TITLE PAGE

KNOWLEDGE OF BREAST CANCER AND EARLY DETECTION MEASURES AMONG REVEREND SISTERS IN ANAMBRA STATE

M.SC. DISSERTATION

BY

MADU, LAURETTE P.N PG/M.SC/09/53806

PRESENTED TO

DEPARTMENT OF NURSING SCIENCESFACULTY OF HEALTH SCIENCES & TECHNOLOGY

COLLEGE OF MEDICINEUNIVERSITY OF NIGERIA

ENUGU CAMPUS

IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF MASTER OF SCIENCE DEGREE IN

MATERNAL AND CHILD HEALTH NURSING

SUPERVISOR: PROF. C. B. OKAFOR

JULY, 2014

i

DEDICATION

This work is dedicated to our merciful and unconditional loving father who

endowed me with the strength of will and resilience for accomplishing this task

of study.

ii

CERTIFICATION

This is to certify that I am responsible for the work submitted in this dissertation,

that the original work is mine except as specified in acknowledgements and

references, and that neither the dissertation nor the original work contained

therein has been submitted to this University or any other institution for the

award of a degree.

Madu, Laurette P.N. ______________________

Signature

_____________________

Date

Supervisor: Prof. Okafor, C.B. _____________________

Signature

_____________________

Date

iii

APPROVAL PAGE

This dissertation has been approved for the award of Masters of Science Degree

in Nursing in the Department of Nursing Sciences, Faculty of Health Sciences

and Technology, University of Nigeria, Enugu Campus.

By

____________________ _______________

Prof. C.B. Okafor Date

Supervisor

______________________ _______________

Dr Uche V. Okolie Date

Head of Department

________________________ _______________Prof. Obinna OnwujekweDean of the Faculty Date

_______________________ _______________External Examiner Date

iv

ACKNOWLEDGEMENTS

I am highly indebted to the Almighty God who sustained me throughout the period of

this study. I am grateful to my supervisor, Prof. Chinyere B. Okafor, and the

dissertation readers, Drs Uche V. Okolie and Ngozi Ogbonnaya whose constructive

criticisms, intellectual guidance, diligence and invaluable attention and advice spurred

me on throughout the period of this study.

I will ever remain appreciative to my Head of Department, Dr Uche Okolie and

Department of Nursing Post Graduate coordinator, Dr (Mrs) Ijeoma Ehiemere, whose

encouragement and positive motivation lent credence to the research. I am equally

grateful for the guidance of all my lecturers, Dr Grace Madubuko and others whose

meticulous but valuable and constructive criticisms/contributions helped to make the

difference in this study.

I am also highly indebted to my friend, motivator, and colleague, Dr. (Mrs) Anthonia

U. Chinweuba and family, whose benevolence and availability was simply

unprecedented.

I owe eternal gratitude to my Mother General Emeritus, Rev. Mother Mary Dominica

Odita of the congregation of the Sisters of the Immaculate Heart of Mary Mother of

Christ, for the opportunity to pursue this course of study in the first instance, and my

present Superior General, Rev. Mother Mary Claude Oguh for allowing me the time to

conclude the study. I remain ever appreciative of the moral support enjoyed from my

fellow sisters at Immaculate Heart Convents, Ihiala and Uli, as well as my nuclear

family, especially my mother, Nneoma Caroline Onyeagba Madu for their

understanding and support all these years of study. I cannot thank Ichie S. M. Anyigbo

enough for his inestimable support and encouragement as I carried out the study.

v

TABLE OF CONTENTS PAGE

Title page i

Dedication ii

Certification iii

Approval iv

Acknowledgement v

List of tables viii

List of figures ix

Abstract x

CHAPTER ONE: INTRODUCTION

Background to the study 1

Statement of the problem 5

Purpose and objectives of the study 6

Research questions 7

Significance of the study 7

Scope of the study 9

Operational definition of terms 9

CHAPTER TWO: REVIEW OF RELATED LITERATURE

Conceptual review 10

Concept of breast cancer 10

Types of breast cancer 18

Staging and grading of breast cancer 19

Risk factors for breast cancer 22

Manifestations of breast cancer 43

Epidemiology of breast cancer 44

Breast cancer screening guide/early detection practices 53

Breast self examination: 54

Techniques for Performing BSE: 56

Factors affecting breast self examination 60

vi

Clinical breast examination (CBE): 62

Mammography 62

Biopsies 65

Breast ultrasound 67

Management of breast cancer 68

Nursing implication 73

Concept of reverend Sisters 76

Theoretical review 81

Health belief model 81

Empirical review 86

Studies on knowledge of breast cancer and its early detection measures 96

Summary of reviewed literature 102

CHAPTER THREE: RESEARCH METHODS

Research design 105

Area of study 105

Population of the study 106

Sample size 106

Sampling procedures 108

Instrument for data collection 108

Validity of instrument 108

Reliability of instrument 109

Ethical considerations 109

Procedure for data collection 110

Method of data analysis 110

CHAPTER FOUR: PRESENTATION OF RESULTS 108

Summary 125

CHAPTER FIVE: DISCUSSION OF FINDINGS

vii

Discussion of major findings 127

What the reverend sisters know as breast cancer 127

What the sisters attribute as risk factors/causes of breast cancer 128

Early warning signs of breast cancer identified by the respondents 129

Reverend sisters knowledge of early detection measures of BCa 130

Early detection measures the respondents know 131

Breast cancer preventive measures respondents know 132

Respondents’ sources of knowledge on breast cancer 133

How respondents do breast examination respondents 134

Factors identified by respondents as militating against their use of

detection and preventive health behaviours 136

Conclusion 137

Implications to the study 138

Limitations of the study 139

Recommendations 140

Suggestion for further studies 141

Summary 141

REFERENCES 144

APPENDICES

Appendix A: Questionnaire 149

Appendix B: PPMCC calculation for reliability of instrument 153

Appendix C: Introduction letter from the Department 156

Appendix C: Ethical Approval letter 157

LIST OF TABLES

viii

Table 1:Number and sample distribution of Sisters from various congregations 107

Table 2: Socio- demographic characteristics of the respondents 112

Table 3: What breast cancer means to the respondents (n = 324) 113

Table 4: Breast cancer risk factors/causes identified by the respondents 114

Table 5: Early warning signs of BCa identified by respondents 116

Table 6: Breast cancer early detection practices respondents know 118

Table 7: Breast cancer preventive measures respondents know 119

Table 8: Respondents’ sources of information 120

Table 9: How the respondents do breast examination 121

Table 10: When respondents practice breast self-examination 122

Table 11: When respondents do clinical breast examination 123

Table 12: Factors identified by respondents as militating against their use

of detective and preventive health behaviours 124

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LIST OF FIGURES

Figure I: Conceptual model for the study 86

Figure II: Responses on whether women who had prolonged exposure

to ovarian hormone have high risk of developing breast cancer 115

Figure III: What breast examination means to the respondents 117

ABSTRACT

This study assessed the knowledge of breast cancer and early detection measures of reverend sisters in Anambra State. Eight objectives and eight research questions were

x

raised to guide the study. Cross-sectional descriptive survey design was used. A sample size of 324 respondents was drawn from an estimated population of 794 sisters of the various congregations living in communities located in Anambra State through stratified, proportionate and convenient sampling techniques. Data were collected by administration of a 17-item self-developed questionnaire through personal contacts by the researcher and 3 research assistants. Data were analysed descriptively using frequencies and percentages. Unpaired t-test was used to compare the responses of the two groups of respondents. There was significant difference in the knowledge of breast cancer preventive measures among the respondents. Only 61 (18.8%) of the sisters described breast cancer as uncontrolled multiplication of breast tissue. As many as 52 (16.0%) of the respondents had no idea of what breast cancer means. Painless lump was identified by 141 (43.5%) respondents as the early warning sign of breast cancer. There was no significant difference in the awareness of early warning signs/symptoms of breast cancer among the two groups (0.7438>p0.05) and what the two groups knew as breast examination (0.8608>p0.05). Most popular breast cancer early detection practices identified was breast self examination. More sisters in the active group seem to be aware of this than the contemplatives. A good number of them had never done breast self examination 50 (15.4%) and clinical breast examination 158 (48.8%). As many as 148 (45.7%) respondents were not aware of where to obtain the services, and 73 (22.5%) avoided the detection measures because of fear of lumps. Not being aware of where to obtain the services was a factor to reckon with, while at the same time, the sisters preferred to live in ignorance for fear of a lump being detected. Congregations should establish policy guidelines aimed at promoting adequate and urgent dissemination of all relevant information about breast cancer; and, integrate breast cancer screening procedures into their curriculum. There should be free access to screening services in the government health institutions.

xi

KNOWLEDGE OF BREAST CANCER AND EARLY DETECTION MEASURES AMONG REVEREND SISTERS IN ANAMBRA STATE

BY

MADU, LAURETTE P.N PG/M.SC/09/53806

DEPARTMENT OF NURSING SCIENCESFACULTY OF HEALTH SCIENCES & TECHNOLOGY

COLLEGE OF MEDICINEUNIVERSITY OF NIGERIA

ENUGU CAMPUS

JULY, 2014

xii

CHAPTER ONE

INTRODUCTION

Background to the study

Breast cancer (BCa) is a malignant tumour that has developed from breast cells, which

has no cure at present. However, it can be managed with modern technological tools,

and one’s life can be prolonged. In the last four decades, with the introduction of

screening programmes that efficiently detect cervical cancer in its early stage, BCa has

been seen to overtake cervical cancer in incidence and has become number one

neoplasm among women (Okolie, 2012). BCa has therefore become a worldwide major

health problem. The vast majority of it occur invasively in women (National Cancer

Society [NCS], 2013). It accounts for 16% of all female cancers, and 22% of it are

invasive. In both men and women, it accounts for 18.2% of all cancer deaths (NCS,

2013). Adebamowo and Ajayi (2006) corroborate the opinion of NCS and maintain

that BCa is the commonest cancer among women in the world and in Nigeria too.

Adebamowo and Ajayi (2006) opine that it has become the commonest malignancy

affecting Nigerian women. Also, according to Smeltzer, Bare, Hinkle and Cheever

(2010), among the ten leading types of cancers by gender determined on the basis of

estimated new cases and deaths in the United States in 2004, BCa accounts for 32% and

the highest in female while prostate cancer accounts for 33% in males, which is the

highest among them. Some of its common threats to physical wellbeing according to

Adejumo and Adejumo (2009) include effects of treatments, recurrence and metastasis,

fatigue, arm and shoulder discomfort, as well as lymphedema.

Unfortunately, Nigeria (which is the home country of the reverend sisters that are the

focus of this study) remains ill-equipped to deal with the complexities of cancer

xiii

detection and care as the testing and care facilities are still very few. The prevalence of

BCa within the country is 116 per 100,000, and 27,840 new cases were expected to

develop in 1999 (Adebamowo & Ajayi, 2006). In 2005, between 7 and 10,000 new

cases of BCa developed.

This increasing incidence of BCa in Nigeria is in line with the situations in other

developing countries, and even those advanced countries that used to have a low

incidence now record high incidence. The relative frequencies of BCa among other

female cancers, from Cancer Registries in Nigeria were 35.3% in Ibadan, 28.2% in Ife-

Ijesha, 44.5% in Enugu, 17% in Eruwa, 37.5% in Lagos, 20.5% in Zaria and 29.8% in

Calabar (Banjo, 2004 ). Similarly, in all the centres, except Calabar and Eruwa, BCa

rated first among other cancers.

Further reports showed that majority of cases occurred in premenopausal women, and

the mean age of occurrence ranged between 43–50 years across the regions. The

youngest age recorded was 16 years, from Lagos (Banjo, 2004). This trend was

attributed to several factors such as: the acceptance of fine needle aspiration as an

accurate diagnostic evaluation, and increased awareness about BCa and usefulness of

breast self-examination (Thomas, 2000).

 Several other factors are responsible for this increasing detection, but the most

important in the researcher’s view are: increased access to diagnostic

facilities;empowerment of women, which is increasing women's ability to make

independent decisions about their own health-care; increasing westernization of dietary

products;and physical activity; obstetric and gynaecological factors among others.

Conventionally, breast self-examination (BSE) is the easiest and simplest procedure for

xiv

detecting breast masses because a woman who knows the texture, contour, and feel of

her own breasts is far more likely to detect changes that may develop (ACS, 2007).

The above notwithstanding, the American Cancer Society (2010) made the following

recommendations: monthly self breast examination (SBE) beginning at the age of 20,

from the fifth day of the menstrual cycle to one week following menstruation; clinical

breast examination every three (3) years, from age 20 to 40, then annually, beginning at

age 40; and mammogram, at age 40, and above annually. Adejumo and Adejumo

(2009) recommend that in addition to the above promotive health behaviours, needle

aspiration may be performed when ultrasound reveals a suspicious lesion. The

researchers advanced that imaging techniques offer new and emerging technologies that

aid diagnosis of the disease at its rudimentary stage.

Anecdotal knowledge and experience have revealed that the knowledge of preventive

and promotive health behaviours of reverend sisters is highly militated against,

probably owing to their life-style, ignorance and fear on their part, and inability of the

health team to create adequate awareness. This, may lead to increase in the rate of high

sisters mortality, sequel to BCa, as evidenced by the number of deaths (7), recorded by

the congregations, which occurred in quick succession. Such deaths would have been

averted if the sisters were responsive to preventive health behaviours of early BCa

detection practices. Moreover, early detection of BCa will lead to early intervention at

an early phase of cancer progression, resulting in improvement in years of survival for

the clients/sisters.

There are two categories of reverend sisters, the contemplatives and the active ones.

The active reverend sisters are the sisters that live in convents from where they interact

xv

and operate with the outside world, committing themselves to some hours of private and

community prayers. The conservatives are popularly known as nuns who live in

monasteries and take vow of stability, in addition to the vows of chastity, poverty and

obedience. They live strict life of enclosure.

There is an urgent need to assess the knowledge of BCa and its preventive health

behaviours among the different congregations for early detection and prompt

intervention, so as to avert deaths sequel to its occurrence. Okolie (2012) maintains that

BCa is now a manageable disease, and attributes this to early diagnosis and advances in

surgical techniques, chemotherapy and radiation, with the main thrust being, early

diagnosis. The reverend sisters therefore have a role to play in diagnosis by performing

monthly breast self examination (BSE), obtaining routine screening, via mammography

and seeing a health professional for regular breast examinations, as well as going for

ultrasound (though secondary), in order that BCa could be detected early enough for

prompt intervention/s, given their nulliparous nature. The researcher’s concern is

basically to find out what reverend sisters in Anambra State know about BCa and what

they do towards its early detection.

Statement ofProblem

BCa is ranked the second most frequent to cervical cancer in Africa, and Nigeria has a

double rise in the incidence (Adejumo & Adejumo, 2009). Taire (2010) estimates that

between 7,000 and 10,000 new cases were detected in Nigeria in 2005, and that BCa

caused 502,000 deaths (7% all of cancer deaths; almost 1% of all deaths) worldwide the

same year.According to WHO (2005) report in Nigeria, approximately 89,000 people

died from cancer in 2005, and 54,000 of them were under the age of 70.

xvi

Anecdotal information based on observation has revealed an alarming trend in

incidence of BCa among reverend sisters, with high morbidity and mortality rates. In

the three hospitals commonly used by these sisters, there have been records of many

sisters with the complaints of breast changes–tenderness, irregularities in size and

contour, shrinking, irregular swelling, visible veins, retraction of the nipple(s), and/or

discharges from the breast, between May, 2011 and October, 2013, and who were

diagnosed of BCa in their various stages. On the 16th of September, 2013, an 82 year

old sister died of BCa, and in the first quarter of 2012, another sister was said to have

died of BCa. Between, August, 2012, and October, 2013, three had unilateral

masectomy, and even back in 2010 and 2013, two sisters from the same congregation

died of BCa. Retrogressively still, in the years, 2013, 2012; 2011; 2006; 2001; 1983;

1978; and 1977, sisters were lost to BCa (Location, 2013). Currently, two sisters from

the researcher’s community are receiving BCa treatment.

Some other congregations are experiencing similar plight as they have recorded over six

(6) deaths sequel to BCa within a space of three years, 2005 to 2013. For instance, the

agonizing death of a thirty eight (38) year old sister recorded in April, 2012 by

Daughters of Mary Mother of Mercy (DMMM), in Ahiaeke Umuahia; and that from

Handmaids of the Holy Child Jesus(HHCJ) who died in April, 2013 in Ikot Ekpene,

aged forty eight (48) years. This rising incidence of BCa can be attributable to the

characteristics of the reverend sisters with uncompromising modesty and the tendency

to endure pains and discomforts for the higher goal of supernatural benefits. One

wonders if this aspect of their sacrificial life is worth the price paid. The non-

compliance to annual check- ups and undue modesty of most of them could all be

contributory factors to the above anomaly. Most of the cases were detected through

xvii

routine clinical breast examination, as the sisters fall within the category of

professionals socialized into high tolerance for discomforts, including pains. At times,

this works against them because pains which are obvious indicators of BCa, and which

would have compelled one for early detection of the disorder is glossed over, giving

rise to late detection of BCa. Where the culture of pondering things over in one’s heart

without complaining prevails, there is need for greater emphasis for early detection of

diseases, including BCa, through BSE; CBE; and mammography.

It is against the above backdrop therefore, and given the fact that the researcher, as a

reverend sister living in the convent, is directly involved, and feeling very

uncomfortable with the prevailing situation, the researcher was spurred to embark on

this study, so as to bridge the existing gap and consequently promote positive healthful

living among the sisters.

Purpose of the study

The main purpose of the study is to assess the knowledge of BCa and early detection

measures among reverend sisters in Anambra state. The specific objectives include to:

Ascertain what the reverend sisters know as breast cancer.

Ascertain what they attribute as causes/risk factors of breast cancer.

Identify the reverend sisters knowledge of BCa early warning signs.

Ascertain what the reverend sisters know as early detection measures of breast

cancer.

Ascertain how BCa can be prevented as perceived by the sisters.

Identify reverend sisters’ sources of knowledge on BCa.

Find out how reverend sisters practice early breast cancer detectionmeasures.

Identify the factors that militate against their practiceof early detection measures

Research Questions

xviii

The following research questions guided the study:

1) What do the reverend sisters know about BCa?

2) What do reverend sisters attribute as causes/risk factors of breast cancer?

3) What are the warning signs of BCa as perceived by the reverend sisters?

4) What are the early detection measures of breast cancer the reverend sisters know?

5)How can BCa be prevented as perceived by the reverend sisters?

6) What are the reverend sisters’ sources of knowledge on BCa?

7)How do reverend sisters practice early breast cancer detection measures?

8) What are the factors that militate against the respondents practice of BCa early

detection measures?

Significance of the study

BCa has become the commonest cancer affecting women world-wide. The findings of

the study will inevitably benefit many persons and groups of people. These include: all

reverend sisters; local and regional administration; Superiors General; Medical

Advisory Councils of the various congregations; National Association of Nigerian

Religious Women; health institutions, staff and student nurses/midwives, as well as

medical students at large.

Findings of this study will help provide information on how much knowledge of BCa

and appropriate health behaviours the sisters exhibit, and generate valid data for

adequate assessment of the sisters on the subject matter. The feedback value of the

study will help in making modifications where they are deficient. The implications of

the study will serve as a guide for self-monitoring of both the sisters and prospective

candidates into the sisterhood within the state and beyond. It will give insight into the

attitude of some sisters towards breast- self examination, and also reveal the reason/s

why some detest examination of the breast by health providers.

xix

The findings will equally help design acceptable health promotion/awareness

programmes about BCa. Thus, informing in-service training programmes so that the

incumbent and aspiring sisters can learn and imbibe the skills in BSE and the

disposition to avail oneself of the other detection practices well in advance. The result

of the study therefore will guide the authority of the congregations on how to develop,

structure and organize workshop programmes on BCa in order to derive maximum

benefit for the various categories of sisters in the state. It will also sensitize the

formators and formatees in all formation houses on the need to organize programmes in

their day to day examination of their breasts..

More importantly, the Central administration of each Order may be compelled to

review downwardly, their yearly intake of candidates in order to guarantee adequate

holistic care of each sister.The study finding will add to the already existing body of

knowledge, contributing to new knowledge to Nursing Profession, it will provide

empirical data on the level of knowledge of religious women aged 20 to 70 years, and

more. This study may provide evidence for the requirement of established National

Screening Program for BCa in the future.

Scope of the study

The study is delimited to assessing the knowledge level and early detection health

behaviours practiced by reverend sisters in Anambra State, towards BCa, as well as the

factors militating against the sisters practice of early detection measures of BCa.

Operational definition of terms

xx

Early detection practices: The actions subjects take towards early identification of

signs of BCa, such as breast self examination, clinical breast examination, and

mammography. How often breast self examination could be done, when, how and what

to look for using appropriate skills.

Knowledge of BCa: Ability of the subjects to know the meaning of BCa, risk

factors/causes, early signs, their sources of information, and the factors that influence

their practice of BSE.

Reverend Sisters:Consecrated Catholic women who devote their lives to the service of

God and humanity by living a vowed prayer lives in communities and monasteries.

Active reverend sisters: These are the sisters that live in convents from where they

interact and operate with the outside world, committing themselves to some hours of

private and community prayers.

Conservative reverend sisters: The conservatives are popularly known as nuns who live

in monasteries and take vow of stability,in addition to the vows of chastity, poverty and

obedience. They live strict life of enclosure.

CHAPTER TWO

REVIEW OF LITERATURE

This chapter deals with review of the related literature to the topic of study. There was

paucity of literature in the area. However, available and related literature on the topic

and other fields were reviewed conceptually, theoretically, empirically, and

summarized.

Conceptual review

xxi

Conceptual review was done under the following headings: concept of cancer;

conceptual review of BCa; staging and grading of BCa; risk factors; cancer warning

signs (CAUTION); manifestations of BCa; epidemiology of BCa; who are reverend

sisters?; and BCa screening guide/early detective measures /preventive health

behaviours.

Concept of Breast cancer

The National Institutes of Health, USA (2013) define breast cancer as a type of cancer

that develops from breast cells. This kind of cancer usually starts off in the inner lining

of milk ducts or the lobules that supply them with milk. The abnormal cancer cell forms

a clone and begins to proliferate, ignoring the autonomic regulatory effect on cells.

Porth in Agonsi (2010) defines cancer as a disorder of altered cell differentiation and

growth, with the resulting process known as neoplasia, which means “new growth. The

new growth is called neoplasm. Relatively, the growth of neoplasm is autonomous and

uncoordinated as it lacks the ability to regulate and control cell control and division.

Similarly, Okafor, (2011) defines cancer as a large number of diseases, a group of

distinct diseases with different causes, manifestations, and prognosis, characterized by

uncontrolled cell growth, spread of abnormal cells, with some cancer cells secreting

growth factors to stimulate their own growth.

In cancer, the proliferating cells do not wear out, they rather become immortal and

proliferate indefinitely. The continuous growth and division of cancer cells

differentiates it from normal cells. Instead of dying, they out-live normal cells and

continue forming new abnormal cells.

The above process is very much unlike changes in tissue growth that occur, in a

predictable order. Normal body cells grow, divide, forming tissues and later die in an

xxii

orderly fashion. During the early years of a person’s life, normal cells divide more

rapidly until the person becomes an adult. Thereafter, cells in most part of the body

divide only to replace worn-out or dying cells and to repair injuries. Buttressing the

above, Smeltzer, Bare, Hinkle, and Cheever (2010) corroborated this saying that,

during the life-span, various tissues normally undergo periods of rapid or proliferative

growth which must be distinguished from malignant growth activity. In cancer disease,

cells proliferate indiscriminately and abnormally, insensitive of the growth- regulation

signals in the environment surrounding the cells as maintained by Smeltzer, Bare,

Hinkle, and Cheever (2010).

According to Dolinsky and Hill-Kayser (2012), BCa is the collection of cells that are

growing abnormally, or without control, termed tumours. Adejumo and Adejumo

(2009) define it as a tumour of the breast, in which the cells increase abnormally,

altering the growth-regulating signals in the cells, invading surrounding tissues. Hence,

they gain access to lymph nodes and blood vessels that transport the abnormal cells to

other parts of the body. Tumours that do not have the ability to spread throughout the

body may be referred to as "benign", and are not thought of as cancerous. Tumours that

have the ability to grow into other tissues or spread to distant parts of the body are

referred to as "malignant".

Cancer is a pathological condition that commences when an abnormal cell is

transformed by genetic mutation of the cellular DNA. The abnormal cell forms a clone

and starts to proliferate abnormally, neglecting the growth-regulating signals in the

environment surrounding the tissues. These tissues are infiltrated by the cells and gain

access to lymph nodes and blood vessels, which convey the cells to other areas and

xxiii

systems of the body. This cancer spread to other parts of the body is the phenomenon

termed metastasis (Smelzer, Bare, Hankle, & Cheever, 2010).

Pathologically therefore, cancer is a condition in which a group of cells grow

independently of the normal body controls, invade surrounding tissues, metastasizes to

distant tissues, shows abnormalities of the chromosomes and becomes fatal eventually.

According to Pearce, Miller and Cunningham (1975), there is this psychosomatic

disorder that also hunts cancer victims- cancer-ophobia. This means fear of cancer

which can paralyze an individual. Phobia in this sense implies a morbid fear and

women with this form of fear, brood over it, rarely speak of it, and worry inwardly,

losing sleep and interests, convinced that they are sufferers. Sequel to the above,

women experience a number of manifesting features ranging from loss of loved ones

who are forced to keep their distance for fear of contracting the condition whose cause

they are ignorant of.

Malignant tumours within the breast are called "breast cancer". Theoretically, any of the

types of tissue in the breast can form a cancer. Cancer cells are most likely to develop

from either the ducts or the glands. These tumours may be referred to as "invasive

ductal carcinoma" (cancer cells developing from ducts), or "invasive lobular

carcinoma" (cancer cells developing from lobes) pre-cancerous cells may be found

within breast tissue, and are referred to as ductal carcinoma in-situ (DCIS) or lobular

carcinoma in-situ (LCIS). DCIS and LCIS are diseases in which cancerous cells are

present within breast tissue, but are not able to spread or invade other tissues. DCIS

represents about 20% of all BCas.

Breast cancer is the most common malignancy affecting women in North America and

Europe. Close to 200,000 cases of BCa were diagnosed in the United States in 2001.

xxiv

BCa is the second leading cause of cancer death in American women after lung cancer.

