Screening Practices among First Degree Relatives of Breast Cancer Patients in Nepal

Background Family history is a signicant risk factor for development of breast cancer, particularly for women of rst-degree relatives. For women at high risk for breast cancer, regular screening is the mainstay of risk management. This study aims to nd out the breast cancer screening practices among rst degree relatives of breast cancer patient and determine factors associated with their screening practices. Methods A cross-sectional study was carried out among 150 purposively selected rst-degree female relatives of breast cancer patients undergoing treatment at B.P Koirala Memorial Cancer Hospital, aged between 20 and 60 years. A semi-structured questionnaire was used to collect data by face to face interview. Screening practices were characterized as regular screening practices performed by the respondents, which include any of these screening methods: monthly breast self-examination or clinical examination yearly at least once in 3 years or regular mammogram 1 or 2 yearly. Level of awareness was categorized into two categories ‘high level’ and ‘low level’ taking median score as the cut-off value. Chi-square tests and multiple logistic regression were used to test the association between screening practices and related factors.

Also, in South Asia, it is detected more often in younger females and at a more advanced stage as compared to females of other regions [ 5].
Breast cancer is the second leading cancer among Nepalese women [ 6]. According to the latest WHO data published in May 2014, the age-standardized incidence rate of breast cancer was 15.24 per 100,000 and age-standardized death rate of 8.13 per 100,000. Family history of breast cancer is one of the significant risk factors for development of the disease, particularly for women with first-degree relatives diagnosed with breast cancer [ 7]. Risk of breast cancer is about 2-4 times higher for women with first-degree female relative who has been diagnosed compared to women without a family history [ 8].
American Cancer Society (ACS) recommends women in their 20s and 30s should have a clinical breast examination (CBE) as part of a periodic (regular) health exam by a health professional preferably every 3 years. Starting at age 40, women should have a CBE by a health professional every year and should have a mammogram every year and continue to do so for as long as they are in good health [ 9]. However, the screening practices of women are de pended on their awareness, attitudes, socio-demographic characteristics and cultural issues [ 10]. Breast cancer screening recommendations for women with positive family history are based on expert opinion, and typically dictate shorter screening intervals and screening beginning at an earlier age. Such strategies include annual mammographic screening beginning at age 40 years, or 10 years prior to the earliest age of onset observed in the family (whichever occurs earliest), or starting as young as age 25 years for BRCA mutation carriers [ 11]. Several studies have found that regular screening in women with a family history is benefitted from reporting higher cancer detection rates and favorable prognostic features of screen-detected cancers [ 11,12]. Knowledge of risk factors for breast cancer and breast screening among women are being studied in Nepal, but none has looked at women with family history of breast cancer. This study is the first in Nepal to find out the breast cancer screening practices among first degree relatives of breast cancer patients and factors associated with it.

Study setting and design
This is a cross-sectional study carried out among first degree relatives of breast cancer patients attending B.P Koirala Memorial Cancer Hospital (BPKMCH) for their treatment form December 2016 to May 2017. BPKMCH is situated in Bharatpur, Chitwan district, Central Development Region of Nepal. It is the first national comprehensive cancer center of its kind. It is a 450 bedded hospital and provides high-quality services for the prevention, diagnosis, treatment and research on cancer, and to gain self-reliance in human resource required for the same.

Inclusion criteria
Sister, daughter, and mother of breast cancer women of age group 20 to 60 years accompanying them in the OPD, wards in BPKMCH were included and those with history of previous malignancies were excluded from the study.

Sample size
In a similar study done in Mexico, 38.7% of study participants had performed regular mammogram ( Bird et al., 2011). Based on the proportion, the sample size was calculated on this basis of the following formula.
The estimated sample size in the study was 150 participants.

Methods of data collection
The sample for the study was selected by non-probability purposive sampling method. The data were collected by the corresponding author via face-to-face interviews using semi-Page 5/27 structured questionnaires examining following parts: Part I comprised of socio-demographic characteristics, information regarding the relative (women with breast cancer) and personal medical history of the participant.
Part II comprised of level of awareness of the participant on risk factors and warning signs of breast cancer as adopted from comprehensive breast cancer knowledge test (CBCKT) with some modifications. This tool consists of 20 statements: 12 statements related to risk factors and 8 statements related to warning signs of breast cancer. Response to each statement included 'Yes', 'No' and 'Don't know'. For a correct response to any of the 20 statements on the questionnaire, a score of 1 was provided while an incorrect response or a response indicating 'Don't know' was scored 0. A composite score of all the items combined was calculated which could range from 0-20. The median value of the composite score was 11. The level of awareness, after dichotomization taking the median as the cut-off point, was grouped into two categories: "high level" (Score ≥ 11) and "low level" (Score <11).
Part III comprised of the perceived risk of developing breast cancer of the participant in their lifetime. The perceived risk was expressed in a numerical rating scale which ranges from 0 % to 100 %, where 0% means no risk at all and 100% means will absolutely develop cancer in future.
Part IV comprised of semi-structured questionnaires to assess the screening practices of the participants: Breast self-examination, Clinical breast examination and Mammogram practice were included in this part.
Validity of the tool Content validity of the questionnaire was established by a literature review and consultation with concerned faculties and experts. All sets of questionnaire were translated into Nepali version and re-translated into English language in collaboration with experts.
The final version was compared with old version and necessary corrections were made.
Opinion from the language expert was obtained for comprehensibility and simplicity of language during language translation. Pretesting of the tool was done in 10% of the total sample size i.e. 15 samples in Bhaktapur Cancer Hospital. Necessary modifications, such as sequence of the questions, modification in options, simplicity of the language were done as per required.

