Breast , Cervix and Colorectal Cancer Knowledge among Nurses in Turkey

Cancer is most important problems in the world (Tastan et al., 2013). Cancer is a leading cause of death developed countries and second leading cause of death in developing countries such as Turkey (Jemal et al., 2011). 7.6 million cancer deaths (around 13% of all deaths) are estimated in 2008, and about 70% of all cancer death occurred in low and middle income countries (WHO, 2013). Breast cancer in females and lung cancer in males are the most frequently diagnosed cancers and the leading cause of cancer death for each sex in both developed and developing countries (Jemal et al., 2011). According to the 2008 data of the Turkish Authority for Fighting Cancer, the most common cancer types among women are breast (40.7%), thyroid (16.2%), cervical (13.2%), colorectal (8.6%), followed by other types of cancer (KETEM, 2012). The detection of early sign and symptom for cervical, breast and colorectal cancer provides early treatment and prevents disease progression (WHO, 2013). Breast cancer is the most common type of cancer in women and is an important cause of death (Ozmen, 2008; WHO, 2008). In Turkey, breast cancer incidence rates are rapidly increasing (Ozmen, 2008). The most dependable method of reducing mortality in breast cancer is early diagnosis and treatment. Early diagnosis, in turn, is only possible through informing


Introduction
Cancer is most important problems in the world (Tastan et al., 2013). Cancer is a leading cause of death developed countries and second leading cause of death in developing countries such as Turkey (Jemal et al., 2011). 7.6 million cancer deaths (around 13% of all deaths) are estimated in 2008, and about 70% of all cancer death occurred in low and middle income countries (WHO, 2013). Breast cancer in females and lung cancer in males are the most frequently diagnosed cancers and the leading cause of cancer death for each sex in both developed and developing countries (Jemal et al., 2011). According to the 2008 data of the Turkish Authority for Fighting Cancer, the most common cancer types among women are breast (40.7%), thyroid (16.2%), cervical (13.2%), colorectal (8.6%), followed by other types of cancer (KETEM, 2012).
The detection of early sign and symptom for cervical, breast and colorectal cancer provides early treatment and prevents disease progression (WHO, 2013). Breast cancer is the most common type of cancer in women and is an important cause of death (Ozmen, 2008;WHO, 2008). In Turkey, breast cancer incidence rates are rapidly increasing (Ozmen, 2008). The most dependable method of reducing mortality in breast cancer is early diagnosis and treatment. Early diagnosis, in turn, is only possible through informing 1 RESEARCH ARTICLE

Breast, Cervix and Colorectal Cancer Knowledge among Nurses in Turkey
Isil Isik Andsoy 1 *, Asiye Gul 2 women on the subject and establishing early diagnosis programs (Golbassi et al., 2007;WHO, 2008). Breast self examination (BSE), clinical breast examination (CBE) and mammography (MG) are the most commonly used screening programs for breast cancer (Ozmen, 2008;Yilmaz et al., 2013). In our country, every woman between the ages of 40-69 are tested by MG every two years, and counseling is provided on BSE to every woman above the age of 20 (KETEM, 2012).
Colorectal cancer is the second most common type of cancer in worldwide and the third most common cause of cancer related deaths in women (Jemal et al., 2011). The disease can be caught is its early stages through effective personal risk evaluation and scanning programs, and has a high chance of recovery (Tastan et al., 2013). Colonoscopy, sigmoidoscopy, barium lavement, and fecal occult blood test (FOBT) are among the scanning methods used in colorectal cancer (Tinmouth et al., 2012). In our country, men and women between the ages of 50-70 are advised to be tested for FOBT every two years, and have a colonoscopy every 10 years. The scanning test is stopped for men and women over 70 whose last two FOBT tests were negative, and people with high risk are tested after the age of 40 (KETEM, 2012; Turkey incidence of cancer, 2013).
Among women in the worldwide, cancer of the cervix uteri is the third most common cancer (WHO, 2010;Jemal et al., 2011). Prevention and early diagnosis of cervical cancer reduces the incidence of invasive cancer and mortality (WHO, 2007). The Pap smear scanning method reduces deaths by cervical cancer by almost %80-90 (WHO, 2007;Perry, 2011;Abreu et al., 2012 (KETEM, 2012). In Turkey, to decrease of cancer as primary prevention and early detection of cancer and reduction mortality are among target (Karabulutlu, 2013). In the successful implementation of cancer screening programs, health workers especially nurses may play an important role (Fotedar et al., 2013;Özkahraman and Yildirim, 2013;Yilmaz et al., 2013). Therefore, nurses must be aware of current regular cancer screening program. The study was performed in order to evaluate the knowledge of nurses had on cancers appropriate for early detection that have scanning programs, such as breast, cervix, and colorectal cancers, and the knowledge they had on the application of those tests.