The lifetime risk of any particular woman getting BCa is about 1 in 8, although the

lifetime risk of dying from BCa is much lower at 1 in 28. Men are also at risk for

development of BCa, although this risk is much lower than it is for women. (Cancer

Research UK, 2013)

The most important risk factor for development of BCa is increasing age. As every

woman ages, her risk of BCa increases. Risk is also affected by the age when a woman

begins menstruating (younger age may increase risk), and her age at her first pregnancy

(older age may increase risk). Use of exogenous oestrogens, sometimes in the form of

hormone replacement treatment (HRT) may increase BCa risk. Family history is very

important in determining BCa risk. Any woman with a family history of BCa will be at

increased risk for developing BCa herself. Furthermore, known genetic mutations that

increase risk of BCa are present in some families; these include mutations in the genes

BRCA1 and BRCA2. Between 3% to 10% of BCas may be related to changes in one of

the BRCA genes. Women can inherit these mutations from their parents.

Genetic testing for mutations should be considered for any woman with a strong family

history of BCa, especially BCas in family members less than 50 years, or strong family

history of prostate or ovarian cancer. If a woman is found to carry either mutation, she

has a 50% chance of getting BCa before she is 70. Family members may elect to get

tested to see if they carry the mutation as well. If a woman does have the mutation, she

may choose to undergo more rigorous screening or even undergo preventive

(prophylactic) mastectomies to decrease her chances of contracting cancer. The

decision to undergo genetic testing is a highly personal one that should be discussed

with a doctor who is trained in counselling patients about genetic testing.

xxv

Some factors associated with BCa risk can be controlled by a woman herself. Use of

hormone replacement therapy, drinking more than 5 alcoholic drinks/ week, being

overweight, and being inactive may all among others contribute to BCa risk. These are

called modifiable risk factors. It is important to remember that even someone without

any risk factors can still get BCa. Proper screening and early detection are our best

weapons in reducing the mortality associated with this disease. The incidence of BCa is

decreasing with the largest declines occurring in younger women. It is lower in African

American women than in Caucasian women, though the former experiences higher

mortality rates. In non- Caucasians, it is largely detected at a later stage, with lower

survival rate at all stages.

The high incidence of cancer is occurring at a faster rate in populations of the

developing countries which in the past enjoyed low incidence of the disease (Okobia &

Bunker, 2005; Taire, 2010)). According to the WHO (2005), there are an estimated

100,000 new cancer cases in Nigeria each year although observers believe the figure

could become as high as 500,000 new cases annually by 2010 (Ogundipe & Obinna,

2008). It is feared that by 2020, cancer incidence for Nigerians may rise to an alarming

rate. It is also anticipated that by 2020, death rates from cancer in Nigerian males and

females may reach 72.7/100,000 and 76/100,000 respectively (Ogundipe & Obinna,

2008). It is often associated with a poor prognosis for a variety of reasons, including

ignorance and late presentation.BCa represents 10 per cent of all cancers diagnosed

throughout the world, every year. The incidence of BCa in women in high-income

countries in 2000 was at least twice that of any other cancer.

Male BCa: BCa in men accounts for about 1% of all BCas and about 0.2% of all

cancers in men. There will be about 1,690 new cases of male BCa in 2005, compared to

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213,000 cases in women (Dolinsky and Hill-Kayser, 2012). Risk factors for the

development of male BCa include Klinefelter's syndrome, being of Jewish descent,

mumps orchitis, a family history of male or female BCa and family cancer syndromes

(BRCA1 & 2 gene abnormalities account for 40% of cases). The predominant

presenting symptom in men is a mass in the breast. Other signs of male BCa include

nipple discharge (particularly if bloody), nipple retraction and skin ulceration.

Mammograms are difficult to perform, particularly on thin men, so a biopsy should be

done on a suspicious lump, so as to prevent adverse effects of BC.

Prevention of BCa focuses on studying and modifying behaviours that increase risks,

and interrupting the carcinogenesis process through early and prompt medical

intervention (Adejumo & Adejumo, 2009). Like the uterus, the breast undergoes regular

cyclic changes in response to hormonal stimulation. In anticipation of pregnancy, the

breasts become enlarged, causing some women to experience sensation of tenderness or

pain. When conception fails to occur, then the accumulated fluid through the lymphatic

network drains away. This persists for 3 to 4 days before the onset of menstrual flow, in

few cases; it may persist through the month (London, Ladewig, Ball, & Bindler, 2007).

Knowledge of the normal changes will aid in detecting any presenting anomaly.

Breast cancer conjures up a variety of images for different people, hence, its

consideration for this thesis. Sisters by virtue of their state of life are expected to have

knowledge on almost all issues bordering on women in particular. And being readily

available to people, sisters are in a unique position as they have a supportive role in

educating and motivating women to be assertive in demanding the best of health

services. Owing to their outstanding involvement in women education, it would be

worthwhile to explore their knowledge in the area under study. This invariably would

xxvii

influence their understanding, disposition, and indirectly influence their preventive

health behaviours towards BC.

Types of BCa

According to Burk, Mohn–Brown, and Eby (2011), there are two atypical types of BCa,

namely, inflammatory carcinoma and Paget’s disease. Others they maintain include:

non-invasive/carcinoma in situ and invasive carcinoma. Adejumo and Adejumo (2009)

limit the types to only carcinoma in situ and invasive carcinoma.

Non-invasive/Carcinoma in situ: In carcinoma in situ, malignant cells proliferate

within the ducts or lobules of the breast without invading surrounding tissues. The

nipple and sub-areolar regions are usually involved. This form of cancer is typically

diagnosed when the mass is seen on mammography rather than by palpable breast mass.

Carcinoma in situ often increases the risk for invasive cancer.

Invasive carcinoma: Most BCas are invasive in nature, generating from the immediate

ducts of the breast, and can be differentiated by cell type. Nonetheless, the prognosis

and treatment depend on the stage of the disease. Invasive BCas spread involving breast

tissue, lymph and blood vessels. The cancer is capable of metastizing to distant sites

through the blood stream or lymphatic system. The common sites of this type of

carcinoma are regional lymph nodes, bone, brain, liver, and the skin (Burk, Mohn-

Brown, & Eby, 2011). They assert that invasive lobular carcinoma originates in the

milk glands and accounts for 10- 15% of invasive BCas.

Inflammatory carcinoma: This type of BCa is rare, but most malignant form of BCas

have inflammatory origin. The client presents with a diffuse redness, warmth, and

oedema of the breast. Though a discrete mass may not be palpable, metastases develop

early and widely in clients with this condition, with poor prognosis.

xxviii

Paget’s disease: This is another rare BCa that involves the nipple ducts, with initial

symptoms of itching or burning of the nipple with superficial erosion, crusting, and

ulceration.

Other less common BCas include: medullary carcinoma, which originates from central

breast tissue; mucinous carcinoma (invasive, occurs in post the menopausal); phylodes

tumour (tumour with a leaf- like appearance, extending into the ducts, but rarely

metastizes; and tubular carcinoma (small tumour that is often undetectable by palpation;

and rarely, sarcomas (cancer of the connective tissue); and lymphomas- cancer of the

lymph nodes develop in the breast (Cancer Research UK, 2013).

Staging and grading of BCa

Staging of BCa is very essential, because according to Smeltzer, Bare, Hinkle and

Cheever (2010) and American Health Services (2012), determination of treatment and

prognosis options is based on the stage and grade of the cancer. The histologic or

cellular characteristics of the tumour and clinical spread of the disease are the two basic

methods of classifying BCa. To stage the cancer, the physician may order several

different tests, including blood test, mammogram, a chest x-ray, a bone scan, or a CT

scan. Staging also determines the size of the tumour, and the extent of metastasis.

Though several systems exit, the TNM system developed in the year 2002 by the

American Joint Committee on Cancer is frequently used by most facilities. TNM stands

for: “T”-the extent of the primary tumour; “N”- the lymph node involved, “M”- the

extent of metastasis.

Grading refers to tumour cells classification. It seeks to define the type of tissues from

which the tumour originated and the degree to which the tumour cells retain the

functional and histologic characteristics of the original tissue. Classificationby grade is

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termed Bloom-Rechardson grade. When cells become differentiated, they take different

shapes and forms to function as part of an organ, cancerous cells lose their

differentiation. Cells that usually line up in an orderly manner to make up milk ducts

are disorganised, making division uncontrollable, and cell nuclei become less uniform.

Pathologists describe cells, as well differentiated (low grade), moderately differentiated

(intermediate), and poorly differentiated (high grade). This last grade has worst

prognosis.

Normally, the tumour is assigned a numeric value ranging from grade I, II, III, and IV.

Well differentiated tumours are the grade one tumours, which resembles tissue of

origin. Grade IV is poorly differentiated or undifferentiated as it does not resemble the

parent tissue or tissue of origin. Smeltzer, Bare, Hinkle, and Cheever, (2010) opine that

these cells tend to be more aggressive and less responsive to treatment than the well

differentiated tumours. In order to guide treatment and offer some insight into

prognosis, BCa is staged into five different groups. This staging is done in a limited

fashion before surgery taking into account the size of the tumour on mammogram and

any evidence of spread to other organs is picked up with other imaging modalities; and

it is done definitively after a surgical procedure that removes lymph nodes and allows a

pathologist to examine them for signs of cancer. The staging system is somewhat

complex, but has a simplified version viz:

Stage 0: (called carcinoma in situ) Lobular carcinoma in situ (LCIS) refers to abnormal

cells lining a gland in the breast. This is a risk factor for the future development of

cancer, but this is not felt to represent a cancer itself. Ductal carcinoma in situ (DCIS)

refers to abnormal cells lining a duct. Women with DCIS have an increased risk of

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getting invasive BCa in that breast. Treatment options are similar to patients with Stage

I BCas.

Stage I: This is the early stage of BCa where the tumour is 2cm or less, and has not

spread beyond the breast. There is no lymph node involvement (TNOMO).

Stage II: This is also an early stage BCa in which the tumour is 2cm, and has spread to

the auxiliary lymph nodes (T2NIMO); or the tumour is between 2cm and 5cm (with or

without spread to the lymph nodes under the arm); or the tumour is greater than 5cm

and has not spread outside the breast (T3).

Stage III: At this stage, there is locally advanced BCa whereby the tumour is greater

than 5cm across and has spread to the axillary lymph nodes; or the cancer is extensive

in the underarm lymph nodes; or the cancer has spread to lymph nodes inside the chest

wall or the breastbone or to other tissues near the breast. There is near distant

metastasis.

Stage IV : Stage four connotes a metastatic BCa with the cancer spreading outside the

breast to other distant organs in the body, like the brain, liver, bone and so on (Smeltzer,

Bare, Hinkle, & Cheever, 2010).

Depending on the stage of the cancer, doctors may want additional tests to see if one

has metastatic disease. If it is a stage III cancer, probably a chest x-ray, CT scan and

bone scan may be done to look for metastases. Each patient is an individual whose

doctor will decide what is necessary to adequately stage one’s cancer. In any case, no

matter the type or grade of cancer, all have basically similar factors.

Risk factors for BCa

The term cancer does not refer to a single disease; it refers rather to a group of diseases

characterized by uncontrolled multiplication of cells beyond the body needs. Cancer is a

xxxi

disease process that begins when an abnormal cell is transformed by the genetic

mutation of the cellular DNA. According to American Cancer Society (ACS) (2013),

certain changes in DNA can cause normal cells to become cancer. DNA is the

substance in every individual that makes up the genes. Okafor (2011) asserts that cancer

cells develop because of damage to DNA, which is a substance in every cell that directs

all activities. Most of the times; when a DNA is damaged the body is able to repair it,

but in cancer cells, the damaged DNA is not repaired. Some inherited DNA traits

(mutation) can increase the risk for developing cancer. These inherited traits result in

cancer running in families. For instance, BRCA1 and BRCA2 are tumour suppressor

genes, they keep cancer tumours from forming, but when they are changed, they no

longer cause cells to die at the right time, and cancer is more likely to develop.

According to Okafor (2011) it is a group of diseases with differing causes,

manifestations and prognosis. Various theories according to Okafor elucidate the

aetiology of cancer viz:

A spontaneous error during cell reproduction- overworked or aged cells that create

mutant cells; second theory, an external agent that enters the cell and initiates cancerous

process- carcinogens, such as, cigarette tar; and thirdly, role of oncogens: normally,

oncogens control cell growth but for reasons not well understood, they lose their

controlling effect. They could be activated by certain conditions- age, viruses,

carcinogens and so on. Presence of tumour suppressor genes, and role of suppressor

genes BRCA-1 and BRCA-2 are common causes of the condition.

A risk factor is anything that affects one’s chance of contracting a disease, for instance,

cancer. Different cancers have different risk factors. For example, exposing skin to

strong sunlight is a risk factor for skin cancer. Smoking is a risk factor for cancers of

xxxii

the lung, mouth, larynx, bladder, kidney, and several other organs. In any case, having a

risk factor, or even several of them, does not mean that one would get a disease. Most

women who have one or more BCa risk factors never develop the disease, while many

women with BCa have no apparent risk factors (other than the obvious factors of being

a woman and growing older). It is not easy to know how much of risk factors that must

have contributed towards the development of BCa by a woman, even when a woman

with risk factors develops BCa.

There are different kinds of risk factors. Some factors, like a person's age or race,

cannot be changed. Others are linked to cancer-causing factors in the environment,

while others still are related to personal habits/ behaviours, such as smoking, drinking,

and diet. Some factors influence risk more than others, and a woman’s risk for BCa can

change over time, due to factors such as aging or lifestyle, while some cannot change.

Risk factors that cannot change: These include- gender, aging, genetic risk factors,

family history of BCa, race and ethnicity, dense breast tissue etc.

Gender: The mere fact that one is a woman is the main risk factor for developing BCa.

Most women who develop BCa have no uniform identifiable risk factors other than

their gender. Men can develop BCa, but this disease is about 100 times more common

among women than men (Adejumo & Adejumo, 2009. This is likely because men have

less of the female hormones oestrogen and progesterone, which can promote BCa cell

growth.

Age: Aging is also another factor, a woman’s risk of developing BCa increases as she

gets older. According to the National Health Service (2013), 80% of all female BCas

occur among women aged 50+ years (after the menopause). The incidence of the disease

increases with age and doubles every 10 years until menopause when the rate of

xxxiii

increase declines (Adejumo, & Adejumo, 2009). Singletary (2003) observed that the

relative risk associated with BCa with increased age is 5.8. BCa in younger people

tends to be more aggressive, like, inflammatory BCa which does not present with

lumps, is not detected by mammography or ultrasound. It presents with symptoms of

mastitis. Cancer Research UK 2013) documented that approximately, a quarter of BCa

affect women under the age of 50, a half occur between the ages of 50 and 69, and the

remaining quarter develop in women who are 70 years or older. About 1 out of 8

invasive BCa s are found in women younger than 45 years of age, while about 2 out of

3 invasive BCa s are found in women aged 55 or older (American Cancer Society Inc.,

2012).

Geographical variations: Incidence and death rates for BCa varies between countries.

Though it has been rated as the most common cancer affecting women, both in

developing and developed countries, the age adjusted rate are thrice higher in developed

countries than less advanced countries. There are many differences observed between

Eastern- Asian and Western- European countries. In Japan, and China, the resent age-

adjusted rate for BCa per 100,000 women is 24.3 and 26.5 respectively. Whereas in

England and Wales, Scotland and North America, the rates are 68.8, 72.7, and 90.7

respectively (Adejumo & Adejumo, 2009). According to Dixton (2006), Japanese

women who emigrate to United Sates of America have similar rates of BCa within one

to two generations, hence, the factors relate very much to geographical location.

Genetic risk factors: American Cancer Society (2012) asserts that about 5 – 10% of

BCa cases are thought to be hereditary in certain genes, resulting directly from gene

defects (mutations) inherited from a parent. It is possible for some family members to

pass on these defective genes without suffering cancer themselves. The most common

xxxiv

cause of hereditary BCa is an inherited mutation in the BRCA1 and BRCA2 genes.

BRCA1 is said to account for 16% of all BCas and is present in all families with BCa.

85% by 70 years is the overall risk of BCa for those with a BRCA1 mutation.

According to Stellenberg and Bruce (2007), BRCA2 is present in families that have a

male member with BCa. It is presumed that these mutations either inherited or acquired,

allow uncontrolled divisions, lack of attachment, and metastasis to distant organs.

Usually, normal cells undergo opoptosis when they are no longer needed. Before then,

they are protected from opoptosis by protein pathways, some of which are muted in a

way that they are permanently turned “on” rendering the cell incapable of undergoing

opoptosis. Occasionally, PTEN protein which regulates the protective pathway is

muted, causing the pathway to stick in the “on” position, and the cancer cells fail to

undergo opoptosis.

There could be non-BRCA1 and non-BRCA2 breast tumour which could be associated

with rare syndromes, of which BCa is a singular component. Syndromes of this nature

emanate from mutations in TP53, PTEN and vs49733333768 are also associated with

lower risk of BCa (UK/health news, 2010). Mutations in RAD51C confer an increase

risk for breast and ovarian cancer (Menial & Alfons, 2005).

In normal cells, these genes help prevent cancer by making proteins that keep the cells

from growing abnormally. If a person has inherited a mutated copy of either gene from

a parent, the woman has a high risk of developing BCa during the woman’s lifetime.

The risk may be as high as 80% for members of some families with BRCA mutations.

These cancers tend to occur in younger women and more often affect both breasts than

cancers in women who are not born with one of these gene mutations. Women with

these inherited mutations also have an increased risk for developing other cancers,

xxxv

particularly ovarian cancer. In the United States, BRCA mutations are found most often

in Jewish women of Ashkenazi (Eastern Europe) origin, but they can occur in any racial

or ethnic group.

Changes in other genes: Other gene mutations can also lead to inherited BCas. These

gene mutations are much rarer and often do not increase the risk of BCa as much as the

BRCA genes. They are not frequent causes of BCa and include: ATM gene, TP53,

CHEK2, PTEN, CDHI, and STKII.

ATM: The ATM gene normally helps repair damaged DNA. Inheriting two abnormal

copies of this gene causes the disease ataxia-telangiectasia. Inheriting one mutated copy

of this gene has been linked to a high rate of BCa in some families.

TP53: Inherited mutations of the tumour suppressor gene TP53 cause an abnormal

TP53 protein. This causes Li-Fraumeni syndrome (named after the 2 researchers who

first described it). Women with this syndrome have an increased risk of developing

BCa, as well as several other cancers such as leukaemia, brain tumours, and sarcomas

(cancer of bones or connective tissue). This gene however, is a rare cause of BCa.

CHEK2: The Li-Fraumeni syndrome can also be caused by inherited mutations in the

CHEK2 gene. Even when it does not cause this syndrome, it can increase BCa risk

about twofold when it is mutated.

PTEN: The PTEN gene normally helps regulate cell growth. Inherited mutations in this

gene can cause Cowden syndrome, a rare disorder in which individuals are at increased

risk for both benign and malignant breast tumours, as well as growths in the digestive

tract, thyroid, uterus, and ovaries. Defects in this gene can also cause a different

syndrome called Bannayan-Riley-Ruvalcaba syndrome that is not thought to be linked

to BCa risk.

xxxvi

CDH1: Inherited mutations in this gene cause hereditary diffuse gastric cancer, a

syndrome in which people develop a rare type of stomach cancer at an early age.

Women with mutations in this gene also have an increased risk of invasive lobular BCa.

STK11: Defects in this gene can lead to Peutz-Jeghers syndrome. People affected with

this disorder develop pigmented spots on their lips and in their mouths, polyps in the

urinary and gastrointestinal tracts, and an increased risk of many types of cancer,

including BCa.

Family history of BCa:BCa risk is higher among women whose close blood relatives

have this disease. Having one first-degree relative (mother, sister, or daughter) with

BCa approximately doubles a woman's risk. Having 2 first-degree relatives increases

her risk about 3-fold. The exact risk is not known, but women with a family history of

BCa in a father or brother also have an increased risk of BCa. Altogether, less than 15%

of women with BCa have a family member with this disease. This means that most

(over 85%) women who get BCado not have a family history of this disease (ACS,

2013). Women with a family history of BCa and either hyperplasia or atypical

hyperplasia have an even higher risk of developing a BCa.

Personal history of BCa: A woman with cancer in one breast has a 3- to 4-fold

increased risk of developing a new cancer in the other breast or in another part of the

same breast (ACS, 2013). This is different from a recurrence of the first cancer.

Race and ethnicity:Overall, white women are slightly more likely to develop BCa than

are African-American women, but African-American women are more likely to die of

this cancer. However, in women under 45 years of age, BCa is more common in

African- American women. Asian, Hispanic, and Native-American women have a

lower risk of developing and dying from BCa (ACS, 2013).

xxxvii

Dense breast tissue:Women with denser breast tissue (as seen on a mammogram) have

more glandular tissue and less fatty tissue, and have a higher risk of BCa (American

Health Services, 2012). Unfortunately, dense breast tissue can also make it harder for

doctors to spot problems on mammograms.

Certain benign breast conditions:Women diagnosed with certain benign breast

conditions may have an increased risk of BCa. Some of these conditions are more

closely linked to BCa risk than others. Doctors often divide benign breast conditions

into 3 general groups, depending on how they affect this risk. They include: non-

proliferative lesions, proliferative lesions with atypia and proliferative lesion without

atypia (ACS, 2013).

Non-proliferative lesions:These conditions are not associated with over-growth of

breast tissue. They do not seem to affect BCa risk, or if they do, it is to a very small

extent. They include: Fibrosis and/or simple cysts ( called fibrocystic disease or

changes); mild hyperplasia; adenosis (non-sclerosing); ductal ectasia; phyllodes tumour

(benign); a single papilloma; fat necrosis; periductal fibrosis ; squamous and apocrine

metaplasia; epithelial-related calcifications; mastitis. Other benign tumours include-

lipoma, hamartoma, hemangioma, neurofibroma, adenomyoepithelioma).

Proliferative lesions without atypia: These conditions show excessive growth of cells

in the ducts or lobules of the breast tissue. They seem to raise a woman's risk of BCa

slightly (1½ to 2 times normal). They include: usual ductal hyperplasia (without atypia);

fibroadenoma; sclerosing adenosis; and several papillomas (called papillomatosis).

Proliferative lesions with atypia: In these conditions, there is an over-growth of cells

in the ducts or lobules of the breast tissue, with some of the cells no longer appearing

normal. They have a stronger effect on BCa risk, raising it 3.5 to 5 times higher than

xxxviii

normal. These types of lesions include: atypical ductal hyperplasia (ADH); and atypical

lobular hyperplasia (ALH).

Lobular carcinoma in situ: In lobular carcinoma in situ (LCIS) cells that look like

cancer cells are growing in the lobules of the milk-producing glands of the breast, but

they do not grow through the wall of the lobules. LCIS (also called lobular neoplasia)

is sometimes grouped with ductal carcinoma in situ (DCIS) as a non-invasive BCa, but

it differs from DCIS in that it does not seem to become an invasive cancer if it is not

treated. Women with this condition have a 7- to 11fold increased risk of developing

invasive cancer in either breast. For this reason, women with LCIS should make sure

they have regular mammograms and clinical visits.

Menstrual periods:Women who have had more menstrual cycles because they started

menstruating at an early age (before age 12) and/or went through menopause at a later

age (after age 55) have a slightly higher risk of BCa. The increase in risk may be due to

a longer lifetime exposure to the hormones oestrogen and progesterone (ACS, 2013).

American Health Services (2012) opine that oestrogen exposure begins when periods

start, and drops dramatically during menopause.

Previous chest radiation: American Health Society (2012) posits that undergoing X-

ray and CT scans may raise a woman’s risk of developing BCa slightly. Women who,

as children or young adults, had ionized radiation therapy to the chest area as treatment

for another cancer (such as Hodgkin disease or non-Hodgkin lymphoma) have a

significantly increased risk for BCa. This varies with the patient's age when they had

radiation. The risk of developing BCa from chest radiation is highest if the radiation

was given during adolescence, when the breasts were still developing (ACS, 2013).

Radiation treatment after age 40 does not seem to increase BCa risk.

xxxix

Diethylstilbestrol (DES) exposure: From the 1940s through the 1960s some pregnant

women were given the drug diethylstilbestrol (DES) because it was thought to lower

their chances of miscarriage. These women have a slightly increased risk of developing

BCa. Women whose mothers took DES during pregnancy may also have a slightly

higher risk of BCa (ACS, 2013).

Red No. 3: Robb, Haley and Balducci in Agonsi (2010) opine that Red No. 3 which is a

colouring agent used in some foods, read the presence of human breast cell DNA was

found positive for damage when put in contact with Red no. 3.

Apart from the above factors, there are some lifestyle- related factors and BCa risks

which include: nulliparity/having children, hormones, recent oral contraceptive use,

hormone replacement therapy after menopause, combined hormone therapy, oestrogen

therapy, reproductive factors, not breast feeding, obesity, height, physical activity, and

alcohol.

Lifestyle-related factors and BCa risk

Nulliparity/having children:Women who have had no children or who had their first

child after age 30 have a slightly higher BCa risk (ACS, 2013). Having many

pregnancies and becoming pregnant at a young age reduce BCa risk. Pregnancy reduces

a woman's total number of lifetime menstrual cycles, which may be the reason for this

effect.

Hormones: When there is persistently increased blood level of oestrogen, there is

associated increased risk of BCa. The same applies to increased levels of androgens,

androstenidione, and testosterones which can be converted by aromatase to oestrogens,

esterones and estradiol. Whereas, the above researchers maintain that increased blood

level of progesterone are associated with a decreased risk of BCa in premenopausal

xl

women. Women with diabetes are 20% more likely to develop BCa after menopause

(Nordqvist, 2012).

Recent oral contraceptive use:According to American Cancer Society (2013)

women using oral contraceptives have a slightly greater risk of BCa than women who

have never used them. This risk seems to go back to normal over time once the pills are

stopped. Women who stopped using oral contraceptives more than 10 years ago do not

appear to have any increased BCa risk. When thinking about using oral contraceptives,

women should discuss their other risk factors for BCa with their health care team.

Hormone replacement therapy after menopause: Post-menopausal hormone therapy

PHT) with oestrogen (often with progesterone) has been used for many years to help

relieve symptoms of menopause and to help prevent osteoporosis (thinning of the

bones).This treatment goes by many names, such as post-menopausal hormone therapy,

hormone replacement therapy (HRT), and menopausal hormone therapy (MHT).There

are 2 main types of hormone therapy. For women who still have a uterus (womb),

doctors generally prescribe both oestrogen and progesterone (known as combined

hormone therapy). Progesterone is needed because oestrogen alone can increase the risk

of cancer of the uterus. For women who no longer have a uterus, may be as a result of

hysterectomy, oestrogen alone can be prescribed. This is commonly known as

oestrogen replacement therapy or just oestrogen therapy).

