Abstract

Background: In Togo, awareness is very low and patients regularly present with advanced stages of breast cancer. Objective: Determine the knowledge of risk factors and means of breast cancer screening by women seen in gynecological consultation of the Sylvanus Olympio University Hospital (CHU SO). Methods: This was a descriptive cross-sectional study conducted at the gynecology-obstetrics clinic of the CHU SO of Lomé, from March 1 to July 15, 2022. Results: We surveyed 1,566 gynaecological outpatients. Six hundred (600) patients agreed to answer our questions freely, giving a participation rate of 38.3%. The average age of the respondents was 31.9 years old. In 25.5% of cases, the respondents were high school graduates. Five hundred and forty-five of the respondents, or 90.8% had already heard of breast cancer. The most frequent sources of information were medical staff in 34.1% of cases. The presence of nodule in the breast was cited as a clinical sign in 68.4% of cases, breast self-examination as a means of screening in 72.6% of cases, personal history of breast cancer in 51.7% of the cases has non-modifiable risks and smoking as a modifiable risk factor by 58.9% of the respondents. In 31% of cases, they performed breast cancer screening on their own. Breast self-examination was performed by 27.7% of them. Occupation and level of study were statistically associated with women’s knowledge of breast cancer. Conclusion: Most women recognize the existence of breast cancer but their knowledge about signs and risk factors remains low. Few of them, practice screening.

Keywords

Breast Cancer, Screening, Women, Knowledge, Togo

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1. Introduction

Breast cancer is a malignant tumor developed at the expense of the mammary gland, arising in the vast majority of cases from the epithelial lining of the lobules or galactophoric ducts [1] . It is the first female cancer in the world followed by cervical cancer. In 2020, 2.3 million women with breast cancer and 685,000 deaths from breast cancer have been reported worldwide. Most breast cancer and breast cancer deaths are reported in low- and middle-income countries [2] . In sub-Saharan Africa, half of women who die from breast cancer are under the age of 50 [2] . In Togo, breast cancer is a real public health problem. Awareness is very low and patients regularly present with advanced stages of breast cancer [3] [4] . Breast cancer silently kills women mainly those who have no knowledge and who are still unaware of breast cancer and diagnostic breast screening methods for early detection [5] . In 2016, Darre et al. [6] reported 9.9% cases of breast cancer in all types of cancers and 21.2% of breast cancer in women. Bassowa et al. [7] recorded 58.4% of breast cancer deaths in 2018 at the Sylvanus Olympio University Hospital (CHU SO) in Lomé. To our knowledge, no study has specifically looked at women’s knowledge of breast cancer screening. Darre et al. [5] has related the Knowledge, Attitudes on Risk Factors and Means of Screening by Medical Students from Lomé, Togo. Also, in our communities, the discovery of breast cancer is most often at an advanced stage of the disease, hence the need to focus on screening. Faced with the extent of the pathology, and the delay in diagnosis, we conducted this study to determine the level of knowledge of women seen in external gynecological consultation on risk factors and means of breast cancer screening.

2. Materials and Methods

This was a descriptive cross-sectional study conducted in the external gynecological consultation unit of the gynecology-obstetrics clinic of the CHU SO of Lomé. It ran from March 1 to July 15, 2022. It was probability sampling. All patients seen on an outpatient basis in the department, of sufficiently lucid age to answer the questions and who had not yet been asked to complete the questionnaire (Appendix) and who agreed to participate freely and in an informed manner in the survey.

The data was collected, using a pre-established survey sheet and tested. We drew up the questionnaire ourselves. The questionnaire was pre-administered to 20 patients who were no longer part of the sample. This allowed us to make certain modifications before administering it to our study population. The questionnaire was then administered to all patients received in external gynecological consultation, after free and informed consent. They were given the free choice to leave the process at any time. The women were given a questionnaire containing 59 questions divided into six parts: A section containing socio-demographic information, Information about breast cancer, A section on knowledge of breast cancer risk factors, A section on knowledge of the clinical signs of breast cancer, A section on knowledge of screening methods, A section on the practice of breast self-examination. The patients were approached after being seen in consultation and the questionnaires were read and explained to them. The patient was asked to give her answer without being asked to fill in the survey form. Her answer was then ticked. Each correct answer was worth one point, while an incorrect answer or “don’t know” was worth 0 points. A total score for each participant was calculated by adding up the number of correct answers. Information on socio-demographic characteristics was not taken into account when calculating the score. Based on the responses obtained, we dichotomised the score at the 23.5-point threshold. Scores ≥ 23.5 (>50%) were considered good scores, i.e. good knowledge, and those ≤ 50% were considered bad scores, i.e. poor knowledge. With regard to the practice of breast self-examination, a score was established based on 5 items. Each good practice was worth 1 point and each poor practice was worth 0 points. A total score for each participant was calculated by adding up the total number of points. A score ≤ 2 corresponds to poor practice; a score between 3 and 4 corresponds to less good practice and a score ≥ 4 corresponds to good practice. The collected data was then processed using Epi Info software version 7.1.3.3. The Chi-square test was used for the comparison of qualitative variables, with a statistically significant threshold of p 0.05.