Study design
The study was conducted as a descriptive crosssectional design.

Setting and sample
The study was carried out at Karabuk State Hospital which is located at the Western Black Sea Region of Turkey from April 1 to July 30, 2013. Two hundred fortysix nurses work at the Karabuk State Hospital. 20 male nurses were excluded in the study. Hence, the study was conducted with the participation of 226 nurses.

Data collection
Data for the study was collected by researcher in faceto-face interviews. Nurses who agreed to participate were given a two page self-administered questionnaire. The questionnaire, contains of 44 items, was developed by researchers after a review of the literature (WHO, 2010;Ertem, 2009;Ozmen 2011;Karabulutlu, 2013;Tastan et al., 2013). The questionnaire was divided into three parts.
The first part included 14 questions about sociodemographic information such as; questions regarding title, educational level, work experience, marital status, age of marriage, number of children, age of first menstruation, alcohol and tobacco consumption, exercise, dietary habits and history of cancer in the family. In part two 10 questions were included; the nurses status in applying scans for breast, cervix, and colorectal cancers, their self-perception on cancer risk, and willingness to receive training.
The last part 20 questions were included; evaluating the knowledge of the nurses on breast, cervix, and colorectal cancers. The response categories for this section on knowledge were in a yes/ no/I don't know format. Each correct answer was 5 points, every wrong answer was 0 points, and the questionnaire was calculated from a total of 100 points.

Statistical analysis
Statistical analysis of the data was performed frequency; means, standard deviations and percentage were calculated for all responses in the survey. Data analysis was performed using the student T tests and variance analysis (ANOVA). The Bonferroni test was used in order to determine the group from which the results that turned up meaningful in the variance analysis arose from. Results had 95% confidence interval with p<0.05, indicating statistical significance.

Ethical considerations
The permission from the institutional ethical committee was taken before starting the study. The researchers followed the principles of the Declaration of Helsinki and received oral consent of participants. Participation in the survey was voluntary and nurses were free to withdraw from the study at any time. Nurses were exposed to  Table 1 shows the characteristics of the nurses. The mean age of the nurses was 32.07±8.39. 65% (n=147) of the nurses were married and 44.7% (n=101) had graduated associate degree. Among the nurses, 85.8% (n=194) of them were working as clinic nurses and 34.1% (n=77) were working for 16 years or over. 65.5% (n=148) of the nurses did not smoke and 95.6% (n=216) did not consume alcohol. 69% (n=156) of the nurses reported that they sometimes exercised and 51.3% (n=116) stated that they consumed large amounts of fruits and vegetables. Among the nurses who had a familial history of cancer (n=77), 31.2% (n=24) reported that breast cancer was the most frequent cancer type in family members.