The decision to use hormone therapy after menopause such as depo-

medroxyprogesterone acetate (DMPA or Depo-Provera), an injectable form of

progesterone given once every three months as a “shot” for birth control should be

made by a woman and her doctor after weighing the possible risks and benefits, based

on the severity of her menopausal symptoms and the woman's other risk factors for

xli

heart disease, BCa, and osteoporosis (American Cancer Society, 2013). If a woman and

her doctor decide to give hormones therapy trial for symptoms of menopause, it is

usually best to use it at the lowest dose needed to control symptoms and for as short a

time as possible.

Combined hormone therapy: Using combined hormone therapy after menopause

increases the risk of getting BCa (ACS, 2013). It may also increase the chances of

dying from BCa. This increase in risk can be seen with as little as 2 years of use.

Combined HT also increases the likelihood that the cancer may be found at a more

advanced stage. National Health Services (2012) estimates that there would be an extra

nineteen (19) cases of BCa for every 1,000 women taking combined HRT for ten (10)

years. The increased risk from combined hormone therapy appears to apply only to

current and recent users. A woman's risk of BCas seems to return to that of the general

population within 5 years of stopping combined treatment.

The word bio-identical is sometimes used to describe versions of oestrogen and

progestin with the same chemical structure as those found naturally in people. The use

of these hormones has been marketed as a safe way to treat the symptoms of

menopause. It is important to realize that although there are few hormones, there is no

evidence that they are safer or more effective. The use of these bio-identical hormones

should be assumed to have the same health risks as any other type of hormone therapy.

Along with the increased risk of BCa, combined HT also appears to increase the risk of

heart disease, blood clots, and strokes. It does lower the risk of colo-rectal cancer and

osteoporosis, but this must be weighed against possible harm, especially since there are

other effective ways to prevent and treat osteoporosis. Although ET does not seem to

increase BCa risk, it does increase the risk of blood clots and stroke.

xlii

Oestrogen therapy: The use of oestrogen alone after menopause does not appear to

increase the risk of developing BCa. In fact, some research has suggested that women

who have previously had their uterus removed and who take oestrogen actually have a

lower risk of BCa. Women taking oestrogen seem to have more problems with strokes

and other blood clots, though. Also, when used long term (for more than 10 years), ET

has been found to increase the risk of ovarian cancer in some studies. At this time there

appear to be few strong reasons to use post-menopausal hormone therapy (either

combined HT or ET), other than possibly for the short-term relief of menopausal

symptoms.

Nursing implications of using hormone by post-menopausal women: A number of

nursing implications abound in the use of hormone by post menopausal women- Risk

assessment requires multidisciplinary approach involving the nurse and other health

care professionals (Adejumo & Adejumo, 2009). In order that nurses play active roles,

they need to upgrade their knowledge on epidemiology, etiological factors as well as

genetic concerns. Aside from this, nurses have an in-depth knowledge of risk

assessment. Ability to exercise good counselling skills with genetic education will also

be an advantage. The nurse should constantly upgrade her information as new risk

factors emerge so as to direct the clients accordingly.

The process of communicating the risk factors is quite challenging. It requires effective

communication skills in order to facilitate informed decision making regarding cancer

prevention and early detection measures. The nurses, especially those at the oncology

department should aim at making clients understand their risks, live with their risks and

make cost effective management choices.

xliii

Reproductive factors: Studies have linked nulliparity, age at menarche, first live birth,

and menopause to BCa risk. It is supposed that prolonged exposure to ovarian hormone

increases BCa occurrence. As documented by Cancer Research UK (2013) and Okoh

(2009) as well as ACS, (2013), women who have either early menarche (before 12 or

late menopause, after 55), are twice as likely to develop BCa. Similarly, the risk of

developing BCa in women who have their first child after age of 30 is about twice that

of women who have their first baby before attaining 20 years of age (Cancer Research

UK, 2013).

Women at highest risk are those that had their first baby after attaining 35 years of age;

women who have never been pregnant. The above observations could be attributed to

menstrual cycle effect, because during the menstrual cycles, the woman’s hormonal

levels fluctuates in response to the effects of oestrogen and progesterone causing

several changes within the breast. These changes invariably amplify anomalies in the

cell repair process which in some cases lead to BCa in later life (American Cancer

Association, 2005).

Not breast-feeding: High levels of prolactin have been associated with increased risk

of BCa (Eliassen, Tworoger, & Hankinson, 2007). ACS (2013) suggests that breast-

feeding may slightly lower BCa risk, especially if breast-feeding is continued for 1½ to

2 years. One explanation for this possible effect may be that breast-feeding reduces a

woman's total number of life-time menstrual cycles (similar to starting menstrual

periods at a later age or going through early menopause). This view is supported by

ACS (2007) who also argues that a possible explanation might be the reduction in the

number of menstrual cycles. Not breastfeeding therefore increases the risk of BCa.

xliv

Alcohol:Merck Manual of Diagnosis and Therapy (2003) opines that approximately 6%

(between 3.2% and 8.8%) of cancers reported in UK each year could be prevented if

drinking was reduced to a very low level of less than 1 unit per day. The use of alcohol

is clearly linked to an increased risk of developing BCa. A study of more than

1,280,000 middle-aged women concluded that for every additional drink regularly

consumed per day, the incidence of BCa increases by 11 per 1000 (ACS, 2007).

Similarly, ACS (2009); Cancer Research UK (2013), American Association for Cancer

Research (2010) and American Health Services assert that alcohol is a risk factor for

BCa in women. The risk increases with the amount of alcohol consumed. Compared

with non-drinkers, women who consume 1 alcoholic drink a day have a very small

increase in risk. Those who have 2 to 5 drinks daily have about 1½ times the risk of

women who drink no alcohol. In the same vein, a woman drinking an average of two

units of alcohol per day has 8% higher risk of developing BCa than a woman who

drinks an average of one unit of alcohol per day (ACS, 2013). Excessive alcohol use is

also known to increase the risk of developing several other types of cancers. The

mechanisms of increased BCa risk by alcohol may be as a result of: increased oestrogen

and androgen levels; enhanced mammary gland susceptibility to carcinogens (e-

medicine, 2006);increased mammary DNA damage; and greater metastatic potential of

BCa evolution (Merck Manual of Diagnosis and Therapy, 2003).

Overweight or obesity: Being overweight or obese has been found to increase BCa

risk, especially for women after menopause (Leidy, 1990). Before menopause the

ovaries produce most of the oestrogen, and fat tissue produces a small amount of

oestrogen. After menopause, most of a woman's oestrogen comes from fat tissue.

Having more fat tissue after menopause can increase your chance of getting BCa by

xlv

raising oestrogen levels; thereby predisposing the clients to BCa (Cancer Research UK,

2013). Also, women who are overweight tend to have higher blood insulin levels.

Higher insulin levels have also been linked to some cancers, including BCa.The

connection between weight and BCa risk is complex. For example, the risk appears to

be increased for women who gained weight as an adult but may not be increased among

those who have been overweight since childhood. Also, excess fat in the waist area may

affect risk more than the same amount of fat in the hips and thighs. Researchers believe

that fat cells in various parts of the body have subtle differences that may explain this.

American Health Services (2012),corroborates the ACS and asserted that there are be

higher levels of oestrogen in menopausal women.

Height: Taller than average women says American Health Services (2012) has slightly

greater likelihood of developing BCa than shorter-than-average women. Experts are yet

to be sure of the reason behind this.

Physical activity: Evidence is growing that physical activity in the form of exercise

reduces BCa risk. The main question is how much exercise is needed. In one study from

the Women's Health Initiative (WHI) according to the ACS (2013), as little as 1hour

and 15 minutes to 21/2 hours per week of brisk walking reduced a woman's risk by 18%.

Walking 10 hours a week reduced the risk a little more. A number of factors with

uncertain, controversial, or unproven effects on cancer risks are hereunder discussed.

Diet and vitamin intake:Many studies have looked for a link between what women eat

and BCa risk, but so far the results have been conflicting (ACS, 2013). Some studies

have indicated that diet may play a role, while others found no evidence that diet

influences BCa risk. Studies have looked at the amount of fat in the diet, intake of fruits

and vegetables, and intake of meat, finding no clear link to BCa. According to Cancer

xlvi

Research UK (2013), low fat may play a role in significantly decreasing the risk of BCa

as well as its recurrence. Studies have also looked at vitamin levels, again with

inconsistent results. So far, no study has shown that taking vitamins reduces BCa risk.

This is not to say that there is no point in eating a healthy diet. A diet low in fat, low in

red meat and processed meat, and high in fruits and vegetables may have other health

benefits.

Cancer Research UK (2013) and ACS (2013) assert that BCa is less common in

countries where the typical diet is low in total fat, low in polyunsaturated fat, and low in

saturated fat. Nonetheless, many studies of women in the United States have not found

BCa risk to be related to dietary fat intake. Researchers are still not sure how to explain

this apparent disagreement. It may be at least partly due to the effect of diet on body

weight. Also, studies comparing diet and BCa risk in different countries are

complicated by other differences (like activity level, intake of other nutrients, and

genetic factors) that might also change BCa risk. More research is needed to understand

the effect of the types of fat eaten on BCa risk. However, it is clear that calories do

count, and fat is a major source of these. High-fat diets can lead to being overweight or

obese, which is a BCa risk factor. A diet high in fat has also been shown to influence

the risk of developing several other types of cancers, and intake of certain types of fat is

clearly related to heart disease risk.

Anti-perspirants:Internet e-mail rumours have suggested that chemicals in underarm,

antiperspirants are absorbed through the skin, interfere with lymph circulation, cause

toxins to build up in the breast, and eventually lead to BCa. There is very little evidence

to support this rumour (ACS, 2013). In any case, one small study has found trace levels

of parabens (used as preservatives in antiperspirants and other products), which have

xlvii

weak oestrogen-like properties, in a small sample of BCa tumours. But this study did

not look at whether parabens caused the tumours.

Aluminium salt: According to Cancer Research UK (2013), Dr. Darbre in a research

published in the Applied Toxicology, found that aluminium salts increase oestrogen-

related gene expression in human BCa cells grown in the laboratory.

Bras:Internet e-mail rumours suggest that bras cause BCa by obstructing lymph flow.

There is no good scientific or clinical basis for this claim (ACS, 2013). Women who do

not wear bras regularly are more likely to be thinner or have less dense breasts, which

would probably contribute to any perceived difference in risk.

Induced abortion:Several studies like those of Mahuegaingreco, Ursin, Sullivan

Halley, and Beinstein, (2003) have provided very strong data that neither induced

abortions nor spontaneous abortions have an overall effect on the risk of BCa. It

however remains a controversial issue, and current consensus has concluded that there

is significant risk associated between first trimester abortion and BCa risk. Forney

(2006) noted that higher incidence occur in women who had had abortion at one time or

the other.

Breast implants:Several studies have found that breast implants do not increase BCa

risk, although silicone breast implants can cause scar tissue to form in the breast (ACS,

2013). Implants make it harder to see breast tissue on standard mammograms, but

additional x-ray pictures called implant displacement views can be used to examine the

breast tissue more completely.

Bisphenol A: Bisphenol A (BPA is a common xenostrogen chemical found in plastics,

like, plastic bottles, PCV pipes and in the coating of canned food. Research on mice and

women revealed that exposure to BPA during development has carcinogenic effects and

xlviii

produces precursors of BCa (Catholic Forum, 2008). Recent research has shown

evidence that BPA remains more time in the body than was previously thought. It is

against the above scientific fact that consumer groups wishing to lower their exposure

to BPA have been encouraged to avoid canned foods and polycarbonate plastic

containers unless the packaging indicates the plastic is PBA free. Microwaving food

with plastic containers is condemned

Chemicals in the environment:A great deal of research has been reported and more is

being carried out to understand possible environmental influences on BCa risk. Of

special interest are compounds in the environment that studies in laboratory animals

have found to have oestrogen-like properties. These could in theory affect BCa risk

(American Cancer Centre, 2009). For example, substances found in some plastics,

certain cosmetics and personal care products, pesticides (such as DDE and PCBs

polychlorinated biphenyols) seem to have such properties. This issue understandably

invokes a great deal of public concern, but at this time research does not show a clear

link between BCa risk and exposure to these substances. Unfortunately, studying such

effects in humans is difficult.

Tobacco smoke: for a long time, studies found no link between active cigarette

smoking and BCa, but in recent years though, some studies have found that smoking

may increase the risk of BCa. The increased risk seems to affect certain groups, such as

women who started smoking when they were young. The International Agency for

Research on Cancer (2009) concludes that there is limited evidence that tobacco

smoking causes BCa.An active focus of research is whether second-hand smoke

increases the risk of BCa. Both mainstream and second-hand smoke contains chemicals

that, in high concentrations, cause BCa in rodents. Chemicals in tobacco smoke reach

xlix

breast tissue and are found in breast milk. The evidence on second-hand smoke and

BCa risk in human studies is controversial, at least in part because smokers have not

been shown to be at increased risk. One possible explanation for this is that tobacco

smoke may have different effects on BCa risk in smokers and in those who are just

exposed to smoke (WHO, 2010).

A report from the California Environmental Protection Agency in 2005 concluded that

the evidence about second-hand smoke and BCa is "consistent with a causal

association" in younger, mainly premenopausal women. The 2006 US Surgeon

General's report, The Health Consequences of Involuntary Exposure to Tobacco Smoke,

concluded that there is "suggestive but not sufficient" evidence of a link at this point. In

any case, this possible link to BCa is yet another reason to avoid second-hand smoke.

Inhaling second-hand smoke increases risk of BCa by 70% they maintain.

Night work:Several studies have suggested that women who work at night, nurses on

the night shift for example, have an increased risk of developing BCa (ACS, 2013).

Some researchers think the effect may be due to changes in levels of melatonin, a

hormone whose production is affected by the body's exposure to light (ACS, 2012). In

line with American Cancer Society, American Health Services reports that French

researchers discovered that women who worked at night prior to a first pregnancy had a

higher risk of developing BCa. Canadian researchers equally found out that certain jobs,

especially those that bring the human body into contact with possible carcinogens and

endocrine disruptors are linked to a higher risk of developing BCa. these include-

bar/gambling, automotive plastics manufacturing, metal-working, food canning and

agriculture (American Health Services, 2012).

l

Manifestations of BCa

The early stages of BCa may not have any symptoms. This is why it is important to

follow screening recommendations. However, Okafor (2011) opines that a number of

warning signs (CAUTION), herald the onset of manifestations of BCa and they include:

change in bowel or bladder habits; a sore that does not heal; unusual bleeding or

discharge; thickening/or lump in the beast or elsewhere; indigestion or difficulty

swallowing; obvious change in wart or mole; and nagging cough or hoarseness of voice.

Most breast tumours are discovered by the clients as a small, hard painless lumps, or

masses, found often in the upper outer quadrant of the breast. Skin changes, such as

dimpling, peau d’ orange skin and engorged vessels on the affected breast may occur

(National Health Services, 2013).

The disease can produce a variety of symptoms as enumerated below: small, hard

painless lump initially, or thickening in the breast; tumour, untreated lump may grow in

size and become a tumour with pain; change in size or shape of the breast; nipple

discharge, which could be bloody at times; nipple turning inward; a rash around (or on)

one of the nipples; dimpling, pulling, or retraction of an area of the breast; persistent

skin rash near the nipple area; flaking or eruption near the nipple; redness or scaling,

peeling or flaking of the skin/nipple; ridges/pitting of the breast skin; unusual lump in

the underarm, or above the collar bone; unexplained weight loss, can occasionally

herald an occult BCa, as can symptoms of hyperthermia and chills; and bone or joint

pains, jaundice or neurological features can at times be symptoms of metastatic BCa

(ACS, 2010).

These symptoms do not always signify the presence of BCa, but they should always be

investigated immediately by a healthcare professional. Pain (mastodynia) is an

li

unreliable tool in diagnosing cancer, it may be indicative of other breast health issues.

Clients with bone metastasis may experience pathologic fractures, chronic pain, and

hypercalcaemia. Those with lung lesion may have difficulty breathing, while brain

metastasis may affect mental processes.

Epidemiology of BCa

Worldwide, breast cancer is the most common cancer in women after skin cancer,

representing 16% of all female cancers. The rate is more than twice that of colo-rectal

cancer and cervical cancer. It is about three times that of lung cancer. Mortality

worldwide is 25% greater than that of lung cancer in women. The incidence of BCa

varies greatly around the world, being lower in less-developed countries and greatest in

the more-developed countries. BCa is strongly related to age with only 5% of all BCas

occurring in women under 40 years old. The lifetime risk for BCa in the United States

is usually given as 1 in 8 (12.5%) with a 1 in 35 (3%) chance of death. The United

States have the highest annual incidence rates of breast cancer in the world; 128.6 per

100,000 in whites and 112.6 per 100,000 among African Americans. In 2007, breast

cancer was expected to cause 40,910 deaths in the US (7% of cancer deaths; almost 2%

of all deaths). This figure includes 450-500 annual deaths among men out of 2000

cancer cases.

Both incidence and death rates for BCa have been declining in the last few years in

Native Americans and Alaskan Natives. Nevertheless, a US study conducted in 2005 by

the Society for Women's Health Research indicated that BCa remains the most feared

disease, even though heart disease is a much more common cause of death among

women. Similarly, c, opines that BCa statistics worldwide, is by far the most common

cancer in women worldwide. BCa represents 10 per cent of all cancers diagnosed

lii

throughout the world every year. The incidence of BCa in women in high-income

countries in 2000 was at least twice that of any other cancer.

BCa caused 502,000 deaths (7% all of cancer deaths; almost 1% of all deaths)

worldwide This is congruent with the fact that BCa is the most common, and the second

principal cause of cancer deaths in women globally, Nigeria inclusive (Adebamowo, &

Ajayi, 2006; Igbinoba, 2005; Parkin, Bray, Ferlay & Pisani, 2005, Oluwatosin and

Oladepo, 2006). The lifetime risk for BCa in the United States is usually given as 1 in 8

(12.5%) with a 1 in 35 (3%) chance of death, and the highest annual incidence rates of

BCa in the world; 128.6 per 100,000 in whites and 112.6 per 100,000 among African

Americans. In 2007, BCa was expected to cause 40,910 deaths in the US (7% of cancer

deaths; almost 2% of all deaths), which includes 450-500 annual deaths among men out

of 2000 cancer cases. According to ACS (2012), the most recent estimates for BCa in

the United States reads that, aproximately: 226,870 new cases of invasive BCa will be

diagnosed in women; 63,300 new cases of carcinoma in situ (CIS) will be diagnosed

(CIS is non-invasive and is the earliest form of BCa); and about 39,510 women will die

from BCa. Mortality rates for BCa in Western Europe and North America are in the

order of 15–25 per 100 000 women, being slightly more than a third of the incidence

rate. In UK, 45,000 cases are diagnosed and 12,500 deaths occur per annum.

Early detection and screening programmes in high-income countries altered the

reported rates of both incidence and mortality. Mortality rates for BCa in Western

Europe and North America are in the order of 15–25 per 100 000 women, being slightly

more than a third of the incidence rate. The survival rate from BCa in developing

countries is generally poorer than in developed countries, primarily as a result of

liii

delayed diagnosis of cases. Delayed medico-nursing interventions could also play a

role.

Racial disparities: Several studies have found that black women in the U.S. are more

likely to die from BCa even though white women are more likely to be diagnosed with

the disease. Even after diagnosis, black women are less likely to get treatment

compared to white women. Scholars have advanced several theories for the disparities,

including inadequate access to screening, reduced availability of the most advanced

surgical and medical techniques, or some biological characteristic of the disease in the

African American population. Some other studies suggest that the racial disparity in

breast cancer outcomes may reflect cultural biases more than biological disease

differences. Research is currently ongoing to define the contribution of both biological

and cultural factors. In UK, 45,000 cases diagnosed and 12,500 deaths per annum. 60%

of cases are treated with Tamoxifen, of these, the drug becomes ineffective in 35%.

After increasing for more than 2 decades, female BCa incidence rates decreased by

about 2% per year from 1999 to 2005. This decrease was seen only in women aged 50

or older, and may be due at least in part to the decline in use of hormone therapy after

menopause that occurred after the results of the Women's Health Initiative were

published in 2002. This study linked the use of hormone therapy to an increased risk of

BCa and heart diseases.

Breast cancer therefore remains the most common cancer among American women,

except for skin cancers. About 1 in 8 (12%) women in the US will develop invasive

BCa during their lifetime. According to the ACS (2012), the most recent estimates for

BCa in the United States are: 226,870 new cases of invasive BCa will be diagnosed in

women; 63,300 new cases of carcinoma in situ (CIS) will be diagnosed (CIS is non-

liv

invasive and is the earliest form of BCa); and about 39,510 women will die from BCa.

However, the above notwithstanding, at this time there are more than 2.6 million BCa

survivors in the United States.

Breast cancer is the second leading cause of cancer death in women, exceeded only by

lung cancer. The chance that BCa will be responsible for a woman's death is about 1 in

36 (about 3%). Death rates from BCa have been declining since about 1990, with larger

decreases in women younger than 50. These decreases are believed to be the result of

earlier detection through screening and increased awareness, as well as improved

treatment.

However, BCa in less developed countries, such as those in South America, is a major

public health issue. It is a leading cause of cancer-related deaths in women in countries

like Argentina, Uruguay, and Brazil. The expected number of new cases and deaths due

to breast cancer in South America for the year 2001 were approximately 70,000 and

30,000, respectively. In India, BCa accounts for 19-34% of all cancer cases among

women. There is a high mortality due to late stage diagnosis as patients usually present

at an advanced stage because of lack of awareness and non-existent BCa screening

programs.

Developing countries:As developing countries grow and adopt Western culture and

life-style, they also accumulate more disease that has arisen from Western culture and

its habits which include: fat/alcohol intake; smoking/secondary smoking; exposure to

oral contraceptives; the changing patterns of childbearing; breastfeeding; and low

parity.

In Nigeria in 2005, it was estimated that between 7,000 and 10,000 new cases of BCa

would develop (WHO, 2005). The same year, approximately 89,000 people died from

lv

cancer. 54,000 of those people were under the age of 70. Recent observations show that

the frequency of BCa has risen over that of non-Hodgkin's lymphomas and cervical

cancer in Nigeria (Thomas, 2000). This trend was attributed to several factors; the

acceptance of fine needle aspiration as an accurate diagnostic evaluation, increased

awareness about BCa and usefulness of breast self-examination (Thomas, 2000).

The relative frequencies of BCa among other female cancers, from Cancer Registries in

Nigeria were 35.3% in Ibadan, 28.2% in Ife-Ijesha, 44.5% in Enugu, 17% in Eruwa,

37.5% in Lagos, 20.5% in Zaria and 29.8% in Calabar (Banjo, 2004). In all the centres,

except Calabar and Eruwa, BCa rated first among other cancers. Further reports showed

that majority of cases occurred in pre-menopausal women, and the mean age of

occurrence ranged between 43–50 years across the regions. The youngest age recorded

was 16 years, from Lagos (Banjo, 2004). Other most common cancers documented are

cancers of the uterus and breast for women and cancers of the liver and prostate for

men.

In line with Banjo (2004) and Adebamowo and Ajayi (2006) also report that peak age

of incidence in Nigeria is 42.6 years, and that 12% of cases occurred before 30 years

while postmenopausal women accounted for 20% of cases. These authors were of the

opinion however that, these parameters may be more reflective of the demographic

profile of Nigeria than an inherent difference in epidemiological characteristics of BCa

in Nigeria. The predominant feature of late presentation of BCa had been reported over

a decade in Nigeria (Pillar, 2000; Adebamowo, Ogundiran, Adenipekun, Oyesegun, et

al, 2003; Jebbin & Adotey, 2004; & Okobia, Bunker, Okonofua & Osimi, 2006). This is

probably due to the fact that there is no established National screening Program for

BCa.

lvi

Despite statistics that cancers affecting women are on the rise here, Nigeria remains ill

equipped to deal with the complexities of cancer care. Public health messaging is

scheduled to increase, but testing and care facilities are few. Awareness of early

detection measures of BCa such as clinical breast examination (CBE) and breast self

examination (BSE) are also low (Adebamowo and Ajayi (2006). In an environment

where late presentation is predominant and where most BCas were detected

accidentally by women themselves, Adebamowo and Ajayi (2006) insist that there is an

urgent need for awareness of BCa and its early detection measures. On their part,

Ogundipe and Obinna (2008), opine that the burden of cancer in Nigeria is appreciable.

According to the WHO, there are an estimated 100,000 new cancer cases in the country

each year although observers believe the figure could become as high as 500,000 new

cases annually by 2010. It is feared that by 2020, cancer incidence for Nigerian males

and females may rise to 90.7/100,000 and 100.9/100,000 respectively. It is also

anticipated that by 2020, death rates from cancer in Nigerian males and females may

reach 72.7/100,000 and 76/100,000 respectively.

According to Taire (2010), the incidence of BCa in Nigeria is increasing just like in

other developing countries and those advanced countries that used to have a low

incidence, now experience increase. Several factors are responsible for this increasing

incidence, but the most important are increasing average life expectancy, increased

access to diagnostic facilities, empowerment of

women whichisincreasingwomen’sability to make independent decisions about their

own healthcare, increasing Westernization of dietary, physical activity and obstetric and

gynaecological factors, among others.

lvii

Oluwatosin and Oladepo (2006) noted that predominant feature of late presentation

of BCa had been reported over three decades in Nigeria. This late presentation is

probably due to the fact that facilities for carrying out adequate early detection of BCa

are unavailable in virtually all the hospitals within the state. This goes to support the

observation of the researcher that there is no established national screening program for

BCa. The few hospitals and individuals outside the state that embark on mammography,

charge so exorbitantly that an average reverend sister that seeks to be motivated hardly

address the issue as one of great concern. Awareness of appropriate health behaviours

and early detection measures of BCa such as clinical breast examination (CBE) and

breast self examination (BSE) are also lacking, or low.

Corroborating the opinion of Oluwatosin and Oladepo (2006), Adebamowo and Ajayi

(2006) said that creating awareness about cancer and improving access to testing and

health care facilities will help decrease the steadily rising numbers of cancer cases. But

Nigeria is ill-equipped to deal with the complexities of cancer care. A wobbly health

care infrastructure makes clinical services hard to come by and inadequately distributed.

