Breast cancer is a severe illness that significantly lowers women's mortality and quality of life globally. It is the most prevalent cause of cancer-related death in women and the fifth most common cause of cancer-related mortality worldwide[1]. Treatment delays resulting from delayed diagnosis are one of the primary causes of breast cancer death[2]. The incidence has significantly increased in India. In 2022, 2.3 million women worldwide received a breast cancer diagnosis, and 670000 of them lost their lives to the disease[3]. Breast cancer causes 10.6% (90408) of all deaths and 13.5% (178361) of all cancer cases in India, according to GLOBOCAN data from 2022[4]. The National Medical Journal of India reports that, from 2012 to 2016, Chennai's annual cancer burden was 6100, or 55,000 new cases in Tamil Nadu[5]. Research has shown that screening practices have decreased breast cancer death rates. A 5-year survival rate of 85% is achieved with early discovery, compared to roughly 56% with late detection[6]. Low awareness, stigma, fear of the disease, gender inequity, lack of screening tools and infrastructure, low literacy, and low socioeconomic status are some of the factors contributing to late detection of breast cancer[7, 8].

One effective method for screening for breast cancer is the Breast Self-Examination (BSE). Self-breast examination raises awareness of breast abnormalities in addition to helping with early breast cancer identification[9]. It can inadvertently increase the woman's awareness of breast cancer risk factors. Self-breast examination is cheap and easy to perform. The intervention is non-invasive. The sensitivity of self-breast inspection is 78%[10]. Despite being straightforward, self-breast inspection rates vary greatly between nations; in India, they ranged from 0% to 52%[11, 12]. Despite the existence of self-breast examination and clinical breast examination, the prevalence of breast cancer has not decreased. This could be the result of a lack of practice, attitude, or information. We seek to raise women's understanding and awareness of the disease because early identification can be affordably accomplished by self-breast examination, favoring early treatment before the disease progresses to higher stages. 

In order to assess the level of knowledge about breast cancer, the practice of breast self-examination, and the factors that influence it, this study was conducted. To reduce the burden of breast cancer, the government has developed a number of initiatives and programs. For example, the NPCDCS was introduced in 2010 to promote greater awareness and screening. Despite this, the numbers have not decreased, and most cases are discovered at a somewhat advanced stage. The only way to lessen this increase in instances is to raise awareness about BSE and screening.

The purpose of this study is to assess the level of awareness that women of reproductive age (15–49 years) have about breast cancer and the practice of Breast Self-Examination (BSE), as well as to assess the different factors that affect these features.

A six-month, analytical cross-sectional study was conducted at the Therespuram Urban Primary Health Centre (UPHC), which is connected to the Government Thoothukudi Medical College's Department of Community Medicine, between March and September 2023. All women who visited the Therespuram UPHC Outpatient Department (OPD) between the ages of 15 and 49 were included in the study. Women who refused to participate, those who had received a breast cancer diagnosis in the past, those under treatment for breast cancer, and those who had previously had breast surgery of any kind for any reason were all excluded. Women who were pregnant or nursing were not allowed to participate in the study because of the physiological changes that occur in the breast at these times, which might make self-examination painful, diminish comparability with non-pregnant participants, and increase the chance of false-positive results or excessive anxiety. Using the standard formula for estimating a single proportion, the required sample size was calculated by taking p = 14, q = 100 – p = 86, and the allowable error d = 5%, based on the findings of Kumarasamy H et al., who reported that 14% of the study participants were aware that breast self-examination should be performed once a month[13, 14].

N= Z2 pq / d2

where p= 14, q(100 – p) = 86, d = 5% 

To the obtained sample size, a 10% nonresponsive rate is added. Thus, the study included 220 women who met the eligibility requirements and were enrolled in the UPHC OPD. The eligible women were interviewed until the ultimate sample size of 220 was reached using the convenient sampling technique. Ethical clearance for the study was granted by the Institutional Ethical Committee, and informed consent was obtained from all participants before initiating the study. A pre-designed, pre-tested, semi-structured questionnaire was used to gather data through in-person interviews with the goal of evaluating participants' knowledge and behaviors about breast cancer and breast self-examination (BSE). Once rapport was established and confidentiality was guaranteed, the interviews were held in Tamil, the participants' native tongue.