The risk perception and behavior of nurses for breast, cervix, and colorectal cancers screening program
Among the nurses, 40.7% (n=92) of them thought that they weren't under risk for breast cancer, 62.4% (n=141) were practice BSE when they remembered about it and 46% (n=68) stated that they did not receive mammography because they were not in the relevant age group. 46% (n=104) weren't know whether they are under risk for cervical cancer, 65% (n=147) weren't undergo gynecological examination unless they have a disease symptom, and 39.8% (n=90) weren't take a Pap smear test since they did not think it was necessary. 40.3% (n=91) of the nurses weren't know if they were under risk for colorectal cancer. In addition, 64.2% (n=145) of the nurses would like to receive information about cancer and screening tests (Table 2).
Nurses' knowledge about breast, cervical, and colorectal cancer It has been found that a clear majority of the nurses had given true answers to questions on breast, cervical and colorectal cancers. In general, percentages of "correct" responses for all the knowledge items are higher than "don't know" answers ( Table 3). The majority of nurses gave the response "I don't know" to questions regarding the risk factors of cervical cancer and screening methods. Table 4 shows comparison of the three cancers knowledge scores according to some characteristics of nurses. The differences between marital status, work experience, education level in relation to knowledge scores were found significant (p<0.001). Knowledge score was significantly lower for married nurses (56.13±18.36) compared to single nurses (66.22±17.26). The knowledge scores of the nurses who worked for less than five years (57.77±2.28) were lower than those who worked for 16 years and over (66.88±1.85). The knowledge scores of nurses who graduated from high school (55.08±2.84) were lower than those who had associate (62.75±2.01) and bachelors/master's degree (66.88±1.60). There was no significant difference in breast, cervical, and colorectal cancer knowledge scores according to nurses' familial