Only a few health centres have functioning radiotherapy equipment and the cost of care

remains out of reach for most Nigerians who have received a cancer diagnosis. The

women in most states in Nigeria have access to primary health care centres (PHCs)

which only deal with minor ailments and treatment of common diseases. The women

therefore make use of the health facilities basically for maternity and child care. Since

there is no established National screening program for BCa, this study may provide

evidence for the requirement of such in the future and also provide justification for

training of Nurses in PHC to perform clinical breast examination and teach clients

breast self examination.

lviii

Nursing implications of the epidemiology of BCa: There is need for nurses to be

acquainted with the burden of BCa so as to cooperate maximally with the health team in

enforcing and instituting measures geared towards relieving the individual, significant

others, the family, community and society at large. According to Adejumo and

Adejumo (2009), the concept of creating awareness among young women seen in

developing countries might result in a screening schedule billed to commence early in

life.

All patients should be made to know details of their treatment mode, and be encouraged

to cooperate. Their diet should be well balanced and nourishing. Adequate fluid intake

is imperative to aid excretion of broken-down waste products. Two and half to three

litres of fluid should be taken daily. The bowel movement has to be regulated as

patients taking analgesics tend to be constipated. A patient’s request for pain reliever

should be anticipated to avoid pain establishing since addiction does not arise in this

case. Owing to the fact that anxiety is always associated with the fear of cancer, the

patient should always be told the advances in treatment which are now available and

should be encouraged to be optimistic of their success in their case.

Mounting evidence suggests that healthy lifestyle campaigns and government-

sponsored public health initiatives could stem the growing tide of cancer here. In line

with the above belief, Adebamowo et al (2003) asserts that, creating awareness about

cancer and improving access to testing and health care facilities will help decrease the

steadily rising numbers.  Regrettably however, Nigeria is still ill equipped to deal with

the complexities of cancer care. A wobbly health care infrastructure makes clinical

services hard to come by and inadequately distributed.

lix

Only a few health centres have functioning radiotherapy equipment and the cost of care

remains out of reach for most Nigerians who have received a cancer diagnosis. Nigeria

is also home to only a few medical professionals with expertise in cancer treatments.

According to a Consultative Committee on National Cancer Control, most surgeries

here are performed by surgeons whose primary clinical practice is not oncology. This

unavailability does not encourage the reverend sisters who need to be motivated more

towards the practice of early detection measures of BCa.

Breast cancer screening guide/early detection practices

Screening as currently practiced can reduce the mortality of women but may not reduce

the incidence (Adejumo & Adejumo, 2009). BCa screening guide is a guide that

contains tests to detect early signs of BCa in women. The assumption is that early

detection will improve outcomes.

Breast cancer screening has become a controversial subject over the last few years.

Experts, professional bodies, and patient groups can hardly agree on when for instance

mammography screening should start (American Health Services, 2012). The

differences in the age for screening for various countries and races could be associated

with age of manifestation of the disease. While in the UK women are expected to take

part in mammography at the age of 50, the US advocates commencing at the age of 40

years. In Sub-Saharan African countries that have presentation at an earlier age, might

consider screening early (Dow, 2001). About 1.5 million women are screened for BCa

in the UK each year; BCa screening saves the lives of two women for every one given

unnecessary treatment (Taire, 2010).

Also it has been reported that researchers have found that the benefits of the screening

programme far outweigh any harm it may cause, such as unnecessary treatment for

lx

cancer than viewed otherwise, have remained symptomless (known as over diagnosis),

(Cancer Research UK, 2013). In a research carried out between 1998-2003 on BCa

screening programme, the lead researcher, Professor Duffy said, ‘’if you screen today,

you are not only saving lives tomorrow, you are saving lives years from now on’’

(Cancer Research UK, 2013). BCa screening continues to save many lives each year.

Quality screening mammography done every two years in women 50-69 years of age

should reduce their risk for death from BCa by about 35%’’ (WHO, 2002). The benefits

of BCa screening therefore include early diagnosis and reducing BCa deaths, which are

weighed against the anxiety involved in attending screening and awaiting results, and

the risk of false positive results.

Women considering or undergoing breast screening can discuss any concerns with their

specialist who can advice on the options, techniques and therapies for diagnosing and

treating BCa (NHS and WHO, 2002). However, a number of screening tests have been

recommended by WHO (2006), which include: Self- breast examination (SBE);

Clinical breast examination (CBE); and Mammography. Others include digital

mammography; ultrasound; and Magnetic Resonance Imaging (MRI).

Breast self examination: A breast self examination (BSE) involves feeling the breast

for lumps or other abnormalities. Breast self examination is performed monthly. It is the

best method for detecting breast masses early. A woman who knows the textures and

feel of her own breasts is far more likely to detect changes that develop. Thus, it is

important for a woman to develop the habit of doing routine SBE as early as possible,

preferably as an adolescent. Women who are at high risk for BCa are encouraged to be

attentive to the importance of early detection through routine breast self examination

(BSE).

lxi

The effectiveness of BSE is determined by the women’s ability to perform the

procedure correctly. She should do BSE on monthly bases about 1 week after each

menstrual period, when the breasts are typically not tender or swollen. On their part,

Adejumo and Adejumo (2009) maintain that breast self examination be performed from

the 5th day of the menstrual cycle till about 1week after the end of the cycle, every

month. After menopause, women should perform BSE on the same day each month

(London, Ladewig, Ball and Bindler, 2007). This practice is further buttressed by ACS

(2007) that recommends that CBE be performed from 5 th and 7th day of the menstrual

cycle every month, and could be started as early as age 18 or 20 years. For menopausal

women, a constant period each month is chosen for this all important exercise

(Oluwarotimi, 2011). BCas are more frequently found by the woman themselves than

by a physician during a routine examination.

In recent years, research evidence does not support the effectiveness of BSE because by

the time a lump is large enough to be found it is likely to have been growing for several

years and will soon be large enough to be found without an examination (Agonsi,

2010). Also another study reported that BSE is a useful method in early case detection,

although its effectiveness has not been adequately qualified (WHO, 1984). Nonetheless,

BSE serves the purpose of creating breast awareness, which is part of women’s general

body care. The more someone examines her breasts, the more she will learn about them

and the easier she will be able to detect any unusual occurrence. Obviously, women

who carefully examine their breasts could find little masses of BCa and with better

prognosis.

In a study carried out by Philip, Harris, Flahert and Joslin (1986), 54.0% of 304 patients

with newly diagnosed BCa claimed to practice BSE. Another study also found that

lxii

those who performed BSE had reported their symptoms to health personnel sooner than

other subjects (Ugwu, 2005). In a study among female store clerk working and residing

in Monterrey, Mexico, women aged 18years or older were eligible to participate in BSE

and CBE, for women starting early at this age, and screening at younger ages offers an

opportunity for them and their doctors or nurses to discuss changes in their breasts,

methods of early detection and factors in the woman’s history that might predict future

BCa (Wall, Munez-Rocha, Ana, Martinez and Pena, 2008).

According to Joseph (2011), there are 7Psof BSE which include:

1. Position-in order that the breasts distribute adequately, inspect and palpate with

arms in various positions.

2. Perimeter-the entire breast should be examined, nipple inclusive.

3. Palpation-with the pad of the fingers, palpate without lifting them.

4. Pressure-light, medium and firm pressures are employed during palpation.

5. Pattern-various patterns are adopted in the practice of BSE:stripe, circular and

wedge patterns.

6. Practice-know what to do when new breast changes are observed.

7. Persistence-be persistent in practicing BSE.

Techniques for Performing BSE: The techniques for performing BSE have been

established by the American Cancer Society (Ugwu, 2005). BSE should be done in

good light and should include inspection before a mirror and careful systematic

palpation. The entire breasts, axillae, and clavicle should be examined. Inspection or

active observation of the breast suggests a more direct and active inspection of the

breasts looking for specific signs and symptoms that might indicate an early BCa. Steps

in performing breast- examination are as follows:

Inspection before a mirror

lxiii

Step1.Stand and face the mirror with arms relaxed at the sides or hands resting on the

hips, then turn to the right and the left side, to: Note the size and symmetry of the

breasts. Some difference is normal but that should remain constant at rest. Note

any abnormal contour; note the shape and direction of the breast. They can be

rounded or pendulous with some variations. Normally, breasts point slightly

laterally; observe for colour and venous pattern, checking for redness or

inflammation. A blue colour with marked venous pattern that is unilateral could be

indicative of increasing blood supply due to tumour; observe for thickening or

oedematous area with enlarged pores(orange peel), which may indicate blocked

lymph drainage owing to tumour. Skin dimpling, puckering or retraction when the

hands are pressed together or against the hip suggest malignancy; and note the

nipple size, shape and direction is also noted. An inverted nipple that was

previously erect is suspicious. Deviation, flattening or broadening are noted too.

Step 2 . Bend/lean forward from the waist with arms raised straight over the head.

Step 3. Stand straight with the arms raised over the head, starting with one arm, then the

other and move the arms slowly up and down at the side (observing free

movement of the breasts over the chest wall or otherwise).

Step 4. Press hands firmly together at chin level while the elbows are raised to shoulder

level

Palpation: lying position

Step 1. Place a pillow under the right shoulder and place the right hand behind the head.

This position distributes breast on the chest.

Step 2. Use the finger pads (tips) of the three middle fingers (held together) on the left

hand to feel for lumps.

lxiv

Step 3. Press the breast tissue against the chest wall firmly enough to know how the

breast feels. A ridge of firm tissue in the lower curve of each breast is normal.

Step 4. Use small circulation motions systematically all the way around the breasts as

many times as necessary until the entire breast is covered.

Step 5. Bring the arm down to the side and feel under the armpit where breast tissue is

located.

Step 6. Repeat the examination on the left breast, using the finger pads of the right

hand.

Palpation: Standing or Sitting: Repeat the examination of both breasts while upright

with one arm behind the head. The position makes it easier to check the area where a

large percentage of BCas are found, the outer part of the breast and toward the armpit.

In The Shower: Do the upright BSE in the shower, soapy hands guide more easily over

weight skin. Raise the left arm, with fingers of the right hand flat, examine the left

breast thoroughly, feeling for a lump or thickening. Beginning at the outer edge, press

the flat part of the fingers in small circles, moving the circles around the breast and

spiralling in toward the nipple. Examine the area between the breast and underarm,

including the underarm itself. Then raise the right arm and use the left hand to examine

the right breast (Berman, Snyder, Kozier and Erb 2008).

Palpation patterns:Adebamowo and Ajayi (2006) describe three different patterns of

breast self examination namely circular motion or ‘small circles’ up-and-down lines or

strips, and wedges or radical spokes pattern. Circle motion involves beginning at the

outer edge of the breast move the fingers slowly around the whole breast in a circle,

move around the breast in smaller circles or clockwise gradually working toward the

nipple. For the up-and-down lines:Start in the under arm area and move the fingers

slightly toward the middle and slowly move back up. Move up and down until you

cover the whole area. While with the wedge pattern palpation is started at the outer edge

lxv

of the breast, moving the fingers towards the nipple and back to the edge. The whole

breast is checked, covering one small wedge shaped section at a time. The underarm

area and the upper chest are checked each time.

If a lump is found a few days before or during menstrual period, the breast is re-

examined when the period ends. If the lump does not disappear before the next period

begins, there is need to see a doctor soon. If one notices a lump, a discharge or any

other change during the month whether or not during BSE, one’s doctor should be

contacted (Ugwu, 2005). Some women still do not regularly examine their breasts. A

number of women gave reasons why they do not practice BSE, which include:

embarrassment, lack of confidence, inability to do BSE, complexity of the procedure

and not remembering to do BSE. Factors that increase compliance could include among

others, reminder system, confidence in BSE skill, encouragement from health care

providers etc.

Factors affecting breast self examination

Some factors according to Agonsi (2010) affect the practice of breast self examination.

They include: Age; educational status; socioeconomic background; personal issues;

environmental factors; cultural; and religious belief system.

Age: Breast development is usually a sign that a girl is approaching puberty. As the

breasts grow and develop, one may notice a small lump and other changes in the breast.

At the stage of early puberty also, teenagers do not see any reason for them to have their

breasts examined. The situation is worst with elderly women- premenopausal and

menopausal women feel it is not necessary to examine their breasts regularly since they

do not bear children any longer.

lxvi

Educational status: The level of education of individuals differ, one from another, and

therefore will affect the opportunities of such information on health practices.

Socio-economic background: He stated that individuals of higher class in the society

are often involved in activities which either give their time to practice or time to attend

seminars or medical examination and counselling. This in turn affects the practice of

breast self- examination by this group of people, but those in the lower class are not

likely to have time for medical issues of this nature which will help prevent

complications.

Environmental factors: An environment in which a girl child grows up plays a role in

her abilities to know and practice this. Some environments do not permit a girl child to

talk about herself especially when it has to do with reproductive parts and this in away

affect information given to them about reproduction.

Personal issues: Most women do not just have particular reason for not practicing

breast self examination. Sometimes, when they practice it, they may discover a lump

and for the fear of being diagnosed of BCa, breast self examination is now far from

their monthly activities.

Cultural and religious beliefs: Majority of the culture still practices gender inequality

which most times make women instruments of pleasure and forbidden them from

discussing about their sensitive areas that once they are seen touching or having

anything to do with their breasts, it is termed a taboo. Also some religious beliefs forbid

women from touching their breasts or any reproductive organ in the state that factors

that reduce the access of health facilities could be responsible for the poor practicing of

breast self examination.

lxvii

Fear and anxiety: Person and Svensson (2007) also said that anxiety/fear of

discovering a lump in one’s breasts, lack of faith in one’s ability to perform the

examination, inadequate teaching and health education by parents during the

reproductive developmental stages of life can hinder the practice of breast self-

examination and other reproductive examinations necessary in life. Inadequate

knowledge and practice of breast self-examination among teenagers is as a result of

improper training transmitted through the mass media, health personnel, including

improper health education in schools.

To improve this practice among teenagers, there is need for knowledge acquisition,

theoretical as well as practical, among the teenagers and to achieve this and make breast

self-examination a habit, education about breast self-examination should be provided to

girls at school. The important role of nurses in teaching women to examine their breasts

themselves and reminding them to perform the examination was also emphasized.

Provision of social and health Medias especially in the rural areas will also help in the

circulation of important health messages to people and governmental support is also

needed through funding.

Clinical breast examination (CBE):

Between the ages of 20 and 39, every woman should have a clinical breast examination

every 3 years; and after age 40 every woman should have a clinical breast examination

done each year. A clinical breast exam is an examination done by a health professional

to feel for lumps and look for changes in the size or shape of the breasts (Smeltzer,

Bare, Hinkle, & Cheever, 2010). During the clinical breast examination, one can learn

how to do breast self-examination.

Mammography

lxviii

Once a patient has symptoms suggestive of a BCa or an abnormal screening

mammogram, she will usually be referred for a diagnostic mammogram. A diagnostic

mammogram is another set of x-rays with additional angles and close-up views. Often,

an ultrasound will be performed during the same session. A mammogram is a soft tissue

x-ray of the breast without the injection of a contrast medium. It can detect lesions in

the breast before they can be felt and has gained wide acceptance as an effective

screening tool for BCa. Mammography can detect masses of 0.5cm. Early detection by

mammography may prevent metastasis late in the pre-clinical course. (Ugwu, 2005).

Currently, the ACS recommends that all women aged 40 and above have an annual

mammogram. The National Cancer Institute and the American College of Obstetricians

and Gynaecologists (ACOG) recommend mammograms every 1 to 2 years for women

ages 40 and 49 and annually for all women aged 50 and older (London, Ladewig, Ball

& Bindler, 2007). Mammographic screening for BCa uses x-ray to examine the breast

for any uncharacteristic masses or lumps. The Cochrane collaboration 2009 concluded

that mammograms reduce mortality from BCa by 15% but also results in unnecessary

surgery and anxiety resulting in their view that mammography may do more harm than

good. Many National Organizations recommend regular mammography, nonetheless.

For the average women, the U.S, Preventive Service Task Force recommends

mammography every 2 years in women between the ages of 50 and 74. In women at

high risk, such as those with a strong family history of cancer, mammography screening

is recommended at an earlier age and additional testing may include genetic screening

that tests for the BRCA genes and /or magnetic resonance imaging (Adejumo &

Adejumo, 2009). Annual mammography for women beginning at age 40 was concluded

lxix

in a workshop discussion held by ACS in 1998 following the data generated in their

studies.

Recent study conducted in Sweden also revealed a significant reduction in mortality

among women aged 40-49years who used mammography Millex appropriately. After

12years of follow-up, the Gotthenberg trial has shown a 44% reduction in mortality.

The same criteria of benefit has been the basis for concluding that mammography are

beneficial for women aged 40-49years, said Bjurstam, Bjornel sand Duffy, as was

reported by ACS ( 2005). Although recent evidence points to the superiority of

mammography over clinical breast examination and self breast examination in terms of

sensitivity and specificity, medical opinion is against routine mammography on the very

young. Thicker suggested that women under 35years of age should not have x-rays

unless they are symptomatic or have a family history of early onset of BCa.

Mammography is a way of identifying abnormalities in the breast, but they do not

always tell whether they are benign or malignant. Further tests are sometimes necessary

and these tests include: ultrasound and fine needle aspiration cytology (Ugwu,2005).

Adejumo and Adejumo (2009) added breast Magnetic Resonance Imaging.

There is also the digital mammography which is relatively new type of mammography

that uses digital receptors instead of the conventional screen (Lieberman, 2004). This

involves biopsy of a mass detected by physical examination of mammography

advanced technologies which have improved diagnosis, staging and therapy. Some of

these new and emerging technologies include procedures for tissue analysis and

surgical biopsy. A biopsy is the only way to know for sure if one has cancer, because it

allows doctors to get cells that can be examined under a microscope. There are different

types of biopsies, which differ on how much tissue is removed. Some biopsies use a

lxx

very fine needle, while others use thicker needles or even require a small surgical

procedure to remove more tissue.

Once the tissue is removed, a pathologist would review the specimen, and can tell if the

cells are cancerous or not. If the tumour does represent cancer, the pathologist then

characterizes it by what type of tissue it arose from, how abnormal it looks (known as

the grade), whether or not it is invading surrounding tissues, and whether or not the

entire lump was removed during surgery. The pathologist would also test the cancer

cells for the presence of oestrogen and progesterone receptors.

Biopsies

Procedures for tissue analysis encompass two major types of biopsies: percutaneous

core needle biopsy and surgical biopsy.

a. Percutaneous core needle biopsy:This provides more accurate diagnosis than the

traditional fine needle biopsy. It may assist in pre-operative planning by distinguishing

between invasive and non-invasive cancer (Bock, Hadji, Ramaswamy, Schidt & Duda,

2005).This is performed on an out-patient basis to sample palpable and non-palpable

lesions. It is less invasive than surgical biopsy, and it is a needle or core biopsy that

obtains tissue by making a small puncture in the skin (Smelzer, Bare, Hinkle, &

Cheever, 2010). There are different types viz: fine needle aspiration cytology, core

needle biopsy; stereotactic core biopsy; ultrasound-guided core biopsy, magnetic

resonance imaging-guided core-biopsy, and sentinel lymph node biopsy. Fine needle

aspiration is a non-invasive biopsy technique that involves inserting a small gauge

needle (22 or 25 gauge) attached to a syringe into the lump or area of nodularity with or

without local anaesthetic agent, or through an ultra-sonography to detect the presence of

fluid (a cyst) or solid (malignant or benign) cells (Smeltzer, Bare, Hinkle, & Cheever,

lxxi

2010). False positive and false negative results are possible. Ultrasound-guided core

biopsy does not use radiation; it is faster and less expensive compared to stereotactic

core biopsy.

A biopsy of the first draining lymph node (sentinel) of any organ, lymphatic, axillary,

supra-and intra-clavicular as well as the internal mammary nodes is known as Sentinel

lymph node biopsy (Adejumo & Adejumo, 2009). Galactography is a diagnostic

procedure involving the injection of less than 1ml of radio-opaque material through a

cannular inserted into a ductal opening on the areola, followed by a mammogram. This

is performed to evaluate an abnormality within the duct when a patient manifests

bloody nipple discharge on expression, spontaneous nipple discharge, or a solitary

dilated duct noted on mammography (Smeltzer, Bare, Hinkle, & Cheever, 2010).

b. Surgical biopsy (SB): This is performed using local anaesthesia and intravenous

sedation, to obtain a specimen through an incision for pathological examination. There

are three types of surgical biopsy viz: excision biopsy, incision biopsy, and wire needle

localization. The first type is the standard procedure for complete pathological

assessment of a palpable breast mass. SB could also be termed lumpectomy as involves

the removal of the entire mass, including the margin of the surrounding tissue. To

confirm a diagnosis of a client who had no previous tissue analysis performed, a frozen

section analysis of the specimen may be performed by a pathologist at the time of the

biopsy. When only a portion of a mass is removed, it is called ‘incision biopsy’.

Incision biopsy: Normally, this is done to confirm a diagnosis, and to conduct special

studies like, ER/PR, HER-2/neu which is also referred as ‘ERBB2’. Portion excision is

done because complete excision may not be possible or that immediate excision of the

entire mass may not be beneficial to the patient, taking into cognisance the clinical

lxxii

situation. Women with locally advanced BCa benefit from this type of biopsy, or on

women with suspected cancer recurrence, and whose intervention may depend on the

results of special studies. All the same, this type of biopsy is becoming less common

since pathological information can be obtained with core needle biopsy. When lesion is

not palpable, or there is deposition of calcium detected on mammogram, ultrasound or

MRI requiring excision biopsy, wire needle localization is the technique of choice.

Wire needled localization: In this procedure, the radiologist inserts a long, thin wire

through a needle, which is then inserted into the area of abnormality, with the use of x-

ray. After the needle is withdrawn, the wire remains in situ so as to ensure the precise

location. The patient is taken to the operating room, and the surgeon following the wire,

excises the affected area.

Breast ultrasound

This form of screening was initially used as an adjunct to mammography and it is

considered the most accurate test for diagnosing BCa in young women (Houssami,

Irwig, Simpson, Mckessar, Blome, & Noakes, 2003).The effectiveness of the screening

guide is attributed to the utilization of high frequency probes that improve resolution,

and so allow detection of tiny lesions and differentiates between benign and malignant

nodules (Adejumo & Adejumo, 2009).

Decisions regarding how to screen for BCa (with mammograms, MRI, or both) should

be made between an individual and her physician, based on her individual BCa risk

profile. Early detection of BCa makes for prompt intervention at an early staging of the

disease progression, with resultant improvement in years of survival for the client. With

advancement in imaging techniques and new emerging technologies abound which aid

lxxiii

diagnosis of BCa at its rudimentary stage. Following diagnosis, the cancer is then

staged.

A good caring attitude is imperative in order to optimize the management of clients

more especially those of them with debilitating disease like the disease under

discussion. Every nurse, especially oncology nurse should always have this at the back

of his/her mind so as to guarantee efficient and effective management of the clients.

Management of BCa

American Health Services (2012) argues that a multidisciplinary team should be

involved in a BCa patient’s treatment. The team may consist of an oncologist,

radiologist, specialist cancer surgeon, specialist cancer nurse, pathologist, radiologist,

radiographer, and plastic surgeon/reconstructive surgeon. The team may at times

include an occupational therapist, psychologist, dietician and a physiotherapist. The

team takes the following into consideration: the type of cancer, the grade and stage of

the breast cancer- how large the tumour is , whether or not it has spread, and how far.

Also the check whether or not the cancer cells are sensitive to hormones, the patient’s

overall health, her age, preferences (American Health Services, 2012). Cancer

management can be approached viz: preventive management, surgical intervention,

radiation therapy or both, chemotherapy, and biologic therapy (targeted drug therapy),

as well as follow-up testing.

Preventive management: Adejumo and Adejumo (2009) opine that the prevention of

BCa focuses on studying and modifying behaviours that cause risks, controlling

influence of genetic and environmental risk factors, and interrupting the carcinogenesis

process via early medico-nursing interventions. Cancer being associated with pain and

lxxiv

death, oncology nurses, and in fact every other nurse in particular needs to identify their

own reaction and set measurable and realistic goals towards cancer prevention.

The most important risk factors for the development of BCa, such as age and family

history, cannot be controlled by the individual. Some risk factors may be controlled by

the woman, however. These include among others, things like avoiding long-term

hormone replacement therapy (Dixton, 2006), having children before age 30 (ACI,

2005), duration of breastfeeding (Eliason, Tworoger, & Hakinson, 2007) , avoiding

weight gain (ACS, 2007) through exercise and proper diet, and limiting alcohol

consumption to 1 drink a day or less. For women already at very high risk due to family

history, risk of developing BCa can be reduced by about 50% by taking a drug called

Tamoxifen for five years. Tamoxifen has some common side effects (hot flashes and

vaginal discharge), which are not serious and some uncommon side effects include:

blood clots, pulmonary embolus, stroke, and uterine cancer, which are life threatening.

Tamoxifen isn't widely used for prevention, but may be useful in some cases. Use of

Tamoxifen for prophylactic reasons should be considered carefully by an individual and

her doctor, as its use should be highly individualized. Strategies to prevent or reduce

BCa can therefore be generally focused on hereditary factors, diet, exercise, disuse of

tobacco, moderate use of alcohol, surgical-prevention and chemo-prevention strategy

(Adejumo & Adejumo, 2009).

Right nutrition:Diet modification according to Adejumo and Adejumo (2009) is one of

the effective ways of check- mating cancer causation. Odoh (n.d.) argues that limiting

ones intake of high fat diet particularly those from animal sources, and eating a variety

of healthy foods especially from plant-based sources with lots of fruits and vegetables.

Fruits and vegetables contain anti-oxidants, like vitamin C, beta-carotene, which lower

lxxv

BCa risk. Corroborating the above view, (Okoye, 2009) asserts that weight loss that

occurs in conjunction with a low-fat, high fruit and vegetable diet may help to reduce or

eliminate hot flashes, night sweats, and other symptoms associated with menopause that

constitute triggers to BCa.Low-fat is highly recommended as excess fat inevitably

increases the level of eostrogen and predisposes a client to BCa (ACS, 2007). High fruit

and vegetables with enough fibre diet may help reduce menopausal symptoms.

Reducing alcohol intake or drinking in moderation may help reduce risk too.

Regular exercise: Itis advisableto be physically active for weight control and

enhancement of immune function.

