were diagnosed among which 76.1 percent had breast cancer (Badar & Mahmood, 2021). This increase in mortality is mainly due to late diagnosis of the disease, which is a consequence of lack of knowledge and awareness regarding breast cancer, primarily in the women of developing countries. Early detection of the breast cancer could improve the outcomes of the treatment and thus could reduce the mortality. The disease could be identified 10 to 20 percent times earlier either by diagnosing it via clinical examination or mammography or by the patient herself through Breast Self-Examination (Batool et al., 2018). Still most of the women in Pakistan are reserved in discussing breast associated diseases and seeking medical attention for it. Due to poor literacy rate and social hesitation the situation gets exacerbated and the breast cancer awareness campaigns are looked down upon. In 2018, a study in Peshawar showed that only 15% females were aware of BSE procedure and its importance while only 2.5% were practicing it (Ullah et al., 2021). This huge difference in the knowledge and practice needs to be mended which we decided to bridge through our research.

While the global statistics are alarming, the burden in Pakistan is even more pressing, with incidence and mortality rates among the highest in Asia. This is particularly true in low- and middle-income countries like Pakistan, where limited access to screening tools and a lack of health education exacerbate the issue. In Pakistan, socio-cultural factors strongly influence women’s health behaviors, particularly regarding sensitive topics like breast health. Cultural taboos, religious conservatism, and modesty norms discourage open discussions about breasts, making women reluctant to seek help or even learn about BSE. In many households, female health issues are deprioritized, and decision-making regarding health often lies with male family members. These dynamics contribute to late presentations of breast cancer. Reluctance is often rooted in shame, fear of diagnosis, and misconceptions that a breast cancer diagnosis is equivalent to a death sentence or social disgrace. Moreover, embarrassment and fear of stigma, especially in rural and conservative communities, further deter women from performing BSE or accessing mammographic screening. Although we are spreading awareness and knowledge of BSE among the females but still they are not efficiently practicing it due to one reason or another. Therefore, we planned this research to study attitudes toward breast cancer and BSE, as well as current practices of BSE and mammography, to emphasize the importance of this issue in our community

METHOD

Research Design

This descriptive cross-sectional study was conducted to assess the attitudes, awareness, and practices related to breast cancer and Breast Self-Examination (BSE) among middle-aged women at a tertiary care hospital in Lahore Pakistab.

Study Location and Duration

This study was conducted at Out-patient department (OPD) of Chaudhary Muhammad Akram Teaching and Research Hospital, Azra Naheed Medical College Superior University Lahore Pakistan from March 2023 to May 2023.

Population and Sampling

Fifty females attending OPD of CMA Hospital, aged 35 to 45 years were enrolled in the study after taking informed consent using non-probability consecutive sampling technique. The age range of 35 to 45 years was selected because breast cancer incidence in Pakistani women tends to rise significantly after the age of 35 years, with many cases diagnosed before 50 years, making early awareness and screening especially relevant in this demographic. This group is often overlooked in formal screening programs despite being in a transitional life stage where health education can lead to lasting behavioral change.

Inclusion and Exclusion Criteria

Females aged 35 to 45 years, attending the OPD of CMATRH who gave informed consent were included in the study. Females with a present or past diagnosis of breast abnormalities (cysts, mastitis, benign or malignant tumors) were excluded from the study.

Research Instrument

A structured questionnaire comprising of 3 domains was designed for this study: first domain was regarding attitude towards Breast Cancer having 4 questions graded as yes or no; second domain was about Breast Self-Examination having 4 questions graded as yes or no; and a third domain assessed practices regarding BSE and mammography. The questionnaire was designed to specifically address the objectives of this study, focusing on the attitudes, knowledge, and practices related to breast cancer and BSE among middle-aged women in Pakistan. While the tool was carefully constructed to ensure relevance and clarity, it has not undergone formal validation due to resource constraints and the exploratory nature of this research.

Data Collection Procedure

Demographic information including age, educational status, marital status and socioeconomic background were noted. The structured questionnaire comprising of 3 domains was filled by the participants under supervision of a doctor, to assess attitude towards Breast Cancer, Breast Self-Examination and practices regarding BSE and mammography. All the data was recorded.

Data Analysis

SPSS version 23 was used for the entry and analysis of the data. Descriptive statistics such as frequencies and percentages were calculated for demographic variables and questionnaire responses. Chi-square tests were used to assess associations between educational level, socioeconomic status, and key variables such as awareness and practice of BSE, with a p-value < 0.05 considered statistically significant.

Ethics Statement

The present study was conducted in accordance to the ethical standards laid down in the 1964 Declaration of Helsinki, revised in the year 2000. All the subjects were explained the purpose, benefits and process of the study. Assurance was given to protect the life, health, privacy, and dignity of the human study subjects, confidentiality and anonymity.