3. Operational Definitions

Cohabitation: a common-law union, characterized by a common life with a character of stability and continuity between two people who live together in a sustainable and notorious way without having officially celebrated their union at the town hall.

Irregularity in the practice of breast self-examination and mammography: This does not respect any periodicity.

4. Results

In four and a half months, 1566 patients came to the CHU SO for an external gynecological consultation. Six hundred (600) patients agreed to answer our questions freely, which is a participation rate of 38.3%.

4.1. Socio-Demographic Data

The average age of the respondents was 31.9 years old, with extremes of 14 and 66 years. The [20 - 30] years represented 40.7% of cases. In 41.5% of cases, the respondents lived in cohabitation. Secondary education level represented 44.2% of cases. In 29.2% of cases, the respondents were resellers (Table 1).

4.2. Gestity and Parity

The paucigestes accounted for 69.8% of the respondents and the paucipares 68.2% (Table 2).

4.3. Knowledge about Breast Cancer

Five hundred and forty-five respondents or 90.8% had already heard of breast cancer. The most frequent sources of information were medical staff in 34.1% of cases. The presence of nodule in the breast was cited as a clinical sign in 68.4% of cases, breast self-examination as a means of screening in 72.6% of cases, personal history of breast cancer in 51.7% of the cases as non modifiable risk factors and smoking as a modifiable risk factor by 58.9% of the respondents (Table 3).

4.4. Women Practices on Breast Cancer Screening

Among the 600 women interviewed, 186 (31%) performed breast cancer screening on their own. Breast self-examination was performed by 27.7% of them. Breast self-examination was performed irregularly by 62.1% of them. Only 16.7 of them knew Mammography performance frequency (Table 4).

4.5. Factors Associated with Knowledge of Risk Factors and Means of Breast Cancer Screening

The occupation and level of study were statistically associated with women’s knowledge of breast cancer (p < 0.001). Whether they are married or not, women had not good knowledge with screening (69%) Non educated women had not good knowledge with screening 80.5%. Whatever their socio-economic level, women had not good knowledge with screening, Low level, in 73.2%, had not good knowledge with screening (Table 5).

5. Limitations of Our Study

The way in which the survey was carried out exposes it to bias with regard to the veracity of the information received from the interviewees. In fact, the questionnaire was completed by ourselves and the patients were questioned after the consultation, when they were in a hurry to go home. The extent of this bias remains small, however, and does not fundamentally alter the meaning of our results.