Surgery: Almost all women with BCa will have some type of surgery in the course of

their treatment. The purpose of surgery is to remove as much of the cancer as possible,

and there are many different ways that the surgery can be carried out. Some women will

be candidates for what is called Breast Conservation Therapy (BCT, 2010). In BCT,

surgeons perform a lumpectomy which means they remove the tumour with a little bit

of breast tissue around it, but do not remove the entire breast. Histology of the lump

must be done to confirm diagnosis. BCT always needs to be combined with radiation

therapy to make it an option for treating BCa. At the time of the surgery, the surgeon

may also dissect the lymph nodes under the arm so the pathologist can review them for

signs of cancer. Some patients will have a sentinel lymph node biopsy procedure to

ascertain if a formal lymph node dissection is required.

Sometimes, the surgeon will remove a larger part (called a segmental or partial

mastectomy). This needs to be combined with radiation therapy as well. In early stage

cancers (stages I and II), BCT (limited surgery with radiation) is as effective as removal

of the entire breast via mastectomy. The advantage of BCT is that the patient will not

lxxvi

need a reconstruction or prosthesis, but will be able to keep her breast thereby giving

her some psychological reassurance of her cosmetic look.

Some patients with early-stage cancer prefer to have mastectomy, and this is an

appropriate option as well. More advanced BCas are usually treated with a modified

radical mastectomy. Modified radical mastectomy refers to removal of the entire breast,

that is, physical removal of the tumour, along with some surrounding healthy tissues

that may later become cancerous, as well as and dissection of the lymph nodes under

the arm. Sometimes, patients who have modified radical mastectomy will require

radiation treatment afterwards to decrease the risk of the cancer coming back. Some

patients with DCIS will be candidates for BCT, while others will require modified

radical mastectomy because of the size or distribution of DCIS cells. Most patients with

DCIS who have a lumpectomy are treated with radiation therapy to prevent the local

recurrence of DCIS (although some of these DCIS patients may be candidates for close

observation after surgery).

Patients with DCIS that have mastectomy do not need to have the lymph nodes

removed from under the arm. The surgeon can discuss with the client, the available

options, and the pros and cons of the needed surgical procedures. Many women who

have modified radical mastectomies choose to undergo a reconstruction. A patient who

desires reconstruction should try to meet with a plastic surgeon before her mastectomy

to discuss reconstruction options.

Chemotherapy: This involves use of drugs after surgery which destroys both normal

and abnormal cells. Even when tumours are removed by surgery, microscopic cancer

cells can spread to distant sites in the body. In order to decrease a patient's risk of

recurrence, many BCa patients are offered chemotherapy. Chemotherapy is the use of

lxxvii

anti-cancer drugs that permeate the entire body to eliminate cancer cells that have

broken off from the breast tumour and spread. Many factors go into determining

whether an individual patient should have chemotherapy. Generally, patients with

higher stage disease need chemotherapy. However, chemotherapy can be beneficial

even for patients with early-stage disease. Such drugs as ralixifine gletamoxifen could

be used as chemo-preventive agents in suspected cases of cancer (Agonsi, 2010).

Individual factors such as age, overall health, and biologic properties of a woman's

breast tumour may go into decisions regarding whether or not she should have

chemotherapy. There are many different chemotherapy drugs, and they are usually

given in combinations for 3 to 6 months after which surgical intervention is undertaken.

Depending on the type of chemotherapy regimen received, the woman may get

medication every 2 to 4 weeks. Most chemotherapies used for BCa are given through a

vein, and so it is best given in an oncology clinic. Drugs that are commonly used in

BCa treatment include adriamycin (doxorubicin), cyclophosphamide, and taxanes.

There are advantages and disadvantages to each of the different regimens that the

medical oncologist would discuss with the woman. Based on the woman’s own health,

personal values and wishes, and side effects the client may wish to avoid, the client can

work with her doctor to come up with the best regimen for lifestyle.

Generally, chemotherapy is given after surgery for early-stage BCa. Sometimes,

chemotherapy may be given before surgery to shrink large tumours and allow surgery

to be more effective. For patients with stage IV disease, chemotherapy may be given

without surgery, and a variety of different agents may be tried until a response is

achieved. As contained in the World Journal of Surgical Oncology (WJSO, 2006),

breast cancer drug bevacizumab slows progression but has no overall survival benefit.

lxxviii

The cancer drug bevacizumab (Avastin) offers only a modest benefit in prolonging

disease progression in patients with advanced stage BCa. The woman must be informed

of side effects of chemotherapy such as loss of appetite, vomiting, alopecia, skin

discolouration, weakness, and anaemia.

Nursing implications

Radiotherapy: BCa is often treated with radiation therapy. Radiation therapy refers to

use of high energy x-rays to kill cancer cells. Patients having radiation usually need to

come to a radiation therapy treatment centre 5 days a week for up to 6 weeks to receive

treatment. The treatment takes just a few minutes, and it is painless. Radiation therapy

is used in all patients who receive breast conservation therapy (BCT). It is also

recommended for post-mastectomy patients who have had large tumours, lymph node

involvement, or close/positive margins after the surgery. Radiation is important in

reducing the risk of local recurrence and is often offered in more advanced cases to kill

tumour cells that may be living in lymph nodes (Agonsi, 2010). The r radiation

oncologist can answer questions about the utility, process, and side effects of radiation

therapy in one’s particular case. Radiotherapy is generally very expensive, hence the

few clients that opt for it. There are newer radiation techniques open to clients who can

afford them Accelerated partial breast irradiation (APBI).

Accelerated partial breast irradiation: Some newer techniques for radiation therapy are

being used in certain centres. These are ways to reduce the treatment time needed for

radiotherapy, and usually take 1 – 3 weeks instead of 6 weeks, and are called

accelerated partial breast irradiation (APBI). These techniques may require a patient to

have a radioactive implant placed inside the breast. These techniques are experimental,

and are only indicated for early-stage BCa patients.

lxxix

When the pathologist examines a tumour specimen, he/she may determine that the

tumour is expressing oestrogen and/ or progesterone receptors. Patients whose tumours

express oestrogen receptors are candidates for therapy with oestrogen blocking drugs.

Oestrogen-blocking drugs include Tamoxifen and a family of drugs called aromatase

inhibitors. These drugs are delivered in pill form for 5 - 10 years after BCa surgery.

These drugs have been shown to drastically reduce one’s risk of recurrence where the

client’s tumour expresses oestrogen receptors. They may be accompanied by side

effects, however. When taking Tamoxifen, patients may experience weight gain, hot

flashes and vaginal discharge. Taking Tamoxifen may also increase risk of serious

medical issues, such as blood clots, stroke, and uterine cancer. Patients taking

aromatase inhibitors may experience bone or joint pain, and are at increased risk for

thinning of the bones (osteopenia/osteoporosis). Patients taking aromatase inhibitors

should have yearly bone density testing, and may require treatment for bone thinning.

Biologic Therapy:The pathologist also examines the tumour for the presence of HER-

2/neu over-expression. HER-2/neu is a receptor that some BCas express. A compound

called Herceptin (or Trastuzumab) is a substance that blocks this receptor and helps

stop the BCa from growing. Patients with tumours that express HER-2/neu may benefit

from Herceptin, and this should be discussed with a medical oncologist when the

treatment plan is being decided.

Follow-up testing: Once a patient has been treated for BCa, she needs to be closely

followed for a recurrence. At first, the health professional shall have follow-up visits

every 3-4 months. The longer one is free of disease, the less often one would have to go

for check-ups. After 5 years, the client could see the doctor once a year. The client

should have a mammogram of the treated and untreated breasts every year. Because

lxxx

having had BCa is a risk factor for getting it again, having mammograms done every

year is extremely important. If the client is on Tamoxifen, it is important that a pelvic

examination is carried out each year and any abnormal vaginal bleeding is reported to

the oncologist.

Coping with Cancer: There is absolute need to educate cancer patients to cope with

cancer, side effects, nutrition, general cancer support issues, grief/end of life issues, and

shared survivors’ experiences. This becomes imperative in the present situation of our

nation, as Nigeria lacks an established national mammography screening program.

Problems of impeded access to health care, ignorance of the disease, poverty,

disempowerment of women and a general lack of health education complicate matters

as the incidence of cancer among women increase. These are further buttressed by the

results of the study conducted by Okobia, Bunker, Okonofua, and Osime (2006), where

the practice of breast self examination (BSE) was low; only 43.2% admitted to carrying

out the procedure within a year; and only 91(9.1%) had clinical breast examination

(CBE) within the year.

Concept of Reverend Sisters

From the very beginning of the Church, and according to St. Jerome’s biblical

commentary (1975), as well as Vatican Council 11 (1985), there were men and women

who set out to follow Christ more closely with greater liberty and imitate him more

closely and ardently, by practicing the evangelical councils. They led lives dedicated to

God each in his/her own way. Many of them under the inspiration of the Holy Spirit

became hermits or founded religious families. These, the Church by virtue of her

authority, gladly accepted and approved after much prayers, interrogations and

lxxxi

screening. Thus, in keeping with the divine purpose, a wonderful variety of religious

communities of men and women came into existence. This has significantly contributed

towards enabling the church, not merely to be for every good work (2Tim. 3:17) and to

be prepared for work of the ministry unto the building up of the body of Christ (Eph.

4:12), but also to appear adorned with the manifold gifts of her children, like a bride

adorned for her husband (Apoc.21:2), and to manifest in herself, the multiform wisdom

of God (Eph.3:10).

Amidst such a great variety of gifts however, all those who are called by God to the

practice of the evangelical councils and who make faithful profession of them, bind

themselves to the Lord in a special way. They follow Christ who virginal and poor

(Mat.8:20; Lk. 9:58), redeemed and sanctified men by obedience unto death on the

cross (Phil.2:8). Under the impulse of love (agape), which the Holy Spirit pours into

their hearts (Rom.5:5), they live more and more for Christ and for his body, the church

(Col.1:24). The more fervently, therefore, they join themselves to Christ by this gift of

their whole life, the fuller does the church’s life become more vigorous, and fruitful its

apostolate, through the evangelical vows of chastity, poverty and obedience, lived in

communities and monasteries.

The sisters profess chastity for the sake of the kingdom of heaven, in line with the

gospel of St. Matthew (Mat. 19:22), which they must be esteemed as exceptional gift of

grace. It uniquely frees the heart of people (cf. 1Cor. 7:32-35), so that they come more

fervent in love for God and for all men. As such, it is special symbol of heavenly

benefits, and for the sisters, it is the most effective means of dedicating themselves

whole heartedly to the divine service and works of the apostolate. Thus, for all Christ

lxxxii

faithful, the reverend sisters recall that wonderful marriage made by God, which will be

fully manifested in the future age, in which the church has Christ as her only spouse.

The reverend sisters therefore, at pains to be faithful to what they have

professed/vowed, are encouraged to believe our Lord’s words and relying on God’s

help, they should not presume on their own strength. They should practice mortification

and custody of the senses. At the same time, they are not to neglect the natural means

which promotes health of mind and body. Hence, they should not be influenced by the

false doctrines which alleged that perfect continence is impossible or inimical to human

development and, by a kind of spiritual instinct, they should reject whatever endangers

chastity. Consequently, candidates ought not to go forward, nor should they be

admitted, to the profession of chastity, except after really adequate testing, and unless

they are sufficiently mature- chronologically, psychologically, and affectively.

Commitment to the other vows also demands high degree of socio-psycho-spiritual

maturity.

The sisters take the vow of voluntary poverty, in the footstep of Christ, which is the

symbol of Christ much highly esteemed, especially nowadays, of our technological and

materialistic world, when people, the youth in particular are crazy about acquiring

wealth. The sisters are encouraged to cultivate the virtue of poverty diligently and, if

need be, express it in new forms, which enables them to share in the poverty of Christ

who for our sake became poor, though he was rich, so that we might be enriched

through his poverty (cf. 2Cor 8:9:Mt. 8:20).

lxxxiii

It is not enough that the sisters are subject to superiors in the practice of the evangelical

vow of poverty. They should be poor in fact and in spirit, having their treasure in

heaven (Mat.6:20). They willingly contribute part of what they possess for other needs

of the church, and for the support of the poor, whom all reverend sisters should love

with deep yearning for Christ (Mat.19:21).

The sisters similarly, by their profession of obedience, offer full dedication of their own

wills as a sacrifice of themselves to God, and by so doing, they are united more closely

and permanently and securely with God’s saving will. Following the model of Jesus

Christ, who came to do his father’s will (Jn.4:34;30; Heb.10:17; Ps.39:9), and “taking

the form of a servant” (Phil.2:7) learned obedience through what he suffered (cf.

Heb.10:8), the sisters, moved by the Holy Spirit subject themselves in faith to those

who hold God’s place, their superiors. Through them, they are led to serve humanity in

Christ, just as Christ ministered to his brothers in submission to the father and he laid

down his life for redemption of many (cf.Mt.20:28;Jn.10:14-18). They are thus bound

more closely to the church’s service, and they endeavour to attain the measure of the

stature of the fullness of Christ (Eph.4:13).

The sisters therefore, are humbly submissive to their superiors, in a spirit of faith and of

love, of, God’s will. They are required to bring their powers of intellect and will and

their gifts of nature and grace to bear on the execution of commands and on the fullness

for the fulfilment of tasks laid upon them, realizing that they are contributing towards

the building up of the body of Christ, according to God’s plan. In this way, far from

lowering the dignity of human person, religious obedience leads to maturity by

lxxxiv

extending the wisdom of the children of God, expressed in their living and sharing

things in common.

The sisters common life, in prayer and the sharing of the same spirit (Acts.2:42), should

be constant, after the example of the early church (Christians), in which the company of

believers were of one heart and one soul. This is be nourished by the teaching of the

gospel and by sacred liturgy, especially by the Eucharist. As members of Christ sisters

live together as sisters and should give pride of place to one another in esteem

(Rom.12:10), carrying one another’s burden (Gal.16:12). The sisters communities when

gathered and lived as a true family in the Lord’s name, enjoys his presence through the

love of God, poured into their hearts by the Holy Spirit (Rom.5:5). For love sums up the

law (Rom.13:10), and it is the bond which has crossed over from death to life (1Jn.314).

Indeed, the unity of the brethren, is a symbol of coming of Christ (Jn.13:35;1:21), and is

a greater apostolic power.

Summarily, reverend sisters are consecrated women who fall into two major categories

of contemplative religious and active religious. The contemplatives live in monasteries

while their active counterparts live in community houses, all popularly known as

convents, both being characterized by their devoted prayer life, community-living,

taking of the evangelical vows of chastity, poverty and obedience. Each group of sisters

has an Abbeys or a Superior General respectively whom each member loyal to. Some of

the active religious congregations have three tiers of government, namely: Central

administration, Regional and Local administrations. The contemplative sisters

commonly referred to as nuns in Nigeria further take a fourth vow of stability, so that

while a sister from any of the active congregations can be posted to any of their

lxxxv

communities at short or long intervals, the contemplatives most often than not live and

die in a particular monastery where the sisters were primarily located. Hence, the reason

for taking a fourth vow of stability.

The rising trend in BCa incidence is the same among reverend sisters despite the

paucity of literature that target them. The fact that they are not used to publishing

information on their health status informs the reason for dearth of literature.

Nonetheless, based on anecdotal information, observation, oral communication from

other reverend sisters during conferences, seminars, and workshops devoid of cancer

topics, the researcher noted an uncomfortable high incidence of BCa among the

reverend sisters as they would always comment and clamour that there should be

workshops centred on cancer prevention, to detect it early so that more sisters would

not fall prey to the dreadful condition.

Baseline reports on current level of the sisters’ knowledge and early detective health

behaviours towards BCa would be vital to an effective awareness program, and optimal

health behaviour achievement. It is surprising to note that in spite of the awareness that

has been created on radio, television, newspapers, magazines and so on, on the essence

of engaging in early detection practices for BCa, late presentation of cases at advanced

stage when little or no benefit could be derived from any form of therapy has remained

the hallmark of BCa in Nigerian women, of which the reverend sisters are among, and

the researcher is one of them. This informed the researcher’s interest in the area.

Theoretical review

Health Belief Model

lxxxvi

Analysis of this study was based on the broad theoretical review of Health Promotion

Models, with particular use of Health Belief Model, propounded by Kurt Lewin, and

further developed by Rosenstock in the 1950’s. According to Smeltzer, Bare, Hinkle,

and Cheever (2007), several health promotion models identify health- protecting

behaviours and seek to explain what makes people engage in preventive health

behaviours. Any behaviour performed by people, regardless of their actual or perceived

health condition, with the aim of promoting or maintaining their health, whether or not

the behaviour produces the desired outcome, is a health protecting behaviour (Keleher,

Mac- Doughall & Murphy, 2007).

There is the “Resource Model of Preventive Health Behaviour”, which is yet another

model that addresses the ways in which people utilize resources to promote health

(Keleher, Mac-Dough, & Murphy, 2007). This model can be used by nurse educators to

assess how demographic variables, health behaviours, and social and health resources

influence health promotion of clients and patients under their care. The researcher

employed the health belief model for more appropriateness to the study.

The Health Belief Model (HBM) was designed to foster understanding of why some

healthy people choose actions to prevent illness while others do not. The HBM was

adopted in this study to aid understanding of major issues concerning the utilization of

BCa preventive health behaviours/screening guide; and to prevent BCa adverse effects

among reverend sisters. In other words, the model will help understand some of the

factors that are at play with early detection practices.

There was also a HBM developed by Becker and colleagues in 1974 which is based on

the premise that four variables influence the choice and utilization of health promotion

behaviours (Smeltzer, Bare, Hinkle, & Cheever, 2010). The first variable is

lxxxvii

demographic and disease factors, which include patient characteristics like age, gender,

education, employment, severity of illness or disability, and duration of illness. The

second variable is barriers which embraces factors leading to unavailability or difficulty

in gaining access to a specific health promotion alternative. Resources, the third

variable encompass factors like financial and social support from friends and relations.

The fourth variable is perceptual factors, which comprise how individuals view their

health status, self-efficacy, and the perceived demands of illness. Becker and colleagues

demonstrated that the above four variables have positive correlation with a person’s

quality of life.

The HBM by Rosenstock, attempts to explain preventive health behaviours, particularly

in relation to utilization of health services such as the BCa screening programme. It

addresses individuals’ perceptions of the threat posed by a health problem

(susceptibility, severity), the benefits of avoiding the threat, and factors influencing the

decision to act (barriers, cues to action and self-efficacy). Simply put, the authors

adduced that peoples’ beliefs about whether or not they are susceptible to disease and

their perceptions of the benefits of trying to avoid it, influence very much their

readiness to act. This Model which consists of six constructs is adopted for the purpose

of the work under study.

Constructs of the Model:There are six main constructs that influence people’s

decisions about whether to take action, to prevent, screen for, and control illness. In

order words, people are ready to act if they believe: they are susceptible to the condition

(perceived susceptibility); the condition has serious consequences (perceived severity);

taking action would reduce their susceptibility to the condition or its severity (perceived

benefits); cost/s of taking action (perceived barriers) are out-weighed by the benefits;

lxxxviii

are exposed to factors that promote action (eg. radio/television) and or a reminder from

one’s physician/nurse to get service (Cue to action); and are confident in their ability to

successfully perform an action (self-efficacy).

It is imperative to note that personal susceptibility to disease condition varies from

person to person. This is also dependent on the level of knowledge about the health

problem –the modifying factors, including the demographic, socio-psychological and

structural variables. The modifying factors impinge on the level of knowledge and also

awaken or subdue threat to ta ke recommended action. Modifying factors enable

the individual to evaluate the outcome expected in relation to the constraints. Where the

benefits clearly out-weigh the constraints, the individual is motivated to take

recommended action/s. Individuals must be able to recognize certain important cues

that prompt them to take necessary action/s (National Institute of Health, 2005).

Breast cancer early preventive health behaviours, as a preventive/screening programme

often identifies people who are at risk for BCa and its complications but who took ill.

They may not initiate care early or adhere to instructions for any follow-up. According

to HBM, in settings for instance where the sisters believe that going for BCa screening

is not necessary, they may not adequately utilize the services or follow a specified

pattern, not to mention taking action. Unless in situations where the sisters perceive

themselves as prone to developing some complications of BCa (perceived

susceptibility). They must understand that complications can lead to disabilities such as

severe pain, image disfigurement, psychological and social trauma, anaemia or even,

death (perceived severity).

Early detection through engaging in early detective practices, reporting any

abnormalities in the breast, and positive outcome of early detection will reduce the risks

lxxxix

(perceived benefits) without negative outcomes or excessive difficulty (perceived

barriers). Advice from significant others , for instance, spiritual directors, health care

providers, friends or neighbours, including print and electronic media materials and so

forth might encourage reverend sisters to consistently seek for detective measures

( Cues to action ). For those sisters who have experienced previous complications, a

behavioural contact might help dispel fears of recurrence and so build confidence (self-

efficacy)

The other factors that may determine an individual’s likelihood of utilizing BCa early

detection health behaviours will depend on modifying variables like age, state of life,

educational attainment, access to care, finance, religion, social class, knowledge about

BCa and possible outcomes and so on, as well as availability, and accessibility of

screening services, and friendly attitude of caregivers. It is also important to note that

some sisters may have a high perception about the benefits of the early detection

practices and are equally willing to take action but such factors as high cost of services,

like mammography and ultrasound, long trekking, transportation, and long waiting

(accessibility), time etc, may hinder the likelihood of their taking action. Hence, if the

sisters know that as nulliparous women in particular that they are susceptible to BCa,

they would undoubtedly adhere to the early detection practices of either BSE; CBE or

mammography, which will help detect early breast changes for prompt medico-nursing

interventions. Again, if they are aware of the severity of late diagnosis of BCa, they

would adopt cost-free practices. Moreover, awareness of the benefits of early detection

practices undoubtedly motivates all women who are interested in health promotion to

adopt the measures afore mentioned.

xc

Though Nigeria is regrettably home to only a few medical professionals with expertise

in cancer diagnosis and treatments, the above factors should not pose serious obstacles

to the subjects because every reverend sister is entitled to and has the right to receive

bio-physio-psycho-medical and spiritual attentions. Granted, according to a

Consultative Committee on National Cancer Control (2004), most surgeries in Nigeria

are performed by surgeons whose primary

clinical practice is not oncology

Figure I:Conceptual model for the study

Empirical Review

A number of literatures relate to the topic of study were available to the researcher and

include the following studies:

Studies on Knowledge of breast cancerand its early detection measures

Oluwatosinand Oladepo (2006) carried out a descriptive survey study among rural

women in Akinyele Local Government Area, Ibadan, using a self-structured validated

questionnaire administered to 420 women randomly selected. The various aspects of

facts about breast cancer were assessed in two randomly selected health districts in the

area, scored together so as to determine respondents’ level of knowledge. The results of

xci

Modifying Factors:Demographic variables: Age, marital status, qualification, location, occupation, &years of experience.Socio-psychological variables: sociallity, set/group, personality, etc.Structural variables: knowledge about BCa and the possible outcome, knowledge about BCa preventive health behaviours, and prior contact with persons who practiced the preventive health behaviours (PHB )

Perceived benefits of PHB: Regular use of the screening guide, positive outcome of the usePerceived constraints: costs, resources spent to get to service centers for CBE and mammography, ultrsonography etc

Likelihood of taking recommended action: Availability of BCa screening service, free/subsidized services, cordial providers’ behaviour, Accessibility & affordability of services.

Perceived Threat:Fear of dying sequel to outcome of BCa, or related complications.

Adoption of BCa PHBs/screening guide: For early detect of BCa.

Perceived succeptibility: Belief that she is vulnerable to BCa related implications, belief that BCa involve some risks.Perceived severity: Feeling that BCa related conditions has short or long lasting. undesirable effects.

Cue to action/s: Advice from health care providers, significant others, friends or neighbours. Mass media campaign e.g. GSM, radio and TV programs. Posters, bill boards, handbills, especially during pink month (i.e. October) for mammography.

the study revealed that the mean score of knowledge of breast cancer was 55.4, SD 5.4

(range of scores obtainable was 26–78), while the mean score for knowledge of early

detection of breast cancer was 24.8, SD 2.3 (range of scores obtainable was 12–36). The

leading source of information about breast cancer was "elders, neighbours and friends"

and 63(15.4%) acknowledged this source, while only 18 (4.4%) respondents

acknowledged health workers as source. Only 54 (13.3%) claimed to have heard about

breast self- examination (BSE) however, and the leading source of information about

BSE were health workers. Nine (2.2%) of the respondents claimed this source. This

study revealed that respondents lacked knowledge of vital issues about breast cancer

and early detection measures. It also revealed that health workers were not forthcoming

with information to the public thereby constituting a challenge to community health

nurses and other health workers, to provide vital information to the public.

Adebamowo and Ajayi (2006) carried out a descriptive study on the incidence of breast

cancer in Nigeria using a structured questionnaire. The mean age of the respondents

was 37.4 (S.D. 12.5) years. 212 (52%) identified that the cause of breast cancer is

unknown. 300 (73.7%) of the respondents claimed that they did not know any warning

signs. Onlyeight(1.9 %) identified that a painless lump could be a warning sign of

breast cancer. Twenty six (6.4%) acknowledged swelling, only one person (0.2%)

acknowledged breast skin changes, two (0.5%) acknowledged discharge from the

nipples and another four (1%) considered nipple retraction as a warning signs of breast

cancer. Other signs identified by one respondent each were fever, purities, cold, weight

loss and presence of a wound. While six respondents (1.5%) identified pain as an early

warning sign of breast cancer. Three hundred and forty three (90.7%) of the

respondents did not know anything about treatment of breast cancer. Eighteen (4.8%)

xcii

identified use of drugs (hormone replacement/chemotherapy), two (0.5%)

acknowledged surgery and one respondent identified the combination of chemotherapy,

surgery and radiotherapy. More than half of the respondents 224 (55.2%) however

agreed that early treatment of breast cancer might prevent death while 15 (3.7%) did not

support that early treatment may prevent death. One hundred and sixty seven (41%)

claimed that they did not know. The overall mean knowledge score was 55.4 SD, 5.4.

The range of the scores was 34 – 70.

Further findings revealed that there was no significant difference in the mean

knowledge scores across age groups p = 0.2. However, the lowest mean knowledge

score of 54.4, SD 4.8 was recorded among the 51– 60 years age group while the highest

mean knowledge score of 55.9 SD 5.9 was recorded among the 41– 50 years age

group.There was also no significant difference in the mean knowledge score across

educational groups p = 0.2.

On the knowledge of early detection measures of breast cancer, the respondents

identified various measures that are not within the conventional methods of early

detection measures. These include breast cleanliness, washing the nipples regularly, and

traditional care among others. However, only 26 (6.4%) identified BSE while only 5

(1.2%) identified clinical breast examination and none identified mammography as an

early detection measures. Only 58 (14.3%) of the respondents knew that BSE should be

performed 2–3 days after menstruation monthly, and 43 (10.6%) knew that women who

have reached menopause were expected to choose a specific day of the month to

perform BSE. 49 (12%) were aware of the three processes involved in BSE, that is,

standing in front of a mirror to examine the breasts, lying down and while bathing.