There were six sections to the questionnaire: (1) sociodemographic traits, such as age, income, occupation, and level of education(socioeconomic class was assessed using Modified Kuppuswamy Classification – 2024)[15], (2) general information such as breast cancer's type, curability, and early diagnosis,(3) risk factors such as age, early menarche, late menopause, nulliparity, breastfeeding, age at first childbirth, OCP pill use, estrogen replacement therapy, and physical activity, (4) symptoms such as a painless lump, bleeding, nipple retraction, nipple discharge, asymmetrical breast swelling, and an armpit lump, (5) Breast cancer treatments, such as surgery, chemotherapy, and radiation therapy; and (6) information about breast self-examination, including when and how often BSE should occur, as well as how early diagnosis and treatment can increase the survival rate of breast cancer. The responses came in both yes/no and multiple-choice formats. Every right answer to knowledge-based questions received a score of 1, while every wrong answer received a score of 0. The final score was calculated by summing all individual item scores, with a minimum possible score of 0 and a maximum possible score of 28.Three categories were created from the total score. The scores were divided into three categories: inadequate (less than 50%), moderately adequate (between 50% and 75%), and adequate (more than 75%). After collecting, the data was compiled and entered into a Microsoft Excel sheet. Analysis was done using SPSS software version 16. Quantitative variables were expressed as mean and standard deviation (SD) for normally distributed data, or median and interquartile range (IQR) for skewed data. Categorical variables were expressed as frequency and percentage. The chi-square test was used to assess the association between independent and dependent variables, and statistical significance was assessed if the p-value was less than 0.05, at a 95% confidence interval.

The study participants' average age was 31.4 ± 10.5 years (95% CI), and the highest percentage (18.6%) were in the 31–35 age range. 188 (85.5%) of the 220 women were married. Most of the participants (75.5%) were homemakers, and 29.5% had a diploma. Socioeconomic class IV included 65.9% of the women, according to the Modified Kuppuswamy Classification. 54.9 percent of those surveyed said they were Hindu. [Table. 1] provides specific information about the participants' sociodemographic traits.

Of the study participants, 15 women (6.8%) had a family history of breast cancer, and the mean age of menarche was 13.35 ± 0.24 years (95% CI). Eight (14.8%) of the 54 women who surveyed had taken oral contraceptive pills (OCPs). Women who had given birth provided information on breastfeeding. One hundred and twenty-three (71.5%) of the 172 eligible participants had exclusively nursed their children. Among these mothers, the average breastfeeding duration was 9.67 ± 0.834 months (95% CI) (See [Table. 2]).

Eighty-four percent (184) of the 220 women who were part of the study had heard about breast cancer. Nevertheless, only 12% and 8%, respectively, had sufficient knowledge of the signs and treatment of breast cancer, while the majority (76.4%) showed insufficient knowledge about its risk factors ([Table. 3]). Only 92 participants (41.8%) knew about Breast Self-Examination (BSE), having learnt about it from friends, family, professional healthcare providers, or the media ([Fig. 1]). Only roughly 6% of the women were sufficiently informed about BSE and breast cancer overall. Additionally, only 55 women (25%) had got prior health education exposure about doing BSE correctly.

Of the 92 women who knew about Breast Self-Examination (BSE), only 45 (48.9%) said they did it. Only 45 people (20.4%) out of the entire study group frequently engaged in BSE. The most frequent excuse for not using BSE was found to be fear, which was followed by societal stigma.

A significantly significant association (p<0.05) was found between occupation and breast cancer knowledge, as indicated in ([Table. 4]). It was also demonstrated that occupation, educational attainment, and socioeconomic status were all substantially associated with the practice of BSE.