Operational definitions
Awareness on risk factor and warning signs of breast cancer: Awareness on risk factor and warning signs was defined as high level of awareness and low level of awareness based on their correct responses to the 20 statements of CBCKT on risk factor and warning signs of breast cancer. Descriptive statistics (frequency, percentage, mean and standard deviation, median and inter-quartile range) were calculated along with tabular and graphical presentation. Inferential statistics was done using Chi-square test to find out the association between screening practices and socio-demographic and other related factors at 95% confidence interval where level of significance p=0.05. Those variables significant at 10% level in univariate analysis were included in multiple logistic regression using backward elimination to find out the adjusted effects of different exploratory variables with screening practices.

Ethical consideration
The study was approved by the Institutional Review Committee (IRC), BPKIHS. Permission to conduct the study in B.P Koirala Memorial Cancer Hospital was taken from the academic department of the hospital. All the procedures were carried out after obtaining informed consent from the participants. The participants were assured about the confidentiality and anonymity of their information provided. They were informed that they have full authority to accept or refuse to take part in the study; and were also at liberty to withdraw at any time of the study. Interviews were carried out in privacy as far as possible.

Socio-demographic characteristics
The mean age of the respondents was 37.6 years (SD=10.9). Most of them were Hindus (68.7%) followed by Buddhist (21.3%). A majority (75%) of the respondents were married.
Most of the respondents belonged to nuclear family (62.0%) and the rest belonged to joint families.
Most of the respondents were homemaker (24.7%), followed by professional (16.0%) and agriculture (14.7%). Only 14% were unemployed. Most of the respondents (68.0%) were literate. The respondents below poverty line and above poverty line were in the ratio of 2:3.
Majority of the respondents were non-insured (80.7%). Almost half of the respondents had their mother diagnosed with breast cancer. The respondents who had their sisters diagnosed with breast cancer were 40%. Only 11.3% of the respondents had their daughter suffering from breast cancer patient. The duration of breast cancer was less than one year in most of the relatives of respondents (66.0%) whereas 34% of the relatives of respondents had duration of breast cancer one year and more. Majority of respondents (93.3%) had only one relative with breast cancer while the rest had two relatives with breast cancer (Table 1).

Personal history
Approximately 42.7% of the women had menarche at the age of 11 years and below. The mean age at menarche was 11.6 (SD 1.5) years. Out of 150 respondents, 112 respondents had given birth to their first child, among whom 57.1% had given birth of the first child below the age of 20 years. More than half of the respondents had good self-reported health status whereas 28% rated their health as very good. Only 4 percent of the women stated poor health status. Only 14.7 percent of the women had history of benign breast diseases.
The most common benign breast disease among those women was presence of breast lump (40.9%) which was followed by mastalgia (31.8%). The least common benign breast disease was mastitis (9.0%) ( Table 1). Level of awareness of the respondents on risk factors and warning signs of breast cancer The mean score of the respondents on CBCKT score was found to be 10.8 (SD 2.8).
Likewise, the median score was 11 (IQR 9-13). The level of awareness of respondents was categorized into low level and high level taking median score 11 as cut off value. The ratio of the respondents with low level of awareness to high level of awareness was found to be 2:3. About 54.6% of the respondents perceived their risk of developing breast cancer in their lifetime as 50% and above (Table 2).  screening practices compared to that of illiterate women (51.0% vs 12.5%) which was highly significant (p<0.001). The association was found to be significant with economic status in regards to poverty line, (p<0.001). Regular screening practices were found more in ever-married women than unmarried women (39% vs 37.5%). However, this difference was not found to be statistically significant. Likewise, no significant association of regular screening practices was found with occupation, and distance between nearest health facility and residence. Majority of women (72.4%) with insurance regularly practiced regular breast screening than women without insurance (30.6%) and this difference was found be statistically significant (p<0.001). The number of relatives with breast cancer were not found to be statistically significant with the screening practices. the respondents whose mother were diagnosed with breast cancer were 7.69 times more likely to have regular screening than those having daughter as patient. This difference was found to be statistically significant. Likewise, the duration of disease of the relatives was also found to be statistically significant (p=0.001). women with history of benign breast disease were found to practice regular screening 5.56 times more likely than those without benign breast disease (72.7% vs 32.8%) and this difference was found to be statistically significant (p<0.001). Regular screening was found to be more among women with no history of chronic illness than their counterparts (40.7% vs 29.6%). However, this difference was not found to be statistically significant (p=0.287). As illustrated in table 22, women with history of benign breast disease were found to practice regular screening 5.56 times more likely than those without benign breast disease (72.7% vs 32.8%) and this difference was found to be statistically significant (p<0.001). Regular screening was found to be more among Page 14/27 women with no history of chronic illness than their counterparts (40.7% vs 29.6%).
However, this difference was not found to be statistically significant (p=0.287). The respondents who had heard about hereditary breast cancer were found to be regularly practicing breast screening than their counterpart (47.9% vs 3.2%) and this difference was found to be highly significant (p<0.001) ( Table 4).