Twenty two (5.4%) acknowledged that women who are thin have the advantage of

xciii

detecting breast lump easily while, 33 (8.1%) agreed that it is more difficult for fat

women to detect breast lump. Only 53 (13%) agreed that younger women (< 50 years)

discover breast lump than the older women. The overall mean score was 24.8 SD 2.3

out of a minimum score of 16 and a maximum of 36.

The result on practice of early detection measures, three hundred and ninety four

responded to the question: "Have you ever examined your breast for early detection of

breast cancer?" Three hundred and fifty one (89.1%) said NO, while only 43(10.9%)

said "YES". However, only 26 (6.4%) claimed to have examined their breasts by

themselves, eight (2%) claimed to have been examined by health workers, two (0.5%)

by their mothers, three (0.7%) by their mothers in-law, another three (0.7%) by their

husbands, and one (0.2%) was examined by a friend. In response to the question: "how

many times in a month do you perform breast self examination?" majority of the

respondents, 323 (79.4%) acknowledged that they did not practice BSE. None

examined their breasts once a month. One participant (0.2%), claimed to examine her

breast six times a month. Another five (1.2%) acknowledged examining their breasts

eight times a month, while 66 (16.2%) could not remember how many times a month

they examined their breast.

Three hundred and forty nine (85.7%) of the respondents claimed to have heard about

breast cancer but only 54 (13.3%) claimed to have heard about BSE. Respondents'

leading source of information about breast cancer was "elders, neighbours and friends",

sixty three (15.4%) acknowledged this source. Twenty two (5.4%) acknowledged

television and radio, 21(5.2%) acknowledged getting information from those that had

the disease while only 18 (4.4%) acknowledged health workers as their source of

information. However, the leading source of information about BSE was health

xciv

workers, nine (2.2%) of respondents claimed this source while two (0.5%),

acknowledged television/radio and one (0.2%) claimed "elders neighbours and friends"

and another acknowledged the questionnaire as the first source of information.

In a similar descriptive study carried out by Obaji, Elom, Agwu, Nwigwe and Ezeonum

(2011), to determine the awareness and practice of BNSE in Abakiliki using238 women

aged between20 and 65, following the administration of questionnaire, documented that

only 38.9%; 13.1%; and 13% have heard about BSE, CBE n=and mammography

respectively. Performance of BES was known by only 23.9%, 21.5 were said to have

carried out while 4.0% knew the correct frequency of performing BSE, the same

percentage did it regularly. They therefore concluded that there was low level of

awreness of BSE among the market women, suggesting the need to increase awareness

through campaign.

As reported by Avei and Gozum (2009) in their cross-sectional study carried out in

Ondokus University, Turkey to compare the effects of different educational methods on

the beliefs and behaviours related to the practice of early diagnosis of breast cancer,

using 93 female. Instrument used for the study was questionnaire. There were two

groups of teachers, model and video groups. After the education of the video group,

susceptibility, perceived self-efficacy of BSE was 92%. The model group showed

improvement in their ability to perform BSE, recording 92%. It was observed that thetre

was no difference between the beliefs of both groups. They concluded that both video

and model methods of education were effective in changing health beliefs in respect of

breast cancer screening and the same level of increasing knowledge and practice of

BSE.

xcv

In yet another descriptive cross-sectional study (Cadvar, Akpoleu, Ozbas, Oztekin, and

Ayogu, 2010) which was carried out in Florence Nightingale College of Nursing,

Istanbul, University,Turkey, to determine the female physicians and nurses practice and

attitude towards BSE using 201 female nurses and 149 female physicians, using

questionnaire as the instrument, it was documented that both the female nurses and

female physicians have 100% knowledge of BSE but majority (83%) do not practice it.

It was therefore strongly recommended that the respondents need to improve their

sensitivity regarding BSE so as to improve and maintain their professional roles.

Another descriptive cross-sectional study that examined the of knowledge of breast

cancer, attitude towards BSE and practice among 410 women from 7 health centres in

Treran, Iraq, Hayi-Mahmood (2008), documented that (63%) of the women believed

that it is difficult and time consuming or troublesome; 72% knew how to examine their

breasts but only 6% perform monthly BSE.

In the study carried out by departments of Histology and Gynaecology and Obstetrics,

School of Medicine, Zahedan University of Medical Sciences, Iran, identified the

knowledge of women about breast cancer screening. In the study, 384 women were

selected, their knowledge was investigated through face-to face interview based on a

purposed questionnaire, and data were analysed using descriptive and analytic statistics.

Only 8.3% of women were aware of breast cancer screening methods. About BSE,

21.6% know about mammography, 3.4% had good knowledge.Overall knowledge of

breast cancer screening was insufficient in 67.4%. Only 4.5% of the women performed

BSE on a regular basis, 4.1% had CBE, and 1.3% had a mammography throughout their

life. The findings suggest that knowledge and practice about breast cancer screening

was relatively poor and it needs to be improved.

xcvi

The result of a study in Nigeria about knowledge of women on the breast cancer guide

indicated that education and employment in professional jobs significantly influenced

knowledge of breast cancer screening. Those women with greater than high schools and

those in professional jobs had significantly higher knowledge scores compared with

those in smaller businesses. The result suggests that community dwelling women in

Nigeria have rather poor knowledge of the breast cancer. This may explain the late

presentation seen in over 70% of women with the disease. A mean knowledge score of

42.33% with only 22.9% scoring 50.0% and above portray the abysmal level of

ignorance about risk factors and common symptoms of breast cancer in Nigeria women

(Okobia, Bunker, Okonofua &Osime, 2006). In the same study the practice of breast

self examination was low as only 43.2% of the respondents admitted to have carried out

the procedure within a year, and only 91 (9.1%) had clinical breast examination within

the year.

In developed countries, which have regular programmes for cancer screening, practice

of women could be improved.(Shirazi, 2006), examined screening participation of

women aged 30 years and older. The study showed that screening rates for clinical

breast examinations and mammography among the participants in the study were

higher.

Salaudeen, Akande and Musa (2009) carried out a descriptive cross-sectional and

epidemiological study on knowledge and attitudes towards breast cancer and breast self

examination. The study was conducted at the University of Ilorin Kwara State

Polytechnic, in Northern Nigeria. Seven hundred and forty participants were recruited

for the study. Systematic random sampling technique was adopted for subject selection.

Self administered questionnaire was used as the data instrument. Findings showed that

xcvii

200 (28.6%) had poor knowledge about the cause of breast cancer, 243 (34.7%) had fair

knowledge while 257(36.7%) had good knowledge of the cause of cancer of the breast.

Two hundred and eighty nine (41.3%) of the respondents scored poor, 145 (20.7%)

scored fair and 266 (38.0%) had good knowledge about the age of occurrence of breast

cancer. On symptoms of breast cancer, fifty nine (8.4%) had poor knowledge, three

hundred and twenty three (46.1%) had fair knowledge and three hundred and eighteen

(45.5%) had good knowledge of symptoms of cancer of the breast.

Assessment and scoring of respondents on treatment options available for patients with

breast cancer was done. Ninety-five (13.6%) respondents had poor knowledge, one

hundred and forty seven (21.0%) had fair knowledge and four hundred and fifty eight

(65.4%) had good knowledge of treatment modalities available for patients with breast

cancer. Four hundred and ninety-five respondents (70.7%) knew that there are warning

signs of breast cancer, one hundred and sixty-one (23.0%) did not know, while forty-

four (6.3%) mentioned that there are no warning signs of breast cancer. On the first

source of information about breast self examination 165 (23.6%) respondents

mentioned television,105 (15.0%) mentioned print media and 130 (18.6%) identified

health workers as first source of information on breast self examination. One hundred

and twenty eight respondents (18.2%) mentioned radio and 45 (6.5%) identified friends

as first source of information on breast self examination. Many respondents knew that

one of the thing to look for during breast self examination is the presence of lump in the

breast, this was the view expressed by 447 (63.8%) respondents. Two hundred and

seventy-two (38.9%) respondents mentioned changes in the nipple as one of the things

to look for during breast self examination. Checking the size of the breast and

xcviii

discolouration were mentioned bytwo hundred and sixty-two (37.4%) and two hundred

and sixty-seven (38.1%) respondents respectively.

Result of the study showed that participants had poor knowledge of breast cancer. Mean

knowledge score was 42.3% and only 214 participants (21.4%) knew that breast cancer

presents commonly as a painless breast lump. Practice of breast self examination (BSE)

was low; only 432 participants (43.2%) admitted to carrying out the procedure in the

past year. Only 91 study participants (9.1%) had clinical breast examination (CBE) in

the past year. Women with higher level of education (X2 = 80.66, p < 0.0001) and those

employed in professional jobs (X2 = 47.11, p < 0.0001) were significantly more

knowledgeable about breast cancer. Participants with higher level of education were 3.6

times more likely to practice BSE (Odds ratio [OR] = 3.56, 95% Confidence interval

[CI] 2.58–4.92).Participant's knowledge about symptoms of breast cancer was rather

poor. Only 214 participants (21.4%) knew that breast cancer presents commonly as a

painless breast lump. Fewer participants were able to respond correctly to questions on

non-lump symptoms of breast cancer such as pain in the breast, nipple discharge, and

ulceration of the nipple. In terms of methods of diagnosis, only 432 participants

(43.2%) were able to correctly identify breast self-examination (BSE) as a method for

detection of breast cancer. A very small proportion of study participants indicated

mammography as enhancing in early detection of breast cancer. Four hundred and

fourteen participants (41.4%) correctly noted that breast cancer is curable when

detected early.

There was an indication of positive medical help-seeking behaviour as majority of

participants indicated visiting the doctor as the best approach to breast cancer care.

Only 82 (8.2%) indicated visiting alternative health practitioners for breast cancer care.

xcix

In terms of practice, only 349 participants (34.9%) practice BSE. The source of

information about BSE was from the doctors' offices in 91 participants (21.1%), leaflets

in 117 (27.1%), televisions in 134 (31.0%), churches/religious organizations in 35

(8.1%), feminist organizations in 29 participants (6.7%) and Nigerian Cancer Society

programs in 26 participants (6.0%). Only 91 participants (9.1%) had clinical breast

examination (CBE) in the past year. The main reasons advanced for not having clinical

breast examination (CBE) include not having a breast problem in majority of the

participants (568, 62.5%) and being unaware of the need for CBE in 293 participants

(32.2%).

The mean score of the participants was rather low (42.3% ± 12.3). Only 229

participants (22.9%) scored 50.0% and above. Performance was found to be

significantly related to level of education and occupation. Among 739 participants with

complete information on education and knowledge scores, we found that majority of the

participants with primary school education (163 [84.9%]) scored below 50.0%. Two

hundred and eighty-one participants (76.6%) with secondary education had scores

below 50%. Of those with NCE/Polytechnic education, 47.3% scored below 50.0%

while 43.8% of those with University education had scores below 50.0%. Chi square

test showed a significant relationship between education and level of performance (X2 =

80.66, p < 0.0001). Although age was not significantly related to scores, we found that

older women appear to have higher scores compared with younger women. Forty

percent of women aged 50 years and above compared with 35.5% of those aged 40–49

years and 28.4% of those below the age of 40 years scored 50.0% and above (X2 = 3.23,

p = 0.12). Religion was not significantly related to scores.

c

In a descriptive study, conducted byOluwole(2008) on the Awareness, Knowledge and

Practice of Breast-Self Examination amongstFemale Health Workers at Federal

Medical Centre, Owo, Ondo State, Nigeria. 100 health workers practicing in the

hospital were selected by simple random sampling and interviewed with the aidof

structured questionnaire. The result of the study revealed that most respondents (94%)

were aware of breast-self examination. Some of them (30%)knew the different methods

for screening for breast cancer, however most of them (56%) knew thatbreast-self

examination should be performed monthly. Majority of the respondents (80%) practiced

breast-self examination even though only some (50%) practiced it monthly, while

(11.25%) practiced it quarterly.Majority (56%) of the respondents knew thatBSE should

be carried out on a monthly basiswhile the remaining (44%) did not know.18(22.5%)

practiced it every six months andthe remaining ones practiced it occasionally:8(10%)

and annually: 5(6.25%). The main identified barriers to practiceof BSE according to the

researcher were lack of information (40%) andforgetfulness (26%).Majority of the

respondents(92%) consideredBSE effective.Lack of information (41.2%); do not see the

need (9.3); anxiety (9.3%); absence of symptoms (6.2%) and pressure of work (2.%),

and not convinced about effectiveness (2.1%). Only 30% had breast examination done

by amedical doctor while the rest (70%) never hadclinical breast examination.Very few

respondents (10%) admitted tohistory of benign breast disease while themajority (90%)

did not.Only three of the respondents admitted tofamily history of breast cancer.Sources

of information about breast-self examinationlectures (54%);19% throughtheir

colleagues. Others include: media, internet, books, family members and friends.

Empowering female health workersand creating awareness amongst them couldgo a

long way in enhancing the screeningprogram for breast cancer. Prevention

ci

oridentification of breast cancer at an earlystage is of paramount importance in

savinglives as well as improving the quality of life.Breast cancer lends itself to early

detectionand subsequent early treatment if women useearly detection measures.

The three screening methods recommendedfor breast cancer include breast-self

examination (BSE), clinical breastexamination (CBE) and mammography.Although the

role of regular BSE has beendebated, it can nevertheless be utilized inenhancing breast

cancer awareness amongwomen. In fact regular BSE has beensuggested as part of

overall health promotionconcept. The practice of BSE can helpwomen to know the

structure and compositionof their normal breast thereby enhancing theirsensitivity to

detect any abnormality at theearliest time.BSE once a month contributes to a

woman’sheightened awareness of what is normal forher(Larkin, 2001).

In a cross sectional descriptive survey that assessed the knowledge, attitude and practice

of breast self examination (BSE) among university female nursing undergraduates, was

carried out by Okolie (2012). The study also identified the factors that affected the

students practice of BSE. The total population of the female students was 200. The

instrument used for data collection was questionnaire and descriptive statistics were

used to summarize the data. A good number of the respondents had good knowledge of

breast cancer and BSE as 84% knew that it has familial tendencies and 77% knew it can

be caused by oral contraceptives. They also knew the symptoms such as discharge from

the nipple (92%), change in the skin of the breast (80%), pain in the breast (80%) and

swelling in the breast (68%). Majority (90%) knew about mammography and BSE

(90%) as detection methods. Majority of the respondents (95%) knew how to do BSE,

while 5% did not know how to do BSE. The respondents had a positive attitude towards

BSE (Overall Mean ≥ 2.5). Most of the respondents (32%) affirmed that they examine

cii

their breasts after menstruation and (68%) anytime they felt like. Respondents identified

forgetfulness, procrastination, laziness, lack of time, fear of discovering a lump, no trust

in their practice ability as factors affecting their practice of BSE.

The study further revealed that 76.53% thought breast cancer was caused by oral

contraceptives, 83.69% said it runs in the blood, 45.92% felt it was caused by smoking,

44.39% opted for obesity, 33.67% sexual promiscuity, 25.51% for alcohol, 23.98% for

putting money in the bra, 21.94% for blow to the breast. 25.51% attributed it to spiritual

causes, 6.12% to germs and 76.53% gave other reasons like exposure to radiation,

idiopathic, e.t.c. Additionalfindings also revealed that breast cancer manifests as

change or discharge from the nipple (91.84%), 80.10% as change in the skin of the

breast, 79.59%, as pain in the breast, 68.37% as swelling of the breast, 63.78% as ulcers

of the breast, 17.86% as fever, 4.08% as headache, 2.04% as cough and 9.69% said it

can manifest with symptoms like peau ‘d range, retraction, fixed tender lump in the

skin, e.t.c

Majority, 91.84% knew about mammography as detection method, 90.31% opted for

BSE, and 64.80%, clinical examination. Majority of the respondents (95%) believed

they knew how to do BSE, while 15% admitted not knowing how to do BSE. With an

Overall Mean of 2.6335, which was greater than 2.5, the respondents had a positive

attitude towards BSE as shown in Table 3. Table 4 revealed that majority (92.35%) of

the respondents had examined their breasts, while 7.65% had never examined their

breasts.

Among those that had never examined their breasts, 60% did not feel it is necessary,

while 40% said they did not have time. Sixty-two percent of the respondents examined

their breasts some days after menstruation, 32.14% did not have any particular time for

ciii

examining their breasts, 4.08% examined their breasts during menstruation and 3.57%

before menstruation. Majority (54.60%) examined their breast anytime they felt like,

33.67%, once a month.

In a cross-sectional study conducted using 250 respondents whose data were collected

using a self administrated questionnaire by Al-Dubai, Qureshi, Saif-Ali, Ganasegeran,

Alwan, and Hadi (2011) on Awareness and knowledge of breast cancer and

mammography among a group of Malasian women in Shah Alam revealed that majority

of the women had heard about breast cancer (81.2%) and indicated books, magazines

and brochures as their source of information (55.2%). However, most did not know

about signs and symptoms of breast cancer and many of its risk factors. On multivariate

analysis, significant predictors of breast cancer knowledge were age, race, marital

status, level of education, occupation, family size and family history of other cancers

(p<0.05). 50% of the women were aware of mammography, significant predictors being

age, occupation, marital status and knowledge of breast cancer (p<0.05). Following the

above findings, the researchers concluded that most women were aware of breast

cancer. However, the knowledge about signs and symptoms of breast cancer and

awareness of mammography were inadequate. It is recommended that the level of

knowledge should be raised among Malaysian women, particularly in the young and

less educated women.

In a similar study, by Gwarzo, Sabitu and Idris (2009) in Ahmadu Bello University

Zaria, they assessed the knowledge and practice of BSE among female students of the

university aged 16-28, using self-structure questionnaire, made the following findings:

87% of the respondents have heard about BSE but 72% practice it, while only 19.0% civ

perform BSE monthly. Media and health workers, 45.5% and 32% respectively were

their sources of information. The researchers documented that disparity exists between

high levels of knowledge of BSE when compared with a low level of regular practice.

They maintained that public health education via the media would reduce the

knowledge practice-gap and early detection of lump significantly. Dolar, Brikanath,

Kulkarni, and Karanakar (2012), in their cross-sectional study on assessing the

knowledge, attitude and practice (KAP) of BSE, using 203 female students in India

concluded that there is a significant correlation between knowledge and attitude (p is

less than 0.05).

Somdatta and Baridalyne (2008), studied women of an urban resettlement colony in

South Delhi, India, a community based, cross-sectional study, using a semi- structured

interview schedule to collect information, reported that a total of 333 women were

studied. Only 51% knew about at least one of the signs /symptoms, and only 35%

mentioned about risk factors, 53% were aware that breast cancer can be detected early.

Thus, awareness about breast cancer is low amongst women in this community. The

researchers identified the need for awareness generation programs to educate women

about breast cancer, propagation of correct messages and promote early detection of

breast cancer. Further findings showed that on kknowledge of signs and symptoms, out

of 185 participants who were aware of breast cancer as disease, 51% of them mentioned

at least one of the signs/symptoms of breast cancer. Though 79 women (42%) knew that

a lump is an early symptom, only 5% knew that painless lump is a symptom of breast

cancer. 41% of them identified pain as a symptom. Only 13 women (7%) mentioned

nipple discharge, and another 1.6% identified skin changes. Fever, itching, weight loss,

breast abscess, and presence of breast ulcer were equally identified. On knowledge

cv

about risk factors,only 35% of the women mentioned any of the risk factors of breast

cancerr. 4.9% mentioned advancing age as a risk factor, while 6.5% believed that risk is

more at younger age. 8% on believed that taking oral contraceptive can cause breast

cancer irrespective of the duration of intake. 24% women believed that breast feeding

protects against breast cancer while 5 women thought breast feeding is a risk factor.

Obesity and excessive intake of fat were also identified. Interestingly, 20 % of the

participants believed that trauma to the breast whilefeeding leads to breast cancer.

Findings on knowledge about early detection methods revealed that fifty three percent

of the participants (n=98) were aware that breast cancer can be detected early. Almost

half of them (n=96) said that it could only be detected by a doctor. Though 11% of the

women were aware of breast self-examination, and only two of them have ever done

breast self-examination. These two women have a history of surgical lump removal.

However, none of them do it on a regular basis. Five women have had clinical breast

examination done when they experienced some pain in the breast. Only six women

knew about early detection by mammography. Knowledge about preventive measures

shows that seventeen women mentioned regular check-up by a doctor; others said that

breast cleanliness, washing nipples regularly, and not wearing underwear (brassier) can

prevent breast cancer. On the sourceof information, television is the most common

medium through which women heard about breast cancer. Other sources of knowledge

were neighbors and relatives (41%), hospital staff (19%), print media (9%) and radio

(3%).

Summary of reviewed literature

Available and related literatures to this study were succinctly reviewed from the

conceptual, theoretical and empirical viewpoints. The conceptual perspective dealt cvi

directly with the conceptual review of cancer and breast cancer; stagging and grading of

breast cancer;risk factors; cancer warning signs; manifestations of breast

cancer;epidemiology of breast cancer; breast cancer screening guide/ early detective

measures /preventive health behaviours; and management of breast cancer were given

detailed attention in the review as evidenced by the works of (Oluwole, 2008);

Adebamowo and Ajayi (2006); Shirazi;Oluwatosinand Oladepo (2006); and Somdatta

and Baridalyne (2008)).

Highlighted in the review were also the factors that influence the practice of breast self

examination which include: Age; educational status; socio-economic background;

personal issues;environmental factors; cultural; and religious belief system.The

reviewed works of Smeltzer, Bare, Hinkle, and Cheever (2010)emphasized that during

the life-span, various tissues normally undergo periods of rapid or proliferative growth

which must be distinguished from malignant growth activity.

The theoretical framework dealt directly with theoritical models pertinent to the study,

namely: Resource Model of Preventive Health Behaviour,and Health Belief Model

which has six constructs that influence people’s decisions about whether to take action

to prevent, screen for and control illness. This last model was adopted for the study on

account of its appropriateness to the study. The model centres on the fact that peoples’

belief about whether or not they are susceptible to disease and their perceptions of

benefits of trying to avoid it, influence their readiness to act.

Some indirect empirical studies on aspects of breast cancer were as well reviewed. The

review revealed the fact that most studies except those of Oluwole (2008);

Shirazi,Oluwatosinand Oladepo (2006);Somdatta and Baridalyne (2008),underscored

the essence of assessing the women’s knowledge towards breast cancer in areas like the

cvii

concept, causes, warning signs, detective measures, practice of detection measures and

so on. The need for women to utilize all available early detection measures- breast self-

examination, clinical breast examination, and mammography was brought out clearly

by Wall, Munez-Rocha, Ana, Martinez and Pena (2008). On their part, Adejumo and

Adejumo (2009) assert that ultrasound and breast magnetic resonance imaging are

equally good detection measures of breast cancer. Biopsies are also very useful in

confirming cancer of the breast (Smeltzer, Bare, Hinkle, & Cheever, 2010).

No study was found to be carried out on reverend sisters’ knowledge about breast

cancer, and early detection practices. This shows that the need to assess

sisters’knowledge of the concept, causes, warning signs, detective measures, early

detection practices and so on has been played down or at best has not been

highlighted.Hence, the researcher is poised to bridge this gap, given the fact that the

researcher is equally directly involved.

CHAPTER THREE

RESEARCH METHODS

cviii

This chapter deals with the general method and procedure which the researcher used in

the study and it includes: design of the study; area of the study; population of the study;

sample size; sampling techniques; instrument for data collection; validity of the

instrument; reliability of the instrument; procedure for data collection; and, method of

data analysis.

Research design

The design adopted for the study was a cross-sectional descriptive survey design. This

is considered appropriate because the data for the study was collected at a point in time

from a sample to represent the larger population of the entire sisters in the state.

According to Polit and Beck (2008), a cross-sectional design is one in which data are

collected at one point in time, sometimes used to infer change over time when data are

collected from different age or developmental group. The design has the ability to

describe an existing practice and reveals areas that need change. It as well yields current

and prevailing information about the situation under study.

Area of study

The research was carried out in Anambra state, within the three Catholic Dioceses of

Awka, Nnewi, and Onitsha Archdiocese, with Awka as its capital. The land mass of the

state is approximated at 4815km2. The state has boundaries in the South with Delta

state, North with Enugu state, East with Abia state, and West with Imo state. According

to records from the state Ministry of Health, Anambra state, the population and

number of local government areas are five million, forty six thousand, eight hundred

and seventeen (5046817), and twenty one (21) respectively.

There are various congregations of reverend sisters who belong to different

congregations spread through the State. These include: Immaculate Heart of Mary cix

Mother of Christ (IHM); Daughters of Mary Mother of Mercy (DMMM); Daughters of

Divine Love (DDL); Handmaid of the Holy Child Jesus (HHCJ); Clarissan Missionary

Sisters of the Blessed Sacrament CMSBS; Holy Family Sisters of the Needy (HFSN);

Missionary Sisters of the Holy Rosary (MSHR); Daughters of St. Joseph (DSJ); St.

Scholastica Benedictine Abbey (SSBA); Sisters of Jesus the Saviour (SJS); and Queen

of Peace Benedictine Monastery (QPBM). These reverend sisters live a community life

(for specified congregational members) in secluded areas or institutes called

communities or convents. These communities are sited both in rural and urban areas.

Some of these communities do not have access to good road and health facilities.

Population forstudy

The study population comprised all reverend sisters of the various congregations living

in communities located in Anambra state. According to the National Directory of

Association of Nigeria Conference of Women Religious (2012), the total number of

reverend sisters living in Anambra state at the time of the study was 794. The

population therefore is 794 reverend sisters. The distribution of these reverend sisters

according to their congregations is shown inTable 1below:

Sample

Power analysis was used to estimate the sample size needed for the study so as to

ensure statistical conclusion validity. Creative Research System Software was used,

applying the following formula:

ss= Z 2* (p) * (1-p)

C2

WhereZ= Z value (e.g. 1.96 for 95% confidence level)

P percentage picking a choice, expressed as decimal

cx

(.5 used for sample size needed)

C= confidence interval, expressed as decimal

(e.g., .04= ±4)

ssCorrection for finite population: new ss = 1+ ss – 1

popwhere pop= population

At 95% Confidence and 5.0% margin of error, a sample size of 259 was used. As data

was collected directly from the study subjects, it was anticipated that as many as 20% of

the sisters may default/drop out from the study which could be as a result of, failure to

complete the questionnaire, and incorrect information in the sampling list. The 20%

therefore takes care of the possibility of respondents dropping out of the study. With the

formular: q= n/1-f (where q is the adjusted sample size; n is the original sample size,

and, f is the estimated non- response rate) (ANGEL,n.d.), sample size estimate will be

adjusted from 259 to 259/(1- 0.2). The adjusted sample size isthus, 324. This represents

about 40.8% of the population. Then 40.8% of each congregation was studied as shown

in table 2 below:

Table 1:Sample distribution of Sisters from various congregationsS/N Name of Congregations No. of Srs. 40.8% of Srs.