Every year, the number of cases of breast cancer increases, and the direct medical costs of the disease surpass $7 billion[16]. In national cancer control programs, early detection is still of utmost importance. Reducing mortality rates is mostly dependent on screening, especially for cervical and breast cancers. The success of early diagnosis and screening initiatives may depend on increasing community knowledge and cultivating a favorable attitude toward breast cancer in developing countries like India. The American Cancer Society, however, no longer recommends Breast Self-Examination (BSE) as a screening technique for breast cancer early detection[17].

In this study, women between the ages of 15 to 49 years were asked to rate their knowledge of breast cancer and breast self-examination (BSE). Despite being the most frequent cancer in women, only 184 (83.64%) of the 220 participants in the poll had heard of breast cancer. The knowledge level in this study is much greater than that of previous studies conducted by Jaswanth et al.[17] (44.7%), Sideeq et al.[18] (26%) and Somdatta et al.[19] (44%). A significant percentage of participants (76.4%) in this study lacked sufficient information of breast cancer risk factors, while only 12% and 8%, respectively, showed sufficient awareness about the disease's symptoms and treatment. The present results are somewhat consistent with earlier research by Ahmad et al.[10] where 63.6% of participants lacked adequate knowledge of various risk factors, and Bakthavatchalam et al.[1], where 65.4% of participants lacked adequate knowledge of breast cancer risk factors.

According to the current study, 41.8% of participants knew about BSE, which is in close agreement withRajini S et al.[21] (40.3%) but different from Bakthavatchalam et al.[1] (65%), and Nafissi et al.[22] (30.8%) findings. Of the 220 women who participated in the survey, only 20.4% said they practiced BSE. This is a little more than the 12.9% of respondents who did so in the study by Nafissi et al.[22]. For 41.8% of respondents in this study, the media was their main source of knowledge on breast cancer, followed by friends and family (31%). Research by Jaswanth S et al.[17] (56%) and Somdatta et al.[19] (42%), respectively, is consistent with our findings. Furthermore, in line with the findings of research by Rajini S et al.[21] and Nafissi et al.[22], fear was shown to be the primary obstacle to performing BSE, followed by stigma.

The findings of our study demonstrated that women with higher occupations, educational attainment, and socioeconomic position were better informed about breast cancer and BSE than women with lower qualifications. This aligned with the findings of another research conducted by Jaswanth et al.[17] , Rajini S et al.[21], Nafissi et al.[22] and Kalliguddi et al.[23].

Strengths and limitations:

This study's focus on a high-risk, service-seeking sample of reproductive-age women who visit a primary health center and were probably in need of preventive education was one of its strengths. Internal validity was further enhanced by explicit inclusion and exclusion criteria, such as the exclusion of women with a history of breast illness or breast alterations associated with pregnancy or breastfeeding.

Its cross-sectional design made it impossible to establish causation, and selection bias might have been introduced by convenience sampling of OPD attendees. The results of this single-centre, facility-based urban study might not have applied to other groups, particularly women who did not use health services. Self-reported responses might also have been affected by recall bias.

It appears that increasing women's knowledge and practice, as well as their awareness of breast cancer risk factors and early detection interventions, is crucial for both disease prevention and early diagnosis. This study highlights the knowledge and practice gaps that currently exist among individuals of reproductive ages.

Recommendations:

This study underscores the need for increased awareness among women through various strategies to promote the acceptance of cancer screening programs and address unmet needs. Health-care providers, including public health practitioners, family physicians, and community health nurses, play a vital role in educating individuals about breast health and BSE. To maximize impact, educational programs should be implemented within workplace settings, providing valuable, life-saving information not only to individuals but also to their loved ones. Future research should focus on evaluating the effectiveness of awareness initiatives and efforts to improve self-breast examination behaviors across diverse demographic groups.

The authors extend their gratitude to all study participants for their valuable contribution and to the interns assigned to the Department of Community Medicine during the study period for their assistance in data collection.