RESULTS

A total of 50 females were enrolled in the present study. Majority of the females were aged 35 to 40 years (33, 66.0%) as shown in Table 1. Based on socioeconomic background, 19 (38.0%) females belonged to middle socio-economic status. As depicted in Table 1, majority of the females (17, 34.0%) were undergraduates on educational status followed by 16 (32.0%) illiterate. Forty (80.0%) were married. In the present study, 37 (74.0%) females had heard about Breast Cancer but only 09 (18.0%) were aware about Breast Self-Examination (BSE). Responses to individual clinical questions asked to assess attitudes towards Breast Cancer and BSE are demonstrated in Table 2. Only 09 (18.0%) respondents reported performing BSE while 14 (28.0%) had a history of mammographic scan. Advice from friends (04, 8.0%) was the biggest sources of BSE information for the participants as shown in Table 3.

Table 1. Demographic Variables of the patients

Demographic Variables		Frequency
Age	35 to 40 years	33 (66.0%)
	41 to 55 years	17 (34.0%)
Marital Status	Married	40 (80.0%)
	Unmarried	10 (20.0%)
Educational Status	Illiterate	16 (32.0%)
	Undergraduate	17 (34.0%)
	Graduate	13 (34.0%)
Socio-economic Background	Low	14 (28.0%)
	Middle	19 (38.0%)
	High	17 (34.0%)

Table 2. Responses to questions about Breast Cancer and Breast Self-Examination

Clinical Questions	Response	Frequency
Breast Cancer domain:
Have you heard of Breast Cancer?	Yes	37 (74.0%)
	No	13 (26.0%)
Do you think early detection improves survival chances?	Yes	13 (26.0%)
	No	37 (74.0%)
Do you think mammography helps to diagnose breast cancer?	Yes	05 (10.0%)
	No	45 (90.0%)
Have you had a mammographic scan yourself?	Yes	14 (28.0%)
	No	36 (72.0%)
Breast Self-Examination (BSE) Domain:
Have you heard of BSE?	Yes	09 (18.0%)
	No	41 (82.0%)
Do you perform BSE yourself?	Yes	09 (18.0%)
	No	41 (82.0%)
Do you perform BSE in front of mirror?	Yes	05 (10.0%)
	No	45 (90.0%)
Have you noticed any lump or color change on BSE?	Yes	02 (4.0%)
	No	48 (96.0%)

Stratification according to education level and socioeconomic status revealed significant associations with awareness and practice of BSE. Participants with higher education levels (graduates) and those from higher socioeconomic backgrounds were significantly more likely to have heard of BSE and to perform it regularly (p-value 0.031 and p-value 0.037, respectively) as shown in Table 4 and Table 5. While none of the illiterate or low socioeconomic status participants reported awareness or practice of BSE, these figures improved progressively with increasing education and income levels. Furthermore, belief in the role of mammography in breast cancer diagnosis was more common among higher education and socioeconomic groups, with statistical significance observed for socioeconomic status (p-value 0.028) and a marginally non-significant trend for education level (p-value 0.069).

Table 3. Responses to questions about Breast Self-Examination (BSE) awareness and practices

Clinical Questions	Response	Frequency
Source of BSE Awareness	Family	02 (4.0%)
	Friends	04 (8.0%)
	T.V./Social Media	02 (8.0%)
	Awareness Campaigns	01 (2.0%)
	Not Aware	41 (82.0%)
Frequency of performing BSE	Once a month	01 (2.0%)
	Twice in 6 months	02 (4.0%)
	Once in 6 months	4 (8.0%)
	Rarely	2 (4.0%)
	Never	41 (82.0%)
Frequency of mammographic scan	Once every 6 months	02 (4.0%)
	Once a year	05 (10.0%)
	Rarely	07 (14.0%)
	Never	36 (72.0%)
On identifying any breast abnormality, what should be done?	Consult a doctor	05 (10.0%)
	Tell a family member	09 (18.0%)
	Discuss with a friend	03 (6.0%)
	Ignore it	33 (66.0%)

Table 4. Stratification according to Education level

Responses to questions about Breast Self-Examination (BSE)		Education Level			p-value
		Illiterate	Undergraduate	Graduate
Have you heard of BSE?	Yes	0	3	6	0.031
	No	16	14	11
Do you perform BSE yourself?	Yes	0	3	6	0.031
	No	16	14	11
Do you think mammography helps to diagnose breast cancer?	Yes	0	1	4	0.069
	No	16	16	13

Table 5. Stratification according to Socioeconomic Status

Responses to questions about Breast Self-Examination (BSE)		Socioeconomic Status			p-value
		Low	Middle	High
Have you heard of BSE?	Yes	0	3	6	0.037
	No	14	16	11
Do you perform BSE yourself?	Yes	0	3	6	0.037
	No	14	16	11
Do you think mammography helps to diagnose breast cancer?	Yes	0	1	4	0.028
	No	14	18	13

DISCUSSION

Breast cancer is highly prevalent in Pakistan, with approximately 1 in every 9 women expected to be diagnosed during their lifetime (Abdul Rehman et al., 2024; Tahir et al., 2022). Around 90,000 new cases are detected annually, and 40,000 women succumb to the disease due to delayed detection (Abdul Rehman et al., 2024; Tahir et al., 2022). Furthermore, the rural areas of Pakistan, where literacy rates are low and healthcare resources are limited, experience higher breast cancer rates (Uruntie et al., 2024). Therefore it is vital to increase awareness regarding breast cancer and BSE in Pakistani population so that timely diagnosis and prompt treatment may lead to reduction in disease burden. Regarding awareness and practices related to breast cancer and BSE in our study, 74% of the women had heard of breast cancer, but only 26% believed that early detection improves survival chances. Mammography was recognized as a diagnostic tool by only 10% of participants, with 28% having undergone a mammogram. On the other hand, 82% of women had never heard of BSE, and only 18% performed BSE, with even fewer performing it in front of a mirror (10.0%).