1 Immaculate Heart of Mary Mother of Christ (IHM)

324 132

2 Daughters of Mary Mother of Mercy (DMMM) 75 313 Daughters of Divine Love (DDL) 108 444 Handmaid of the Holy Child Jesus (HHCJ) 55 225 Clarissan Missionary Sisters of the Blessed

Sacrament CMSBS46 19

6 Holy Family Sisters (HFSN) 34 14

cxi

7 Missionary Sisters of the Holy Rosary (MSHR) 8 38 Daughters of St. Joseph (DSJ) 23 99 St. Scholastica Benedictine Abbey (SSBA) 91 3710 Sisters of Jesus the Saviour (SJS) 6 211 Queen of Peace Benedictine Monastery (QPBM) 27 11

TOTAL 794 324Source: National Association of Nigeria Conference of Women Religious, 2012.

Sampling procedures

A combination of stratified, proportionate and convenient sampling techniques, were

employed to draw 324 reverend sisters into the study. The population was stratified

according to the respondents’ congregations, then, 40.8% equivalence of each stratum

(congregation) was selected using convenient and proportionate sampling techniques.

This technique is appropriate because it is definite and target oriented (age 20–70

years), and does not involve giving equal opportunity to the participants in target

population. Therefore, all the reverend sisters within the age bracket who were willing

to participate in the study were selected. Hence, participation was voluntary.

Inclusion criteria include:

All reverend sisters in Anambra state aged between 20 to 70 years, because this

age brackets are actively living in the communities.

All reverend sisters willing to participate in the study.

Instrument for data collection

Data were collected using a set of self-developed instrument having the same content.

The questionnaire contains seventeen items in two (2) sections, all in close-ended

format. Section A centred on demographic data having five items while Section B has

cxii

twelve items, all which were used to collect data on the respondents’ knowledge of BCa

and their measures for early detection of the disease.

Validity of the Instrument

The instrument was subjected to face and content validity. The researcher’s supervisor

and other experts from the Department of Nursing Sciences, University of Nigeria,

Enugu Campus were requested to vet the items of the instrument. Also experts in

Maternal and Child Health Nursing from Department of Nursing Sciences, University

of Ibadan participated in validating the instrument. The above experts were asked to

assess the instrument in terms of relevance to the research questions, accuracy,

coverage of the content areas, and clarity of purpose and to assess the appropriateness

of language usage of each item for the level of study.

Reliability of the instrument

Reliability of the instrument was ascertained by administering thirty-two copies of it to

thirty-two reverend sisters resident in convents in Delta State. The percentage scores of

responses for each section of the instrument were subjected to split-half reliability test.

The items were split into two, on odd numbers and even numbers bases. A Correlation

Coefficient of 0.88 was obtained, using Pearson’s Product Moment Correlation Co-

efficient, meaning the instrument was very reliable.

Ethical consideration

The researcher approached the respective Regional Superiors of the different

congregations to give official permission for the sisters to participate in the study.

During their regional meetings, the questionnaire was administered to the individual

sisters. At this meeting, the objective and study protocol were explained to the study

participants and verbal informed consent was obtained, emphasizing their right to

cxiii

decide to participate or not. They were assured that anonymity of subjects is

guaranteed. Ethical clearance was obtained from the Ethical Committee of Nnamdi

Azikiwe Teaching Hospital, Nnewi (cf. Appendix C) prior to commencement of this

study.

Procedure for Data Collection

With the introductory letter from the Department (cf. Appendix B), and the researcher’s

personal contacts through phone calls and face to face discussions, the researcher

approached the respective Regional Superiors of the different active congregationswho

gave official permission for the sisters to participate in the study. Through the local

superiors, the questionnaire was administered to the individual sisters during their

general meetings/tridium, to avoid concentrating distribution of the questionnaire to

particular regions/communities.The conservative sisters were reached in their respective

monasteries through each Abbes. The researcher administered the instrument directly to

the respondents with the help of three trained preceptors (research assistants), and the

superiors, using the self–developed validated questionnaire. At this meeting, the

objectives and study protocol wereexplained to the study participants,emphasizing their

right to decide to participate or not. Their verbal informed consent was obtained. The

various aspects of facts about BCa were scored and added together to determine

respondents’ knowledge on BCa and early detection measures towards the condition.

Direct administration of the instrument afforded the researcher the opportunity for

clarification where necessary. With the above approach, the researcher enjoyed

maximum cooperation of the participating sisters. Hence, the 324 questionnaire were

returned, showing a return rate of 100%, which is very satisfactory. The data collection

lasted for two weeks.

cxiv

Method of Data Analysis

At the end of the data collection, descriptive statistics including frequencies (f) and

percentages were used to present the data. Percentages were calculated based on the

proportion of individual responses against each group size. Unpaired t-test was used to

compare the responses of the two groups. All statistical analyses were performed using

the Graph Pad Prism version 5.03 bio-statistical software package. The results were

presented in Tables and Figures.

CHAPTER FOUR

PRESENTATION OF RESULTS

This chapter dealt with analysis of data and presentation of results guided by the

research objectives.

Table 2: Socio- demographic characteristics of the respondentscxv

Socio- demographic variables

Active (276, 85.2%)

Contemplative(48, 14.8%)

Total(324)

f(%) f(%) f(%)Age group (years)

20 – 49 205(74.3) 32(66.7) 237(73.1) 50 – 70 71(25.7) 16(33.3) 87(26.9)

Academic qualification

Graduates 151(54.7) 6(12.5) 157(48.5) Non-graduates 125(45.3 42(87.5) 167(51.5)

Type of job Health related 82(29.7) 11(18.8) 91(28.1)Non-health related 194(70.3) 39(81.2) 233(71.9)

Location Urban 139(50.4) 13(27.1) 152(46.9)Rural 137(49.6) 35(72.9) 172(53.1)

Of the 324 reverend sisters that participated the study, 85.2% (276) were active, while

only 14.8% (48) were contemplative. Of these, as many as 237 (73.1%) were aged 20 –

49 years. This age proportion was also reflected on both active and contemplative

groups. Active respondents aged 20 – 49 were as many as 205 (74.3%), only 71

(25.7%) were aged 50 – 70 years. The contemplatives within the age of 20 – 49 were 32

(66.7), the rest 33.3% were aged 50 – 70. The proportion of graduates (157) was close

to that of non-graduates (167) among them. However, only 12.5% (6) of the

contemplatives were graduates against 54.7% (151) of the active that were graduates.

Only 91 (28.1%) of the respondents had health-related jobs, out of which 82 (29.7%)

were active and 11 (18.8%) were contemplative. Majority of the sisters (172, that is,

53.1%) lived in rural areas. Of the 48 contemplatives, only 13 (27.1%) lived in urban

areas, while the rest 35 (72.9%) lived in the rural setting. For the active, however, the

distribution was almost equal – 139 (50.4%) and 137 (49.6%) lived in urban and rural

areas respectively.

Objective 1: To ascertain what the two categories of the Reverend sisters know as

BCa.

Item 6 was used for this objective.

Table 3: What BCa means to the respondents (n = 324)cxvi

Meaning of BCaActive (276)

Contemplatives (48)

Total (324)

f(%) f(%) f(%)Poisonous boil in the breast 107(38.8 19(39.6) 126(38.9)Accumulation of dead breast tissue 56(20.3) 12(25.0) 68(21.0)Uncontrolled multiplication of breast tissue 58(21.0) 3(6.2) 61(18.8)Enlargement of the breast due to much intake of fatty food 16(5.8) 1(2.1) 17(5.2)No idea 39(14.1) 13(27.1) 52(16.0)Unpaired t test resultT 0.9481Df 8P value 0.3708>p0.05NB: Percentage was calculated based on proportion of the groups

Many of the respondents, 126(38.9%) described BCa as a poisonous boil in the breast, a

view shared equally by the active (38.8%) and the contemplatives (39.6%). This

similarity in opinion was almost shared for description of BCa as accumulation of dead

breast tissue (active = 20.3%; contemplative = 25.0%). Only 61 (18.8%) of the sisters

described it as uncontrolled multiplication of breast tissue, more (58) of whom were the

active. Only 16 (5.8%) active reverend sisters and 1 (2.1%) contemplatives said it is

enlargement of the breast due to much intake of fatty food. As many as 52 (16.0%) of

the respondents had no idea of what BCa is. Unpaired t-test of the responses among the

two groups at 8 degrees of freedom showed no significant difference in the conception

of BCa among them (p value = 0.3708>0.05).

Objective 2: To ascertain what they attribute as causes/risk factors of BCa.

Items 7 and 8 were used for this objective

Table 4: BCa risk causes/factors identified by the respondents

Breast cancer risk factors/causes

Active (276)

Contemplatives (48)

Total (324)

f(%) f(%) f(%)Eating of infected or contaminated food 64(23.2) 16(33.3) 80(24.7)Excessive use of cosmetics 64(23.2) 15(31.2) 79(24.4)Cancer of the breast run in the family 62(22.5) 6(12.5) 72(22.2)

cxvii

Too much exposure to sunlight 39(14.1) 8(16.7) 47(14.5)There is no known cause 48(17.4) 8(16.7) 56(17.3)Frequent exposure to electricity 26(9.4) 5(10.4) 31(9.6)Breast cancer is infectious 19(6.9) 6(12.5) 25(7.7)Not giving birth, or having children after age 30 17(6.2) 3(6.3) 20(6.2)Prolonged breast feeding 1 ½ - 2 years 12(4.3) 5(10.4) 17(5.2)Drinking of alcohol to a very high level 43(15.6) 13(27.1) 56(17.3)Being over-weight or obese 19(6.9) 5(10.4) 24(7.4)Lack of physical activity 27(9.8) 7(14.6) 34(10.5)High fat and low intake of fibres, fruits & Vegetables 47(17.0) 12(25.0) 59(18.2)Use of anti-perspirants 47(17.0) 13(27.1) 60(18.5)Wearing of bras 9(3.3) 5(10.4) 14(4.3)Smoking may increase the risk of BCa 59(21.4) 16(33.3) 75(23.1)Night work with electric light 14(5.1) 4(8.3) 18(5.6)Using oral contraceptives 63(22.8) 13(27.1) 76(23.6)Using combine hormone therapy after menopause 41(14.9) 5(10.4) 46(14.2)Chemicals found in plastics like plastic bottles, PVC pipes and in coating of canned food 101(36.6) 27(56.3) 128(39.5)Breast implants 50(18.1) 9(18.8) 59(18.2)Certain chemicals in the environment 74(26.8) 19(39.6) 93(28.7)

Unpaired t test resultT 1.610Df 42P value 0.1148>p0.05

There was a wide variation in responses on the risk factors/causes of BCa. Except for

cancer arising from chemicals found in plastics like plastic bottles, PVC pipes and in

coating of canned food which 128 (39%) and certain chemicals in the environment, 93

(28.7%), the rest of the options were identified by less that 25% of the subjects as

contributing to cancer development. Only 14 (4.3%) said it could be caused by wearing

of bras. Similarly, 17 (5.2%), 18 (5.6%), 20 (6.2%), and 24 (7.4%), attributed BCa

occurrence to prolonged breast feeding 1½ - 2 years, night work with electric light, not

giving birth, or having children after age 30, and being over-weight or obese

respectively. Twenty-five (7.7%) of them said that BCa is infectious. However, more of

the contemplatives appeared to identify majority of the factors as attributing to cancer

cxviii

development than the active, although with marginal differences in many of the items.

For instance, more contemplatives identified chemicals found in plastics like plastic

bottles, PVC pipes and in coating of canned food (56.3%) and certain chemicals in the

environment (39.6%) as factors that expose one to risk of cancer against 36.6% and

26.8% respectively of the active. Generally, there was no significant difference in risk

factors/causes identified by the two groups as the unpaired t-test result at df = 42, tcal =

1.610, tcrit = 0.1148>p0.05.

Figure ii: Responses on whether women who had prolonged exposure to ovarian

hormone have high risk of developing BCa

Result of test of knowledge on whether women who had prolonged exposure to ovarian

hormone have high risk of developing BCa showed that more respondents from the

active group (45.3%) than from the contemplatives (31.2%) were in agreement.

Objective 3:To identify the early warning signs of BCa identified by respondents.

Item 9 was used for this objective.

Table 5: Early warning signs of BCa identified by respondentscxix

Early warning signsActive (276)

Contemplatives (48)

Total (324)

f(%) f(%) f(%)Painless lump 119(43.1) 22(45.8) 141(43.5)Swelling in the breast with pain 49(17.7) 9(18.8) 58(17.9)Skin changes 27(9.8) 3(6.3) 30(9.3)Discharge from the nipple 52(18.8) 9(18.8) 61(18.8)Nipple retraction 23(8.3) 1(2.1) 24(7.4)Fever 8(2.9) 1(2.1) 9(2.8)Weight loss 11(4.0) 1(2.1) 12(3.7)Not aware of any early warning sign/s 12(4.3) 16(33.3) 28(8.6)

Unpaired t test resultT 0.3334Df 14P value 0.7438>p0.05

Early warning signs of BCa mostly identified by the respondents is painless lump in the

breast (141, 43.5%); 58 (17.9%) said that this swelling is painful. However, 61 (18.8%)

said early stage of cancer of the breast is characterised by discharge from the nipple.

Only 9 (2.8%) said that fever occurs at early cancer state. One (2.1%) sister in the

contemplative group each said it is characterized by nipple retraction, fever, and weight

loss while their counterparts in the active group were 23 (8.3%), 8 (2.9%), and 11

(4.0%) respectively. Twenty-eight respondents were not aware of any early warning

signs/symptom of which as many as 16 (33.3%) were contemplatives, and 12 (4.3%)

were from the active group. Comparatively, both active and contemplative reverent

sisters hold similar opinions as analysis showed relatively same proportions in their

responses. Again, t-test comparison of the responses showed no difference (tcal =0.3334,

tcrit = 0.7438>p0.05).

Objective 4: To ascertain what the reverend sisters know as the early detection

measures of BCa.

cxx

Items 10 – 12 were used for this objective

Figure III: What breast examination means to the respondents

Many of the respondents 137 (42.3%) expressed that breast examination is a test to

detect early signs of BCa. Eighty-two (25.3%) said it is breast care expected of every

woman from 20 years of age. Twenty-nine (9.0%) said it simply involves looking at the

breast every day. Few, 31 (9.6%), were not aware of breast examination. The responses

of both active and contemplative reverend sisters on this were relatively the same

(figure III). Unpaired t-test of the responses at df = 10 was tcrit = 0.8608>p0.05 (tcal =

0.1799). There was, therefore, no significant difference in what the two groups

understood as breast examination.

ii:The early detection practices the respondents know:

Item 11 was used for aspect of the objective

Table 6: The BCa early detection measures respondents knowBreast cancer early detection practices

Active (276) Contemplatives (48)

Total (324)

cxxi

f(%) f(%) f(%)Breast self examination 117(42.4 24(50) 141(43.5)Simple X- ray of the breast 57(20.7) 10(20.8) 67(20.7)Mammography 63(22.8) 4(8.3) 67(20.7)Ultra-sound scanning 38(13.8) 9(18.8) 47(14.5)Magnetic Resonance Imaging (MRI) 18(6.5) 4(8.3) 22(6.8)Computerized Tomography (CT) 24(8.7) 4(8.3) 28(8.6)Breast tissue biopsy 37(13.4) 6(12.5) 43(13.3)Clinical breast examination 84(30.4) 16(33.3) 100(30.9)No idea 28(10.1) 16(33.3) 44(13.6)Surgical/incision biopsy 17(6.2) 5(10.4) 22(6.8)

Unpaired t test resultT 0.4832Df 18P value 0.6348>p0.05

Most popular BCa early detection practices among this group of women was breast self

examination identified by 141 (43.5%) of them, followed by 100 (30.9%) that identified

clinical breast examination. The least identified early detection measures among the

respondents were MRI and surgical/incision biopsy with 22 (6.8%) each. Although 67

(20.7%) each identified simple x-ray of the breast and mammography, more

respondents in the active group 63 (22.8%) than in the contemplative identified

mammography. Forty four (13.6%) had no idea of any BCa early detection measures.

The rest had similar proportionate values for both groups; hence the unpaired t-test

result at p=0.05 and df = 18 showed no significant difference among the groups (tcal

=0.4832, tcrit = 0.6348>p0.05)

Objective 5: To ascertain how BCa can be prevented as perceived by the reverend

sisters.

Item 12 was used for this objective.

Table 7: BCa preventive measures respondents know

cxxii

Breast cancer preventive measures

Active (276)

Contemplatives (48)

Total (324)

f(%) f(%) f(%)Genetic counselling especially in women with history of BCa 125(45.3) 11(22.9) 136(42.0)Increasing intake of vegetables especially those with cabbage 100(36.2) 15(31.2) 115(35.5)Intake of high fibre diets like fruits and whole grain 113(40.9) 17(35.4) 130(40.1)Reduced intake of dietary fats and smoked meats or fish 71(25.7) 9(18.8) 80(24.7)Maintaining a normal body weight and avoiding obesity 83(30.1) 6(12.5) 89(27.5)Use of certain drugs called chemo-preventive agents for some years 69(25.0) 3(6.2) 72(22.2)Breastfeeding for not more than a year to maintain endogenous oestrogen 19(6.9) 1(2.1) 20(6.2)Avoiding oral contraceptives and prolonged oestrogen replacement therapy (ORT) 102(37.0) 5(10.7) 107(33.0)Having children before age 30 48(17.4) 2(4.2) 50(15.4)

Unpaired t test resultT 2.367Df 16P value 0.0309*NB: *The scores are statistically significantly different (P < 0.05)

Most common preventive measure known to the respondents is genetic counselling

especially in women with history of BCa with 136 (42.0%). This was followed closely

by 130 (40.1%) that indicated intake of high fibre diets like fruits and whole grain, 115

(35.5%) for increasing intake of vegetables especially those with cabbage and avoiding

oral contraceptives and prolonged oestrogen replacement therapy, 107 (33.0%). Only

6.2% (20) indicated that breastfeeding for not more than a year to maintain endogenous

oestrogen would prevent BCa. It appears that more respondents in the active group

know the preventive measures than those in the contemplatives, as is observed in the

items. Result of unpaired t-test showed a significant difference in the knowledge of BCa

preventive measures among the respondents – at p=0.05 and df = 16, the tcal = 2.367, tcrit

= 0.0309. cxxiii

Objective 6: To identify reverend sisters’ sources of knowledge on BCa.

Item 13 was used for this objective.

Table 8: Respondents’ sources of information

Sources of information

Active (276)

Contemplatives (48)

Total (324)

f(%) f(%) f(%)Through friends/relations 207(75.0) 5(10.4) 212(65.4)Read about it in books 92(33.3) 13(27.1) 105(32.4)Media (newspaper, radio, television) 63(22.8) 8(16.7) 71(21.9)Taught in school as part of a course content

86(31.2) 5(10.4) 91(28.1)

Read about it in the internet 35(12.7) 3(6.2) 38(11.7)At seminars and conferences 81(29.3) 5(10.4) 86(25.5)

Unpaired t test resultT 2.235Df 10P value 0.0494*NB: *The scores are statistically significantly different (P < 0.05)Common sources of knowledge about BCa and its prevention was from friends and

relations as reported by 212 (65.4%). Respondents in the active group seemed to know

about cancer through this 75% (207) more than the contemplatives 10.4% (5). Other

sources (though less popular) include books 105 (32.4%), taught in school as part of a

course content 91 (28.1%) and through seminars and conferences 86 (25.5%). There is

statistically significant difference in the sources of knowledge about BCa among the

active and contemplative groups (at = 0.05 and df = 10, tcal = 2.235, tcrit = 0.0494).

Objective 7: To find out how early detection measures are practiced by the reverend

sisters.

Items 14 and 16were used for this objective.

Item 16 was used for this objective.

Table 9: Technique of practicingearly BCa detection measures

cxxiv

How breast examination is done

Active (276)

Contempla-tives (48)

Total (324)

f(%) f(%) f(%)Standing/sitting in front of a mirror to look for abnormalities 191(69.2) 27(56.2) 218(67.3)Pressing deep on area where I feel discomfort 66(23.9) 11(22.9) 77(23.8)Pressing the entire breasts deeply one after another while standing or sitting to feel for pain 71(25.7) 14(29.2) 85(26.2)Pressing lightly on the breast to feel for abnormal thickness or pain while standing or lying down 46(16.7) 7(14.6) 53(16.4)Pressing lightly on the breast with wet soapy hand in the bathroom to feel for lump or abnormal thickness 37(13.4) 6(12.5) 43(13.3)By pressing the nipples to detect any secretion 23(8.3) 4(8.3) 27(8.3)Go to hospital for breast examination when I feel something is wrong

53(19.2) 9(18.8) 62(19.1)

Unpaired t test resultT 0.1903Df 12P value 0.8523>p0.05

Most of the reverend sisters 218 (67.3%) would stand or sit in front of a mirror to look

for abnormalities like inequality, skin colour change, dimpling or unusual enlargement

in the breast. For those who would touch the breasts to examine them, 85 (26.2%) said

they press the entire breasts deeply one after another while standing or sitting to feel for

pain; 77 (23.8%) also press deep but only on areas where they feel discomfort; 53

(16.4%) press lightly on the breast to feel for abnormal thickness or pain while standing

or lying down; and 43 (13.3%) press lightly on the breast with wet soapy hand in the

bathroom to feel for lump or abnormal thickness. Only 27 (8.3%) would press the

nipples to detect any secretion. However, 19.1% (62) said they would go to hospital for

breast examination when they feel something is wrong. Unpaired t-test of responses by

the two groups showed no difference among them as the tcal = 0.1903,and tcrit at df = 12

was 0.3012>p0.05. Thus, responses to individual items by the groups were similar for

each.

cxxv

Table 10: Respondents timing for breast self-examination

Timing for breast self-examination is done

Active (276)

Contemplatives (48)

Total (324)

f(%) f(%) f(%)Any time but once in a month 76 (27.5) 12(25.0) 88(27.2)Within the first week after menstrual period 45(16.3) 7(14.6) 52(16.0)Within the first two week after menstrual period 28(10.1) 6(12.5) 34(10.5)Once every two weeks 17(6.2) 3(6.3) 20(6.2)Once in a year 22(8.0) 4(8.3) 26(8.0)A week before another menstrual period 29(10.5) 5(10.4) 34(10.5)Once every three months 16(5.8) 4(8.3) 20(6.2)Never done 43(15.6) 7(14.6) 50(15.4)

Unpaired t test resultT 0.0389Df 14P value 0. 9695>p0.05

Timing for practice of breast self-examination seems to vary widely among the

reverend sisters. Eighty-eight (27.2%) of them would do it once in a month but at any

time they feel like doing such. However, 52 (16.0%) said they do it within the first

week after menstrual period. As many as 50 (15.4%) had never done breast self-

examination. Comparing the two groups, the distribution of values for the various items

was almost similar. The unpaired t-test of the responses showed no significant

difference (tcrit = 0.9695>p0.05).

Table 11: When respondents do clinical breast examination

When clinical breast examination is done

Active (276)

Contemplatives (48)

Total(324)

f(%) f(%) f(%)Only when sick and initiated by the care provider

10(3.6) 4(8.3) 14(4.3)

Once every month 37(13.4) 8(16.7) 45(13.9)Any time I suspect problem with my breast 43(15.6) 6(12.5) 49(15.1)Once a year 12(4.3) 3(6.2) 15(4.6)Every 3 years 34(12.3) 9(18.8) 43(13.3)Never done 140(50.7) 18(37.5) 158(48.8)

cxxvi

Unpaired t test resultT 0.9848Df 10P value 0.1947>p0.05

CBE seems not popular among this group of women because as many as 158 (48.8%)

said they had never done it, 140 (50.7%) were from the active group while 18 (37.5%)

were contemplatives. Among those that agreed having ever done it, 49 (15.1%) did so

when they suspect they had problem with their breast. For routine examination, 45

(13.9%) said they did it once every month while 43 (13.3%) said it was every three

years. There was no difference in the respondents’ practice of clinical breast

examination as unpaired t-test at = 0.05 and df = 10 was tcal = 0.9848, tcrit = 0.1947).

Objective 8: Toidentify the factors identified by the reverend sisters as militating

against their use of detective and preventive health behaviours

Item 17 was used for this objective

Table 12: Factors identified by respondents as militating against their use of detective and preventive health behaviours

Militating factors

Active (276)

Contemplatives (48)

Total (324)

f(%) f(%) f(%)Felt not within the age that needs the examination

21(7.6) 6(12.5) 27(8.3)

Financial constraint 52(18.8) 13(27.1 65(20.1)Time factor 30(10.9) 5(10.4) 35(10.8)It is not necessary 29(10.5) 7(14.6) 36(11.1)Difficulty accessing care due to one’s location 36(13.0) 9(18.7) 45(13.9)Afraid that lump may be detected, hence prefer to live in ignorance 57(20.6) 16(33.3 73(22.5)Forgetfulness 28(10.1) 7(14.6) 35(10.8)Religiously, not supposed to be involved in such

35(12.7) 7(14.6) 42(13.0)

cxxvii

Cultural abhors such practices 22(8.0) 5(10.4) 27(8.3)Not aware where the examination is done 117(42.4) 31(64.6) 148(45.7)

Unpaired t test resultT 1.064Df 18P value 0.3012>p0.05

The reasons for the respondents’ inability to engage themselves with BCa preventive

and detection practices abound and vary. As many as 148 (45.7%) were not aware of

where to obtain the services. Of these, 31 (64.6%) were the contemplatives while 117

(42.4%) were from the actives. Seventy-three (22.5%) avoid the detective practices

because they are afraid that lump may be detected, and as such preferred to live in

ignorance, while 65 (20.1%) were prevented from taking necessary actions due to

financial handicaps which affect more of the contemplatives (27.1%) than the actives

(18.8%). At df=18, the unpaired t-test result showed tcal = 1.064,and tcrit =

0.3012>p0.05, showing no significant difference between the two groups.