Regular screening practices and level of awareness and perceived risk of breast cancer
Women with high level of awareness on risk factors and warning signs of breast cancer were found to practice regular screening more than those with poor level of awareness; (58.3% vs 25.6%) this difference was found to be statistically significant (p<0.001). Women who perceived their risk of acquiring breast cancer in the future 50% or more were found to practice regular screening more (OR=16.67) than those who perceived less than 50% risk (63.4% vs 8.8%) and this difference was found to be highly significant (0<0.001) ( Table   5). Literate women were almost 7 times more likely to practice regular screening than illiterate women. Likewise, the odds ratio of regular screening practices in women above poverty line to that of women below poverty line was found to be 2.62 (CI: 1.01 -6.80). The female who had history of benign breast disease were almost 5 times more likely to perform regular screening than the women without benign breast diseases. Further, the perceived risk of developing breast cancer was also found to be important predictor in regular performance of breast cancer screening (OR=14.17, CI: 5.10-39.41) ( Table 6).

Discussion
The first degree relatives of breast cancer are in greater risk of developing breast cancer.
This is the first study in Nepal, to the best of our knowledge, to investigate the screening practices among the first degree relatives of breast cancer. Early menarche is one of the risk factors of breast cancer, thus finding of the study shows that 42.7 percent of the women are exposed to one of the risk factors of breast cancer [ 13]. Only 14.7 percent of the respondents had history of benign breast disease, which was similar to the finding in another study done in Philippines [ 14]. Women with a family history of breast cancer are more likely to develop benign breast disease and are also at increased risk for developing high-risk types of BBD such as atypical hyperplasia [ 11].
More than half of the respondents were aware of the risk factors like early menarche, delayed menopause, positive family history and also the protective role of breastfeeding and exercise. In another study done in Nepal, awareness on these risk factors was found to be low in contrast to the above findings of the present study [ 15]. The reason behind this contrasting result could be, in the present study only first-degree female relatives of breast cancer patients were considered whereas, in another study, the participants were general population. As our study group is a risk group they might have enquired about the disease and may have gained knowledge.
In the present study, majority of the respondents were aware of screening procedures. The self-breast examination was the most known screening procedure among the respondents and mammogram was the least known. This finding correlates with the result of the study done in Malaysia [ 16]. On the other hand, in a study done in Nepal among the female residents of Pokhara valley, more than half of the respondents were unaware of clinical breast examination and mammogram [ 5]. This suggests that compared to general population, these high-risk group women are more aware of the screening procedures.
Nevertheless, every woman should have access to information on screening modalities.
The present study reveals that majority (77.3%) of the respondents had ever performed breast self-examination. Likewise, in Nigeria, 61.4 percent of the first degree relatives of breast cancer had ever performed breast self-examination [ 17]. The women who had practiced monthly breast self-examination account for 34.7 percent of women among total respondents. On the other hand, in various studies done among the women without positive family history of breast cancer, the proportion of women performing breast selfexamination in regular basis was found to be lower than the finding of the present study i.e.
As in the present study, the proportion of women conducting breast self-examination was high; however the regular performers were rather low. Various modifiable and non-modifiable risk factors of breast cancer have been studied so far. Family history is one important non-modifiable risk factor. Therefore, adherence to screening methods is crucial for early detection and better prognosis. Paradoxically, a large proportion of women with a family history of breast cancer do not make use of available screening methods. Moreover, irregular screening practices and poor competency in performing self-breast examination could miss the chance of early detection of cancer leading to late-stage presentation. This puts a high burden on the already overburdened healthcare services. Awareness of different screening modalities should be raised among these women. Future studies should try to explore the lived experiences of women with positive family history of breast cancer, using qualitative approach. This will help to understand better how the family experience influences their practice of breast screening.
There are some limitations to the study. First, the data was collected from one hospital and non-probability sampling was used, thus this study cannot be generalized. However, the chosen hospital is the largest and nationally representative cancer hospital where 50% of the cancer cases from around Nepal are treated. Furthermore, this study does not allow us to make definitive inferences about the effect of risk factors associated with screening practices, as it has a cross-sectional design and this study used self-reported data.

Conclusions
Screening practices among the first degree relatives of breast cancer patients were found to be low in the present study. Likewise, the level of awareness on risk factors and warning signs of breast cancer was also found to be low among the respondents. Health care providers should provide these women opportunities to discuss their thoughts and experiences with breast cancer. There is a need to provide comprehensive, updated, and inclusive information and support and interventions aimed at increasing awareness of the importance of healthy behaviors in cancer prevention among these high-risk groups. Future studies should try to explore the lived experiences of women with positive family history of breast cancer, using qualitative approach. This will help to understand better how the family experience influences their practice of breast screening.