The findings of our study align with several previous studies, which highlight a significant gap in both knowledge and practice of BSE among women. A previous study from Lahore showed that only 19.3% of the participants knew about the BSE (Batool et al., 2018). From Karachi, Ali et al. (2020) reported 67.3% females had adequate knowledge about BSE, 31.9% females practiced BSE and 48.6% females had positive attitude, showing that overall knowledge level regarding BSE was inadequate. An Indian study from Tamil Nadu reported 26% women to be aware of BSE while only 5% practiced BSE regularly (Kumarasamy et al., 2017). Al-Qazaz et al. (2020) demonstrated that 42.7% women had BSE knowledge in Iraq but only 30.3% of the females who knew BSE performed it themselves. From Jordan, Alkhasawneh et al. (2009) reported BSE knowledge in 85% female nurses while 17.7% performed BSE on a monthly basis. The study by Abo Al-Shiekh et al. (2021) showed 80.2% female university students had information about breast cancer, 96.5% participants having BSE comprehension whereas only 31.4% did BSE regularly. Furthermore, factors such as education, socio-economic status and family history influence BSE engagement, with higher levels of education and wealth being associated with more frequent BSE practices. These comparisons underscore the need for targeted interventions and education to improve awareness and promote regular BSE practices, especially in resource-limited regions like Pakistan where breast cancer detection and survival rates are compromised by late-stage diagnoses. The results of these studies emphasize the need for targeted interventions, including educational campaigns, screening programs, and healthcare professional counseling, to improve breast cancer and BSE knowledge and compliance among middle-aged women, ultimately promoting earlier detection and better breast health outcomes.

In this study, educational level significantly influenced awareness and practice of Breast Self-Examination (BSE), with higher education correlating with increased knowledge and regular practice of BSE. These findings are consistent with previous studies, such as Batool et al. (2018) and Ali et al. (2020), which also found that educated women were more likely to perform BSE. Conversely, illiterate women in our study had minimal awareness and did not practice BSE, aligning with global research indicating that lower educational levels are associated with lower BSE practices (Kumarasamy et al., 2017). This highlights the need for targeted educational interventions to improve BSE awareness, especially among less-educated women. To improve BSE awareness and practices in Pakistan, educational interventions should focus on community-based workshops that include practical demonstrations and involve both men and women to reduce stigma. Media campaigns on TV, radio, and social media, with culturally appropriate messaging and visual aids, can address literacy barriers. Additionally, engaging community leaders, particularly in rural areas, can help normalize BSE and encourage women to seek information and support, fostering a culture of openness about breast health.

Limitations of the present study include a small sample size, which may limit the generalizability of our findings to a broader population. Additionally, the study was conducted at a single institution, potentially failing to capture the experiences and practices of women from different regions or healthcare settings. Selection bias is another concern, as participants were not randomly selected, possibly leading to an overrepresentation of certain demographics or behaviors. Future studies should aim for a larger, more diverse sample from multiple institutions to enhance the generalizability of the findings. Longitudinal studies could provide more comprehensive insights into the long-term impact of BSE education and practices. Additionally, incorporating qualitative data would help better understand the barriers and motivations surrounding BSE, especially in communities with lower awareness. Lastly, the reliance on self-reported data presents another limitation, as it may introduce recall or social desirability bias, with participants potentially underreporting or overreporting their behaviors. Addressing these factors in future research will improve the accuracy of results and support the development of more effective interventions.

CONCLUSIONS

Attitude regarding breast cancer and BSE was poor in our study. Our study highlights the need to promote knowledge and awareness regarding breast cancer and BSE by educational programs, public health messages, seminars and through social media. Family physicians play a crucial role in providing the necessary tools and guidance to help women learn and practice BSE, while also working to destigmatize BSE and mammography, motivating women to regularly examine their breasts and undergo mammography, as early detection of any changes or abnormalities can significantly aid in identifying breast pathology. To enhance BSE practices in Pakistan, it is essential to implement structured educational programs that focus on both awareness and practical demonstration of BSE techniques. These programs should be conducted in community health centers and schools, targeting women of all ages, with an emphasis on areas with low literacy levels. Additionally, using mass media campaigns through television, radio, and social media can reach a wide audience and promote regular BSE practices. Collaborative efforts with local healthcare professionals and community leaders are vital for creating culturally sensitive and supportive environments that encourage women to adopt BSE. Finally, integrating BSE education into routine healthcare visits and ensuring that family physicians provide guidance on breast health could significantly improve regular practice and early detection of breast cancer.

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