Summary of results

Only 61 (18.8%) of the sisters described BCa as uncontrolled multiplication of

breast tissue.

There was no significant difference in the conception of BCa among the two

groups.

There was no significant difference in risk factors/causes identified by the two

groups.

There was no significant difference in early warning signs of BCa identified by the

two groups.

There was no significant difference in what the two groups knew as breast

examination.

cxxviii

Most common preventive measure known to the respondents, especially the

activegroup, was genetic counselling.

There was significant difference in the knowledge of BCa preventive measures

among the respondents.

Common source of knowledge about BCa and its prevention was from friends and

relations.

There is statistically significant difference in the sources of knowledge about BCa

among the active and contemplative groups.

Most popular BCa early detection practices identified by these groups of women

was breast self examination; no significant difference among them.

Most of the reverend sisters (67.3%) would only look at their breast while standing

or sitting in front of a mirror to check for abnormalities.

There was no significant difference among them.

Timing for practice of breast self-examination varied widely among the reverend

sisters, but there was no significant difference among the group.

There was no difference in the respondents’ practice of clinical breast examination.

Many had never done clinical breast examination.

Many, (45.7%) were unable to engage themselves with BCa preventive and

detection practices because they were not aware of where to obtain the services.

CHAPTER FIVE

DISCUSSION OF FINDINGS

This chapter dealt with the discussion of the findings of the study. Report on the

findings were done under: discussion of the major findings, conclusions, implications of

the findings, recommendations, limitations of the study, suggestions for further studies,

and summary of the study.

Discussion of the major findingscxxix

Findings of the study were discussed covering: what the two categories of reverend

sisters understood as breast cancer; what they attribute as causes of breast cancer; their

understanding of early detection practices of breast cancer; early warning signs andhow

breast cancer can be prevented; their sources of knowledge; the breast cancer early

detection practices respondents know;the early detection measures they practice, how

and when they practice early detection measures; and factors identified as militating

against their use of detection and preventive health behaviours.

What the reverend sisters know as breast cancer

Result showed that out of the 324 reverend sisters, only 61 (18.8%) described breast

cancer as uncontrolled multiplication of breast tissue – an observation shared by both

groups; while the rest gave different meanings which, of course, were not actually

related to cancer description. The fact that as many as 126 of the respondents described

breast cancer as a poisonous boil in the breast and 52 without any idea of what breast

cancer is explains this the more. This was in line with the findings of abysmal level of

ignorance about risk factors and common symptoms of breast cancer among Nigeria

women by Okobia et al (2006). This was also corroborated by that of Oluwatosinand

Oladepo (2006) whose study revealed poor understanding of breast cancer by the

subjects. This could be so owing to the fact that the sisters before now were not

keen about their health status. They believe prayer can take care of most diseases,

and so aligned themselves more towards intensified prayer life and asceticism.

Lack of appropriate knowledge of this concept may increase their vulnerability because

they may likely not adopt necessary preventive health behaviours.

What the sisters attribute as risk factors/causes of breast cancer

cxxx

There was a wide variation of responses on the risk factors or causes of breast cancer

among the sisters, granted this was not dependent on the category. Although no

previous studies seemed to have dealt on this, it appears that the knowledge of

environmental factors’ causation of cancer is already widespread. This may imply that

public enlightenment programme on relationship between environment and incidence of

cancer has spread to even populations that live in seclusion. However, there is still need

for health education programmes on other factors such as night work with electric light,

and being over-weight or obese which these women are prone to.

More of the contemplatives appeared to identify majority of the factors as attributing to

cancer development than the active group of sisters, but with marginal differences in

many of the items. This finding was surprisingly opposed to the expected, considering

that there are higher percentages of active sisters who were graduates (54.7%) and those

with health related jobs (29.7%) than in the contemplatives (27.1% and 18.8%,

respectively). There is, therefore, need for further studies on why these groups with less

education would seem to have more knowledge than the better educated. Despite these

observations, there was no significant difference in risk factors/causes generally

identified by the two groups. This was at variance with Salaudeen et al (2009) where

majority of the respondents had good knowledge of the risk factors/cause of breast

cancer. On the other hand, it corroborates the finding of Okobia et al (2006) which

portrayed an abysmal level of ignorance about risk factors of breast cancer in Nigeria

women.

Early warning signs of breast cancer identified by the respondents

Findings of this study revealed that many of the respondents have some knowledge of

early warning signs of BCa. The sign mostly identified by the respondents was painless

cxxxi

lump in the breast (43.5%) which 17.9% said is painful. A good number also said that

early stage of this condition is characterised by discharge from the nipple. Contrary to

the finding of this study, Adebamowo and Ajayi (2006) reported in their study that

majority of their respondents did not know any BCa warning signs. However, in this

present study, 28 respondents (made up of 33.3% of the contemplatives and 4.3% of the

active sisters) were not aware of any early warning sign/symptom. Comparatively, both

the active and contemplative reverend sisters were in relatively same proportions for the

various responses. This variation could be linked to differences in the social

background and exposure of the individual reverend sisters.

Reverend sisters’ knowledge of early detection measures of BCa

Many of the reverend sisters said that breast examination is a test to detect early signs

of breast cancer, the most popular of which was breast self examination. This opinion

was held by both the active and contemplative reverend sisters. This reveals that the

active reverend sisters have no edge over the contemplatives despite the fact that they

are in closer contact with the society and should have had more opportunities to attend

workshops and conferences. However, the finding attests to the submission of Agonsi

(2010) which recorded that breast examination is a positive guide for early detection of

breast cancer as indicated by a good number of his subjects. The finding was also in

line with that of Somdatta and Baridalyne (2008) which revealed that fifty three percent

of the participants (n=98) were aware that breast cancer can be detected early through

appropriate detection measures.

It is encouraging to have observed that eighty-two (25.3%) respondents maintained that

breast examination is breast care expected of every woman from 20 years of age. The

cxxxii

knowledge of this will at least sensitize them of the need to seek or even personally

detect any breast changes and/or abnormalities. The 9.0% that said breast examination

simply involves looking at the breast every day and 9.6% who were not aware of breast

examination, though individually negligible they may seem, is worrisome. Agonsi

(2010) and Obaji et al (2011) also observed similar lack of awareness of breast

examination as BCa early detection measure. There is, perhaps, the need for further

public awareness campaign and teachings, not merely through talking but also with

practical illustrations on methods and steps involved in breast self examination. Also,

those who already know should be encouraged to share their knowledge with others

around them.

Early detection practices the respondents know: Breast self examination was the major

early detection practice the respondents know, as evidenced by the number that

identified this - 141 (43.5%). This was followed by clinical breast examination (30.9%).

In similar studies by Oluwatosin and Oladepo (2006) and Somdatta and Baridalyne

(2008) only 13.3% and 11% of their subjects respectively had heard about breast self-

examination, contrary to the present finding. Again, the above findings counter those

from the study carried out by the Departments of Histology and Gynaecology and

Obstetrics, School of Medicine, Zahedan University of Medical Sciences, Iran (2007)

which identified the knowledge of women about breast cancer screening, using 384 of

them, where only 8.3% of the women were aware of breast cancer screening methods.

Only 21.6% and 3.4% knew about breast-self examination and mammography

respectively.

cxxxiii

However, Cadvar et al (2010) discovered that all their respondents had knowledge of

BSE, though majority (83%) of them did not practice it. Forty-four (13.6%) respondents

had no idea of any breast cancer early detection measures.

The observation was however, in line with that of Oluwatosin and Oladepo (2006) who

recorded that as many as 89.1% never heard of any form of early detection practices of

breast cancer. The finding also tallies with the report of ACS (2007), which maintains

that BSE is the easiest and simplest procedure for detecting breast masses because a

woman who knows the texture, contour, and feel of her own breast is far more likely to

detect changes that may develop. Responses on specific early detection practices

obtained from both groups were relatively the same meaning that the knowledge of the

active and contemplative reverend sisters BCa early detection practice was about the

same.

The knowledge exhibited by the respondents from both groups in the present study is

satisfactory; their higher scores for breast self- examination, clinical examination, and

simple x-ray/mammography and low response rate on Magnetic Resonance

Imaging(MRI) and surgical/incision may be clue that they are aware that the last two

are secondary detection measures. Further studies are needed here.

Breast cancer preventive measures respondents know

The most common preventive measure known to the respondents is genetic counselling

especially in women with history of breast cancer as shown in table 6 where 136

(42.0%) made the observation. The above finding tallies with that of Adejumo and

Adejumo (2009), which noted that increased screening and risk identification of women

through genetic counselling would make for timely decision and so prevent breast

cxxxiv

cancer. Similarly, Agonsi (2010) noted that diet rich in fresh vegetables and fruits are

preventive measures of breast cancer.

The result of the present study revealed that more respondents in the active group know

the preventive measures more than those in the contemplative. This variance could be

attributed to the fact that the contemplatives are more prayer conscious than the active

group of sisters. Again, the contemplatives conventionally resign to God’s will and

providence and more often than not would not border about the much feared terminal

diseases. Their firm believe in the saying of St. Paul, ‘alive or dead we belong to God’,

plays active role in their not seeking preventive behaviours.

Respondents’ sources of knowledge on breast cancer

Friends and relations are the common sources of knowledge about breast cancer. This

finding is corroborated by Oluwatosin and Oladepo (2006), though they equally

reported health workers as a source. In the same vein, Adebamowo and Ajayi (2006)

recorded that their respondents' leading sources of information about breast cancer were

"elders, neighbours and friends", but also reported television and radio, from those that

had the disease, health workers, and questionnaire as their additional sources of

information. The reverend sisters appeared to be limited in their source of knowledge.

This could be linked to their secluded life pattern. Individual responses by the active

and contemplative groups serve as evidence for this suspicion. The active group of

sisters whose life pattern brings them closer to the larger society than the

contemplatives had wider sources of knowledge than the latter. Again, it appeared that

the reverend sisters who are health workers were not forthcoming with information to

their colleagues, hence, constituting a challenge to the health team, to provide vital

information to their colleague and the public at large. Education is power. The impact

cxxxv

of information and communication on behaviour change cannot be underplayed. The

educational programmes have the advantage of enlightening the respondents on

behaviour changes and benefits associated therein.

Other less popular sources of information were through books, taught in school as

course content and through seminars and conferences. Conversely, Salaude et al (2009)

in their study observed doctors' offices, leaflets, televisions, churches/religious

organizations, feminist organizations and Nigerian Cancer Society programs, as

sources. Granted, the researchers also observed that media, internet, and books were

also identified in their study. On their part, Al-Dubai et al (2011) corroborated with the

finding in relation to books as they reported in their study, that books, magazines and

brochures were sources of information on breast cancer.

The statistically significant difference that exists in the source of information about

breast cancer among the active and contemplative groups of sisters could be linked to

their area of residence and living pattern. The contemplatives live in strictly enclosed

monasteries with highly limited information reaching them. They do not avail

themselves to conferences and seminars as do their counterparts and a good number of

them leave their natural (biological) homes early in life, and so could not benefit from

friends and relations.

How respondents do breast examination

Except for standing or sitting in front of a mirror to look for abnormalities in the breast

which as many as 218 (67.3%) of the reverend sisters would do, it appeared that many

still were not sure what should be the correct practice for BSE; hence just few could go

as far as touching their breasts and pressing them deeply to examine them while

standing or sitting to feel for pain or lightly with wet soapy hand in the bathroom, to

cxxxvi

feel for lump or abnormal thickness. It is possible that fear may cause one to deviate

from this norm, hence 77 (23.8%) of them pressed deep on some areas of breast only

because they felt some discomfort therein. This later fact may also be reason for the

19.1% (62) who said they would go to hospital for breast examination when they feel

something is wrong. All hope is not lost after all, given the fact that a significant

number of the sisters attempt examining their breasts, though only 62 of them sought

clinical breast examination. Both groups of sisters will greatly improve on their skill if

exposed to a seminar or workshop on BCA early detection practices. Arranging a

formal education programme will also be beneficial to them.

Timing of BSE and CBE as early detection measures practiced by respondents: The

time early detection measures are practiced depends on the particular measure. For

BSE, the timing varied widely among the reverend sisters: 27.2% would do it once in a

month but at any time they feel like doing so, just as Oluwole (2008) and Okolie (2012)

observed. The finding aligns very much with the submission of Okobia et al (2006)

which documented that though as many as 72% of the subjects knew how to examine

their breasts, only 43.2% actually ever did it. Hayi-Mahmood (2008) and Somdatta and

Baridalyne (2008)also noted this. Only 16.0% said they do it within the first week after

menstrual period , while as many as 50 (15.4%) had never done breast self-examination.

This result clearly shows how much these group of women were uninformed about the

importance of BSE for BCa early detection, This alludes to the fact that both the active

and contemplative reverend sisters played laissez faire attitude towards BSE, either

because they do not have the interest/belief on importance of this exercise, or, the

services necessary for their awareness creation are not accessible to them. One may say

conclusively that the approach of the respondents is to some extent encouraging, but cxxxvii

there is still the need for specific programme on BSE so that the women would acquire

the required standard skills inherent in BSE.

Factors identified by respondents as militating against their use of detection and

preventive health behaviours

A number of reasons were identified by the respondents for not engaging themselves in

BCA prevention and detection practices. Ignorance was a major factor as an alarming

number 148 (45.7%) were not aware of where to obtain the services, a higher

percentage of which were the contemplatives. Fear of the unknown and approach-

avoidance principles may also have influenced the sisters’ decision not to avail

themselves for the various BCa detection and detection practices. As shown in the

result, 73 (22.5%) of the sisters avoided the detection measures because they were

afraid that lump might be detected and, as such, preferred to live in ignorance. Few

other respondents identified forgetfulness, time, finance, culture, difficulty accessing

guide, ignorance, age, the feeling that the exercise is not necessary and the fact that one

is a sister as factors militating against their use of detection and preventive health

behaviours. The finding was strengthened by the assertions of Adebomowo and Ajeyi

(2000)who opine that Nigeria remains ill-equipped to deal with the complexities of

meaning of cancer, and its detection and care, since the testing and care facilities are

still very few.

Most of the above findings especially forgetfulness, lack of time, fear of discovering a

lump are in consonance with the study reported by Okolie (2012), which was carried

out among undergraduate student nurses, except that, procrastination, laziness and lack

of trust in their ability were also identified by these students. In line with the findings

still, Salaude, Akinde and Musa (2009) reported that the main reasons advanced for not cxxxviii

having clinical breast examination include not being aware of the need for CBE, but in

contrast observed, ‘not having a breast problem’ as a serious barrier. The findings of the

study are also partially contrasted by the report of Oluwole (2008) who stated that aside

from forgetfulness and not seeing the need for any detection measures, lack of

information, anxiety, absence of symptoms, pressure of work, and not convinced about

effectiveness of detection measures, were identified obstacles. The findings of the study

disproved the report of Agonsi (2010) who highlighted that educational status;

environmental factors; and religious belief system were militating factors to BSE. In the

same vein, Hayi-Mahmood (2008), documented that though 72% of the subjects of

study knew how to examine their breasts, only 6% perform monthly BSE, while (63%)

believed that it is difficult and time consuming or troublesome.

It is really surprising that the above barriers should be associated with reverend sisters

who should be catered for holistically, and who should be imbibed with enough

knowledge for virtually every issue related to women in particular. In any case, one

may not forget the fact that lack of seriousness on non-spiritual activities and the desire

to appear modest and mortified could be playing a latent role unconsciously in the

sisters in this regard.

Conclusion

This study has shown that the reverend sisters in Anambra State have poor knowledge

about breast cancer and the early detection practices, including meaning; risk factors;

warning signs, or early detection practices. It is therefore imperative that realistic and

adequate awareness be created and the sisters educated through aggressive education

campaign programmes so as to eliminate misconceptions relating to the topic. During

the training programmes, emphasis should be laid on early warning signs, significance

cxxxix

of a painless lump, and correction of misconceptions. The information should be

disseminated through appropriate means to the elderly reverend sisters who may not be

able to attend the general programmes, such as taping, videoing and relaying same to

them at their convenient time and places/homes.

Implication of the study

The result of the study has provided empirical evidence with respect to the knowledge

of breast cancer and early detection practices among reverend sisters in Anambra State.

The study was able to reveal the reasons behind inadequate knowledge and

unsatisfactory utilization of breast cancer early detection practices among reverend

sisters. A significant number of the respondents observed that not being aware of where

to obtain the services was a factor to reckon with. Another factor identified was the fear

that a lump may be detected, and as such the sisters preferred to live in ignorance as

evidenced by the responses of many of the participants. Difficulty in accessing

measures/services was equally identified. The study also revealed that health workers

were not forthcoming with information to the public thereby constituting a challenge to

community health nurses and other health workers, to provide vital information to the

public.

In order that these problems be given desired attention, all stakeholders – Superiors

General; Regional Superiors; Health Coordinators, and in fact all policy makers should

be involved in addressing the problem accordingly; and, within the ambit of health

promotion, and health education, as well as the health belief model that is the

framework on which the study was anchored. Improvement and service delivery and

advocacy approaches could be employed in addressing the problem.

cxl

The health units of all the congregations need to embark on health education

programmes through conferences, seminars and workshops targeted at all sisters

irrespective of age, so as to allay fear and anxiety, and furnish them with the correct

meaning of the concept and everything inherent in it. Health professionals within the

individual congregations should be motivated to participate in the programmes. The

nurses in particular should be prepared always to educate and provide advice readily.

As a matter of seriousness, there should be evidence based policies backed by

appropriate legislation mandating sisters to be committed to the mapped out

programmes. There should be policy guidelines which should contain plans for training

and retraining all health workers with the aim of disseminating knowledge and skills for

the best practice.

Finally, the implication of this study to health professions is that unalloyed attention

should be strategized to improve the sisters’ knowledge on breast cancer detection

practices. This suggests strongly that breast cancer detection measures should be co-

opted in the time table of candidates in formation houses- juniorates; postulates; and

novitiates, as well as scholasticates.

Limitations of the study

This study was carried out in Anambra State only; findings of the study, therefore, may

not be generalized to sisters outside the State.

The study considered only reverend sisters aged between 20 and 70 years, but the death

of a sister aged 82, caused by breast cancer which occurred on the 16 th of September,

2013, from the researcher’s own congregation, proves the age bracket not exhaustive

for adequate coverage of this group of women.

cxli

There is dearth of literature on using these groups of women, therefore, comparisons

may not have yielded much dependable results. Further studies on the population are

needed to further validate results obtained in the present study.

Recommendations

Sequel to the findings of this study, the researcher recommends viz:

Each religious congregation should establish policy guidelines aimed at

promoting adequate and urgent dissemination of all relevant information

concerning breast cancer.

The health professional members of each congregation should endeavour to keep

abreast with the knowledge of early breast screening services.

The Government of Anambra State should establish cancer screening centres as

she is committed to face the challenges inherent in realizing MDGs 4, 5 and 6.

The State should, therefore, disprove the observation that ‘Nigeria is ill-equipped

to deal with the complexities of cancer care’.

There should be free access to screening services in the government health

institutions during the month of October (Pink month) designated for breast

cancer screening, utilizing mammography.

Superiors General should designate a specific month yearly for free medical care

with emphasis on breast examination and health talk on the topic.

cxlii

The congregations already embarking on yearly medical checks-ups should be

encouraged to continue the healthy practice.

Sisters who fail to turn up for the exercise should be severely sanctioned.

The nuns who may not have their own health facility should approach their local

ordinaries for yearly free medical check-up and treatment in diocesan health

institutions.

The various congregations should integrate breast cancer screening procedures

into their curriculum for basic education of formatees programmes.

Every formator should be well informed of the concept, in-service training in the

area is imperative.

Suggestion for further studies

1. Breast cancer being a distressing condition in human health, a larger sample

should be used to replicate the same study which should include all age groups.

2. A study of the most common early detection practice (BSE) should be carried

out using a larger population.

Summary of the study

This study examined the knowledge of reverend sisters aged 20-70 years on breast

cancer and early detection practices. The subjects were selected from all convents and

monasteries in Anambra State. A combination of stratified and convenient sampling

methods was used to select a sample size of 324 participants. The study revealed that:

cxliii

Majority of the sisters were ignorant of what breast cancer means; only 27.2%

described it as uncontrolled multiplication of breast tissue. There was no significant

difference in the conception of breast cancer among the two groups of sisters.

There was no significant difference in risk factors/causes identified by the two groups.

There was no significant difference in what the two groups understand as breast cancer

early detection practices.

Most popular breast cancer early detection practices among the two groups of women

was breast self examination, followed by clinical breast examination.

Most common preventive measure known to the respondents is genetic counselling

especially in women with history of breast cancer; followed closely by intake of high

fibre diets like fruits and whole grain and increasing intake of vegetables. Result of

unpaired t-test showed a significant difference in the knowledge of breast cancer

preventive measures among the respondents

The common source of knowledge about breast cancer and its prevention was from

friends and relations, which was more from respondents in the active group. Generally,

there was statistically significant difference in the sources of knowledge about breast

cancer among the two groups.

Timing for practice of breast self-examination varied widely among the reverend

sisters, but no difference among the sisters.

Clinical breast examination is not popular among the sisters, 48.8% had never done it.

There was no difference in the respondents’ practice of clinical breast examination.

Most of the reverend sisters would stand or sit in front of a mirror to look for

abnormalities like inequality, skin colour change, dimpling or unusual enlargement in

the breast.

cxliv

Reasons why the respondents did not engage themselves with breast cancer preventive

and detection practices abound and vary, but not among the two groups.

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APPENDIX A

QUESTIONNAIRE

Dear Respondents,

The researcher is an M.Sc. student of University of Nigeria, Enugu Campus, studying

on: “Knowledge and Early Detection Practices of Reverend Sisters in Anambra State

towards Breast cancer”. Kindly supply the information needed. Your responses shall

be treated with utmost confidentiality and would be used for research purposes only. Do

not indicate your name.

Thank you and God bless.

Yours Sincerely,

Madu, Laurette P. N.

Section A: Socio-Demographic Data: Indicate with a thick ( ) in the box below

your response as applicable.

1. Age (a) 20- 49 years (b) 50-70 years

2. Academic Qualification: (a) Graduate (b) Non- graduate

3. Type of job: (a) Health related (HR) (b) Non- HR

4. Location: (a) Urban (b) Rural

5. Type of order (a) Active (b) Contemplatives

Section B:Cancer Knowledge and Detective Health Behaviours Questionnaire

(CK-DHBQ).

cl

Respond to each of the items below as they relate to you and indicate your response with a tick ( ). Please note that there is no wrong or right answer for each of the items. Be as objective as possible in responding to each.

6. What do you understand as Breast cancer?

Poisonous boil in the breastAccumulation of dead breast tissueUncontrolled multiplication of breast tissueEnlargement of the breast due to much intake of fatty foodNo idea

7. Which of the following would you identify as risk factors/cause of Breast cancer?

Eating of infected or contaminated foodExcessive use of cosmeticsCancer of the breast runs in the familyToo much exposure to sunlightThere is no known causeFrequent exposure to electricityBreast cancer is infectiousNot giving birth, or having children after age 30Prolonged breast feeding 1 ½ - 2 yearsDrinking of alcohol to a very high levelBeing over-weight or obeseLack of physical activityHigh fat and low intake of fibres, fruits & vegetablesUse of anti-perspirantsWearing of brasSmoking may increase the risk of Breast cancerNight work with electric lightUsing oral contraceptivesUsing combine hormone therapy after menopauseChemicals found in plastics like plastic bottles, PVC pipes and in coating of canned foodBreast implantsCertain chemicals in the environment

8. To the best of your knowledge, do women who had prolonged exposure to ovarian hormone have high risk of developing Breast cancer?Yes No

9. Which of the following is/are early warning signs of Breast cancer? Tick as many as you think appropriate.Painless lumpSwelling in the breast with pain

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Skin changesDischarge from the nippleNipple retractionFeverWeight lossNot aware of any early warning sign/symptom

10. When talking about early detection measures of Breast cancer, what do you understand by this?Health action expected of women of all agesTest to detect early signs of Breast cancerBreast care expected of every woman from 20 years of ageLooking at the breast every dayNot aware of breast examinationHealth action taken by women with problem in their breast

11. To the best of your knowledge, which of the following is/are Breast cancer early detection measure(s)? Tick as many as you deem appropriate.Breast self examinationSimple X- ray of the breastMammographyUltra-sound scanningComputerized Tomography (CT)Breast tissue biopsyClinical breast exam (physical examination of breast by health personnel)Surgical/incision biopsy I have no idea of any

12. Which of the under-listed would you describe as appropriate Breast cancer preventive measure(s)? Tick as many as you deem necessary.Genetic counselling especially in women with history of Breast cancerIncreasing intake of vegetables especially those with cabbageIntake of high fibre diets like fruits and whole grainReduced intake of dietary fats and smoked meats or fishMaintaining a normal body weight and avoiding obesityUse of certain drugs called chemo-preventive agents for some yearsBreastfeeding for not more than a year to maintain endogenous oestrogenAvoiding oral contraceptives and prolonged oestrogen replacement therapy (ORT)Having children before age 30

13. From where did you get your information about Breast cancer?Through friends/relationsRead about it in booksMedia (newspaper, radio, television)Taught in school as part of a course contentRead about it in the internet

clii

At seminars and conferences

14. When do you perform breast self-examination?Any time but once in a monthWithin the first week after menstrual periodWithin the first two week after menstrual periodOnce every two weeksOnce in a yearA week before another menstrual periodOnce every three monthsNever done

15. When do you perform clinical breast examination?Only when sick and initiated by the care providerOnce every monthAny time I suspect problem with my breastOnce a yearEvery 3 yearsNever done

16. Which of the following best describes how you do breast examination?Standing or sitting in front of a mirror to look for abnormalities like inequality, skin colour change, dimpling or unusual enlargementPressing deep on area where I feel discomfortPressing the entire breasts deeply one after another while standing or sitting to feel for painPressing lightly on the breast to feel for abnormal thickness or pain while standing or lying downPressing lightly on the breast with wet soapy hand in the bathroom to feel for lump or abnormal thicknessBy pressing the nipples to detect any secretionGo to hospital for BE when I feel something is wrong

17. Which of the following will you identify as factor(s) preventing you from using detection measures and taking necessary actions towards Breast cancer prevention? You may tick more than one.I am not within the age that needs the examinationFinancial constraintTime factorIt is not necessaryHave difficulty accessing care due to my locationAfraid that lump may be detected, hence prefer to live in ignoranceForgetfulnessReligiously, I am not supposed to be involved in suchMy cultural abhors such practicesI am not aware where the examination is done

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