6. Discussion

Breast cancer is the first female cancer in terms of prevalence and mortality in our country and is a real public health problem. It occurs more and more in young Togolese women and the diagnosis is often made at advanced stages [4] . The fight against this scourge begins with prevention, hence the need to know the risk factors and the means of screening. Those under 30 were the most represented with a rate of 49.9% and an average age of 31.9 years. This result is similar to that reported by Okobia et al. in Nigeria where 61.9% of the population was under 30 years old, with an average age of 29.13 years [8] . This proves the extreme youth of the African population in general and Togolese in particular. Only 25.5% of our study population reached the upper level versus 44.2% who reached the secondary level. In their study, Okobia in Nigeria [8] and Keita in Morocco [9] also reported a low rate of university-educated women of 11.9% respectively and 15.3%. These different results show the difficulties girls have in being able to perform higher studies in our communities, and also, because the free schooling that had stopped at primary school until then was extended to secondary school only in September 2021 [10] . In 90.8%, respondents said they had already heard about breast cancer and the most cited source of information was medical staff in 34.1% of cases. Keita et al. reported a lower rate of 76.6% having already heard of breast cancer and as a primary source of information, relatives; medical staff was cited by only 8% of respondents. This reflects efforts to raise awareness about breast cancer in Togo by medical staff especially through the campaigns of October “Pink October” but this rate of 34.1% is still low and requires more awareness by the health professional. At each medical consultation, a small awareness could be proposed. Regarding breast cancer risk factors, 34.3% of participants knew that the probability of breast cancer increases with age; this is very low compared to the 76% of participants found by Keita in Morocco [9] . Genetic factors and personal history of breast cancer were considered by our respondents, as risk factors with respectively in 33.9 and 51.7%. Genetic factors were reported by Ngowa et al. [11] in Yaoundé in 63.1%, as risk factors. Igiraneza et al. [12] reported in 2021 that 68.7% of participants considered alcohol consumption a major risk factor, followed by smoking (67.5%). A breast tumor, galactorragia, breast enlargement and breast ulceration were recognized as clinical signs of breast cancer by 68.4%, 55%, 60.5% and 58.3% of our participants, respectively. Maram et al. [13] in 2023 reported the onset of breast or armpit mass (95.8%), followed by any change in breast size or shape (76%), as the best known symptom. All this could be explained by the multiplicity of clinical signs. Breast self-examination was considered a means of breast cancer screening by 72.6% of our participants. Keita et al. [9] reported a similar result of 62.7%. This knowledge rate is acceptable. This could be explained by the fact that during awareness campaigns, the focus is placed in our context on breast self-examination, although this is not the safe screening method since the tumor is already at the clinical stage. Especially since mammography is not accessible to all, whether it is financially or geographically, financially or geographically. Mammography was still recognized as a screening method in 51% of cases. This proves that the message of awareness passes in a certain way. It is therefore necessary to also emphasize mammography during awareness campaigns on breast cancer in Togo, and also, that the State can organize mass screening, and subsidize this examination. One hundred and eighty-six of the participants (31%) used screening devices on a personal basis. This rate is higher in the study of Ngowa et al. [11] in Yaoundé with 80.5% of participants who performed screening on a personal basis. This poor practice of screening in our population is explained by the fact that in our communities, the prevention of the disease, especially in cancer is not yet a habit. People are afraid to think about it, since most of them consider this pathology as a “death sentence”. The factors statistically associated with women’s knowledge of breast cancer were occupation (p < 0.0001) and level of study (p = 0.0001). Keita et al. [9] in Morocco also reported age and level of study as factors statistically associated with women’s level of knowledge. Gangane et al. in 2015 [14] in India had made the same observation. This finding shows that the older and more educated women are, the more they know about breast cancer. In addition, it is when they get older that they worry more about their health and they go to information. As for the level of education, the more educated one is, the more curious one is and the preventive attitude to diseases differs. Finally, whether they are married or not, women had not good knowledge with screening.

7. Conclusion

Breast cancer is the most common cancer of women in the world and especially in Africa and Togo. Most of the women in this study recognized the existence of the disease but their knowledge on risk bills, clinical signs and screening means remains low as well as their practice on screening. It is therefore necessary to strengthen awareness of the disease and especially to encourage women to the practice of screening, to make a plea for the subsidy of mammography and the establishment of a sustainable project of mass screening and also to encourage women to consult immediately when faced with any evocative sign.

Appendix Thème: Connaissance Des Facteurs De Risque Et Moyens De Dépistage Du Cancer Du Sein

Questionnaire

Caractéristiques socio-démographiques:

- Nom et prénom de la patiente:

Âge de la patiente:

Adresse: Profession:

Niveau socio-economique: Elevé: Moyen: Bas:

Niveau d’étude: Analphabète: Secondaire: Supérieur: Primaire:

Statut matrimonial: Célibataire: Mariée: Divorcée: Veuve: Concubinage:

Gestité: Parité:

Information sur le cancer du sein

Avez-vous déjà entendu parler du cancer du sein: Oui: Non:

Si oui Sources d’information: Proches: Personnels médical: Radio: Télévision: Internet: Sensibilisation: Autres:

Selon vous qu’est-ce que le cancer du sein? --------------------------------------

Connaissance des facteurs de risque du cancer du sein:

Facteurs non modifiables

Effet du vieillissement: Augmente l’incidence: Baisse l’incidence: Aucun effet: Ne sais pas:

Age précoce des premières menstruations (≤12 ans): Augmente l’incidence: Baisse l’incidence: Aucun effet: Ne sais pas:

Ménopause ≥ 55 ans: Augmente l’incidence: Baisse l’incidence: Aucun effet: Ne sais pas:

Age précoce et ménopause tardive: Augmente l’incidence: Baisse l’incidence: Aucun effet: Ne sais pas:

Facteurs génétiques: Augmente l’incidence: Baisse l’incidence: Aucun effet: Ne sais pas:

Antécédent familial de cancer de sein (1^er degré): Augmente l’incidence: Baisse l’incidence: Aucun effet: Ne sais pas:

