Breast cancer awareness among pharmacy and physiotherapy students of medical university

Objective: To evaluate the knowledge and awareness of students at a medical university regarding possible risk factors and screening modalities of breast cancer. Methods: The cross-sectional study was conducted from January to April 2019 at the People's University of Medical and Health Sciences for Women, Nawabshah, Pakistan, and comprised young female students from first year to final year at the Institute of Pharmaceutical Sciences and the Institute of Physiotherapy and Rehabilitation Sciences of the university. Data was collected using a predesigned questionnaire, and was analysed using SPSS 21. Results: Of the 450 students approached, 375(84%) completed the questionnaire. The mean age of the participants was 21.06±1.164 years (range: 18-26 years). Overall, 225(60%) students said contraceptive pills could increase the risk of breast cancer, 267(71.2%) agreed that breast-feeding could reduce cancer risk, while 361 (96.27%) students had good mammography and clinical breast examination knowledge. Also, 308(82.13%) respondents knew about breast self-examination, but were not aware of its procedure. Conclusion: Majority of the subjects had knowledge and awareness about breast cancer, its risk factors, diagnostic parameters and possible treatment options, but they did not have knowledge regarding the procedures of breast

Many of the possible characteristics attesting to be risk factors include family history, weight, age, hormonal changes, reproductive factors, physical activity and smoking. Females belonging to middle class families are considerably at high risk of breast cancer, having advancing age, higher body mass index (BMI) and a high proportion of incomplete pregnancies. 10 The risk could be decreased to a certain degree by keeping a healthy body mass, breastfeeding and physical workout. Some screening methods for early detection, like mammography, clinical breast examination (CBE) and breast self-examination (BSE), are used. At initial stage when breast cancer is just a localised growth, annual mammography is thought to be the utmost useful procedure for diagnosis. 12 At the population level mammographic screening might not be the best technique for early diagnosis of breast cancer due to lack of adequate resources in middle-income countries, including Pakistan. CBE assures cancer reduction at the diagnostic stage because of early detection of symptoms. BSE is not studied for downsizing the tumour at the diagnostic stage, but it improves early identification and reporting of symptoms of breast cancer. 11 The current study was planned to assess the awareness and knowledge of students at a medical university regarding the risk factors of breast cancer.

Subjects and Methods
The cross-sectional study was conducted from January to April 2019 at the People's University of Medical and Health Sciences for Women, Nawabshah, Pakistan. After approval from the institutional ethics review committee, the sample size was calculated based on 5% margin of error and 95% confidence level using Rao software. 13 The sample was raised using non-probability convenience sampling method from among young female students from the first to the final year of studies at the university's Institute of Pharmaceutical Sciences and the Institute of Physiotherapy and Rehabilitation Sciences. All medical, nursing and public health students were excluded.
After taking consent from the subjects, data was collected using a pre-designed questionnaire which explored 6 domains: demographics; level of awareness about possible risk factors of breast cancer; awareness about the signs and symptoms of breast cancer; awareness about the diagnostic modalities of breast cancer, especially the attitude of the participants towards mammography and CBE; assessment regarding BSE practice; and knowledge about possible treatment options, including chemotherapy, radiotherapy, lumpectomy and mastectomy.
Data was analysed using SPSS 21.

Results
Of the 450 students approached, 375(84%) completed the questionnaire. The mean age of the participants was 21.06±1.164 years (range: 18-26 years). The majority of the participants belonged to the rural areas of Sindh province ( Figure-1). Overall, 330(88%) subjects knew that breast cancer chances increased with advancing age, 261(69.6%) had knowledge that the risk of breast cancer increased with positive family history, 259(69.06%) claimed that breast cancer is not a contagious disease, and 278(74.13%) agreed that poor personal hygiene enhanced the risk of breast cancer. A significant number of participants agreed that alcohol consumption, junk food intake and obesity were the leading risk factors of breast cancer, and 267(71.2%) marked that breast-feeding can decrease the risk of breast cancer, while 225(60%) claimed that contraceptive pills increased the risk of breast cancer (Table).
Further, 243(64.8%) students responded that bloody discharge from the nipple in unmarried females might be an early symptom of breast cancer; 341(90.93%) had knowledge that breast pain can be the cause of breast carcinoma; 352(93.86%) responded that existence of lump in breast was significant indicator of cancer in breast; and 330(88%) were aware of the morphological changes in the presence of breast carcinoma (Figure-2   With regards to BSE, 308(82.13%) participants had knowledge about BSE, and 332(88.53%) agreed that BSE is an important tool for the early detection of breast cancer symptoms. There was poor association between the knowledge and practice of BSE (Figure-4).

Discussion
The current study highlighted the awareness of breast cancer among the students of a medical university in Nawabshah, Sindh. The students will have interaction with the community in their professional lives and they can educate the masses about breast cancer and its modalities. 14 Although the awareness of Pharmacy and Physiotherapy students was comparatively better than the other university students of general disciplines, 15 the overall knowledge was insufficient because they ranged from the first year to the final year, and most of them were from the rural areas of Sindh. More than 85% students agreed that advancing age increased the risk of breast cancer. However, studies have shown that females have suffered in early ages but were diagnosed later in developing and under-developing countries. 16 A significant number of participants agreed that poor personal hygiene, alcohol consumption, obesity and junk food intake increased the risk. 17 Various studies on cancers explained these factors as potential risk factor in breast cancer, but physical inactivity and tobacco use are the foremost sources of non-communicable illnesses, including different kinds of cancers. 18 About 60% of the students agreed that the usage of contraceptive pills was the enhancing risk factor for breast cancer. A few studies have reported the positive association between breast cancer and longterm usage of contraceptive pills. 19 About 96% participants of the current study had sufficient knowledge about mammography, which is considered an early detection tool for screening of breast cancer, but is quite costly and out of the reach for people living in rural areas of Sindh. 8 About 71% participants pointed out that breast-feeding decreased the risk of breast cancer. Studies have reported that the number of pregnancies and breast-feeding decreased the numbers of menstrual cycles in a female life and minimised the total exposure to endogenous hormones. 20 While 82% students had heard about BSE, over 50% of them did not know its procedure.

Conclusion
Majority of participants had knowledge about breast cancer, its risk factors, diagnostic parameters and possible treatment options, but they did not have knowledge regarding BSE procedure. Intervention is needed to cover this gap between BSE knowledge and practice in order to detect this problem at an early stage.