Discussion
This study was conducted to evaluate the current information about the level of knowledge for breast, cervical and colorectal cancer screening among Turkish nurses. Cancer is a preventable disease thus it is important to determine of its precancerous form by screening at an early stage (WHO, 2010). Determining nurses' level of knowledge about cancer screening programs is very important for cancer protection. Approximately one-third of the nurses who participated in our study had a family member diagnosed with cancer. According to Turkish cancer statistics, breast cancer is the most prevalent cancer type in women (Eser et al., 2010). Less than half of the nurses who participated in our study did not think they were under risk for breast cancer. However, every woman is at risk for breast cancer and breast cancer incidence is increasing in Turkey and in the World. The early detection of the breast cancer by screening may reduce mortality (Ozmen, 2011). BSE is the most effective way to recognize the early signs and symptoms. The majority of the nurses practiced BSE when they remembered to, whereas a few are doing it regularly. Among the nurses, 46% did not receive MG because they were not in the relevant age group. In the literature reported that 80% of the masses   DOI:http://dx.doi.org/10.7314/APJCP.2014.15.5.2267 Breast, Cervix andColorectal Cancer Knowledge among Turkish Nurses in breasts were found during BSE (Yilmaz et al., 2013). Fotedar et al. (2013) stated that 54% of the nurses carried out of BSE practice at least once every month. Odusanya and Tayo (2001) determined that the majority of nurses practices BSE and that only a small number of nurses received MG in the last 3 years. Gencturk (2013) reported that 19.7% of health professionals practiced BSE regularly and that 1.3% received MG once a year. In this study, similar results were found. Although the result of the study are similar to other studies, the fact that the rates of having a MG was low in most of the nurses may be explained by the starting age suggested for MG being lower than 40 in the study group. Additionally, the fact that nurses didn't have scan tests for breast cancer despite almost half of the nurses perceiving themselves as under risk for breast cancer is worrisome.
Colorectal cancers can be scanned just like breast and cervix cancers (WHO, 2007). The main goal of screening for colorectal cancer is to detect adenomatous polyps. Colorectal cancer screening has been shown to decrease the incidence and mortality (Al-Naggar and Bobryshev, 2013;Hwang, 2013). Approximately one third of them think they are not at risk for colorectal cancer, their age is younger can be the cause of this idea. Colorectal cancer incidence rates are rapidly increasing some factors such as; changes in dietary patterns, obesity, and an increased prevalence of smoking (Jemal et al., 2011). Although there were no studies evaluating the colorectal cancer knowledge of nurses in our country, health personnel are aware of the risk factors for colorectal cancer.
Cervical cancer has an important among women's cancer (Karabulutlu, 2013). In the study, almost half of the nurses stated that they didn't know if they were under risk of cervical cancer. However, 65% of nurses are married and they are at risk for cervical cancer. Sexually transmitted Human Papilloma Virus (HPV) is one of the factor causing cervical cancer (Bekar et al., 2013). In current study, the majority of the group reported that they don't find it necessary and 32.4% of them stated they are single. The American Cancer Society recommends all women should begin cervical cancer testing at age 21, women age 21-29 should have a Pap test every 3 years. Beginning at age 30, the preferred way to screening is with a Pap test combined with an HPV test every 5 years (American Cancer Society, 2013). Pap smear is the appropriate screening test for detection premalignant lesion of cervical cancer (Thippeveeranna et al., 2013). The number of participants who had a Pap smear test regularly was also low. Most of them stated that they wouldn't go for a gynecological examination unless there was a symptom for a specific disease. In similar studies, nurses were found to shy from gynecological examination, and either not have Pap smear tests unless there is a symptom present, or have them regularly but less often than suggested (Udigwe, 2006;Nwanko et al., 2010;Awodele et al., 2011;Singh et al., 2012). Thippeveeranna et al. (2013) determined that nurses' knowledge of Pap smear test as a screening procedure for cervical cancer is high, but practice is low and the most common reason for avoiding a Pap smear test was lack of any symptoms (58.4%), fear of vaginal examination was 20.5%. It is a point of importance that nurses, who have a goal of preventing disease and protecting, sustaining, and improving the health of individuals, families, and the society, should have cervical cancer scanning tests regularly themselves.
In cancer, alongside scanning programs, it is important to raise awareness regarding risk factors and possible scanning methods (WHO, 2013). In current study, majority of nurses were aware of BSE, CBE and mammography as a screening method for early breast cancer. Nurses are the most effective people for doing these. It is important for studies evaluating the knowledge of nurses on cancer types in our country to be performed (Yaren et al., 2008;Ertem, 2009;Gencturk, 2013). Ertem (2009) found that 60.8% of the nurses thought that nursing was very important in preventing cancer. Other studies found that the nurses have good level of knowledge about breast cancer and its screening (Fotedar et al., 2013;Lemlem et al., 2013). Although the answers nurses gave in our study regarding the methods of scanning for breast, cervix, and colorectal cancers, there were answers signaling lack of knowledge to questions regarding cervical cancer, which was interesting. In similar study, the knowledge of nurses on breast cancer was found to be on a more competent level when compared to cervix cancers (Yaren et al., 2008). There were no studies evaluating the level of knowledge of nurses in our country regarding colorectal cancer. In order to increase the knowledge nurses have on cancer and their awareness on cancer scanning methods, we think that these topics should be covered in continuing education programs.
In our study, nurses' marital status, work experience, and educational status significantly related to cancer information scores. On the other hand, there were no significant relationships between familial history of cancer, willingness to receive education, and risk perception regarding breast, cervical, and colorectal cancer and knowledge scores. Lemlem et al. (2013) found that knowledge of breast cancer was found to be significantly associated with family history of respondents. Kozlowska et al. (2011) found a significant relationship between educational status and knowledge scores. Nwanko (2010) also determined a significant relationship between nurses' work experience and knowledge scores. In our study, the knowledge scores of the nurses who had a bachelor's degree were found to be higher, which was the expected result. Increased work duration leads to an increase in experience as well as theoretical knowledge. Therefore, this was not a surprising result.
In conclusion, it is recommended to detect cancer at early stages and to conduct screening programs in order to decrease the incidence of invasive cancer and mortality. It is essential for nurses to recognize the importance of cancer screening programs, in order to protect their own and other individuals' health. Nurses play an active role in health education and they can be a positive role model in the society. The increase in nurses' self-awareness would, in turn, increase society's awareness. Special education about cancer screening programs may be useful for nurses.