Existence de cancer du sein chez les enfants de même père: Augmente l’incidence: Baisse l’incidence: Aucun effet: Ne sais pas:

Existence de cancer du sein chez les enfants de même mère: Augmente l’incidence: Baisse l’incidence: Aucun effet: Ne sais pas:

Existence d’anomalie chromosomique BRCA1/BRCA2: Augmente l’incidence: Baisse l’incidence: Aucun effet: Ne sais pas:

Antécédent personnel de cancer du sein: Augmente l’incidence: Baisse l’incidence: Aucun effet: Ne sais pas:

Maladies bénignes du sein (Nodule, mastodynie): Augmente l’incidence: Baisse l’incidence: Aucun effet: Ne sais pas:

Densité mammaire: Augmente l’incidence: Baisse l’incidence: Aucun effet: Ne sais pas:

Facteurs modifiables

N’avoir jamais accouché jusqu’à la ménopause: Augmente l’incidence: Baisse l’incidence: Aucun effet: Ne sais pas:

Age de la première grossesse menée à terme ≥ 30 ans: Augmente l’incidence: Baisse l’incidence: Aucun effet: Ne sais pas:

Allaitement maternel: Augmente l’incidence: Baisse l’incidence: Aucun effet: Ne sais pas:

Contraception hormonale: Augmente l’incidence: Baisse l’incidence: Aucun effet: Ne sais pas:

Traitements hormonaux de la ménopause: Augmente l’incidence: Baisse l’incidence: Aucun effet: Ne sais pas:

L’obésité: Augmente l’incidence: Baisse l’incidence: Aucun effet: Ne sais pas:

Activité physique: Augmente l’incidence: Baisse l’incidence: Aucun effet: Ne sais pas:

Tabagisme: Augmente l’incidence: Baisse l’incidence: Aucun effet: Ne sais pas:

Consommation régulière de fruit: Augmente l’incidence: Baisse l’incidence: Aucun effet: Ne sais pas:

Consommation de graisse animale: Augmente l’incidence: Baisse l’incidence: Aucun effet: Ne sais pas:

Connaissances des femmes sur les signes du cancer du sein:

Peut-on découvrir le cancer du sein en l’absence de signes cliniques? Oui: Non: Ne sais pas:

Ecoulement mamelonnaire de sang: Oui: Non: Ne sais pas:

Tumeur au niveau du sein: Oui: Non: Ne sais pas:

Changement de couleur de la peau du sein: Oui: Non: Ne sais pas:

Rétraction du mamelon: Oui: Non: Ne sais pas:

Augmentation de taille du sein: Oui: Non: Ne sais pas:

Ulcération au niveau du sein: Oui: Non: Ne sais pas:

Ganglion axillaire: Oui: Non: Ne sais pas:

Connaissances des femmes sur les moyens de dépistage:

Auto palpation des seins: Oui: Non: Ne sais pas:

Si oui quand faut-il le faire? ----------------------------------------------------

A quelle fréquence? --------------------------------------------------------------

Mammographie: Oui: Non: Ne sais pas:

Si oui quand faut-il le faire? ----------------------------------------------------

A quelle fréquence? --------------------------------------------------------------

Où peut-on le faire? --------------------------------------------------------------

Le coût: --------------------------------------------------------------------------

Echographie: Oui: Non: Ne sais pas:

Examen annuel chez le médecin: Oui: Non: Ne sais pas:

Qui doit faire le dépistage du cancer du sein? ------------------------------

Quand? -----------------------------------------------------------------------------

Comment prévenir le cancer du sein? ------------------------------------------

Est-ce une maladie grave? Très grave? Pas grave? Ne sais pas:

Est-ce une maladie curable? Incurable? Ne sais pas:

Maladie contagieuse: Oui: Non:

Maladie transmissible: Oui: Non:

Evaluation de la pratique de l’autopalpation des seins

Score ≥ 4: Bonne pratique

Score entre 3 et 4: Moins bonne pratique

Score ≤ 2: Mauvaise pratique

Score de connaissance ≤ 50% >50%

Pratique du dépistage du cancer du sein par les femmes

Avez-vous recours au dépistage à titre personnel? Oui Non

Quelle méthode utilisez-vous? Auto examen des seins

Echographie Mammographie

A quelle fréquence pratiquez-vous la mammographie?

Une fois l’an

Tous les 2 ans

Irrégulière

A quelle fréquence pratiquez-vous l’auto examen des seins

Tous les mois

Tous les 3 mois

Irrégulière

Conflicts of Interest

The authors declare no conflicts of interest.

References