Screening of Breast among Women: A Cross-Sectional Study in Nepal

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Introduction
Breast cancer is a signifcant global health issue that has been steadily increasing over the past decade.Breast cancer was the second most common cancer among women in Nepal in 2012, after cervix cancer, according to data from seven major cancer service hospitals [1,2].In the year 2012, GLOBOCAN estimates that there were 1,700 new cases of breast cancer diagnosed in Nepal, with an age standardized rate (ASR) of 13.7 new cases per 100,000 women, and 870 female fatalities, with an ASR of 7.2 fatalities per 100,000 women [3].Te WHO has recommended that early detection of breast cancer can improve breast cancer outcome and survival [4].Te fve-year survival rate is 90% in the frst stage, 75% in the second stage, 50% in the third stage, and <10% in the fourth stage [5].For the early detection of breast cancer, regular screening of all women is necessary.Tere are three methods of screening, i.e., breast self-examination, clinical breast examination, and mammography, and these are usually done in combination [6].
Tere is a huge challenge for nations with limited resources, where there are few facilities for therapy and diagnostics and where the cost of appropriate care for breast cancer typically exceeds monthly income [7].Te majority of breast cancer patients receive their diagnosis at a late stage, which makes treatment more challenging and less successful, according to several studies conducted in environments with limited resources [8,9].Individual factors (low breast cancer awareness and knowledge, myths and misconceptions, mistrust in the health care system, and fnancial and access barriers) and systemic factors (poor quality and availability of health care services, absence of specialized public services and necessary drugs, high diagnosis and treatment costs, and low breast cancer awareness) have been identifed as contributing factors to late presentation to health care providers [9][10][11][12][13].In high-income nations, breast cancer screening programs are widely available; however, in low-and middle-income countries (LMICs), where treatment options are limited locally and the population is young, there are few or no screening programs and they are likely to be both inefective and expensive [14].Te current state of breast cancer screening in Nepal is characterized by lack of resources and awareness, particularly in rural areas [15].
To guide the development, expansion, and strengthening of health care system and breast cancer screening programs, it is crucial to estimate the prevalence of breast symptoms which need diagnostic service and likely follow-up and treatment [16].However, there are very few literatures which cover the fndings of the breast screening in our country.Terefore, the current study aimed to assess the prevalence, clinical profle of breast diseases, and their association with sociodemographic variables among females in the Tokha Municipality of Nepal.Te fndings of the study are very essential in regards to see the disease burden, association of abnormal breast condition with sociodemographic variables, and the need for change in the breast cancer screening protocol.

Design and Setting.
A cross-sectional study was conducted in Tokha Municipality on 100 female participants.Among 11 wards in Tokha, 4 wards were chosen randomly.Te random sampling method was employed in the chosen wards.Randomly selection was carried out to minimize sampling bias and to ensure representation of the population.Data collection was done by the principal researcher along with three trained research assistants with a public health background.Medical doctors from Maharajgunj Medical College also assisted in data collection in Tokha Municipality.All the enumerator went through comprehensive orientation session where the study protocol, methodologies, and the technique of self-breast examination to the participants were thoroughly explained.Te enumerators taught the respondent the correct technique to identify abnormalities.Te respondents were then asked to perform the same technique on their own and if they reported any abnormalities they were sent for radiological examinations.In addition to suggesting clinical and cytological diagnoses for reported breast abnormalities, this study ofered 100 women the chance to learn about breast abnormalities.A normal breast was painless, had clear skin, no lumps, a normal temperature, no discharge, and normal or abnormal mobility.Abnormal breasts were any divergence from the normal characters.

Sample
Te variables selected include a wide variety of sociodemographic and behavioral variables that are known to afect breast health.Tese variables were chosen to capture diferent aspects, including age-related susceptibility, cultural biases, lifestyle habits, reproductive background, and health-seeking behaviors.Te goal of this study is to understand the intricate interactions between these variables and breast abnormalities.3.

Statistical
Relationship between the complaints and sociodemographic and characteristics of the respondents.
Tere is a signifcant correlation between the age at frst marriage and the complaints, specifcally 18.8% of all participants who married before the age of 20 had abnormal cases, with a P value of 0.04, as shown in Table 4.

Factors Associated with the Complaints.
Tere was a signifcant relation between use of contraception and abnormal breast (P value 0.02), as shown in Table 5.

Discussion
Our fnding revealed that 19% of the total participants complained about abnormal breast.Out of which 31.7% reported lumps, 26.31% reported discharge , another 26.31% reported pain, and the remaining 15.7% reported soreness.Te upper outer quadrant and lower inner quadrant each individually accounted for 33.33% of the abnormal fndings.In our study, variables such as age at marriage, number of pregnancy, and contraception showed signifcant association with the complaints of the participants.In this study, we have projected the need for the change of breast cancer screening in our health system since a substantial proportion of the participants reported abnormal breast fndings.
In our study, 19% of the participants reported abnormal breast which is similar to the study of Malmartel et [23].
In the same way, in our study, use of contraception was signifcantly associated with abnormal breast fndings, which was consistent with the study in Ethiopia by Ayele et al. [19].In a meta-analysis of several studies has shown a slight increased risk of abnormal breast fndings ranging from 8 to 24% [24,25].Early studies found no association between contraceptives and breast cancer, with Kelsey even suggesting a potential protective efect [18,26].However, more recent research has documented an increased risk of breast cancer among hormonal contraceptive users although the overall risk remains low.Tese fndings highlight the need for further research to fully understand the impact of contraception on breast health.
In the study of Ayele et al., age at frst menstruation was signifcantly associated with abnormal breast fndings whereas in our study, it was not signifcant [19].Tis study's fndings on abnormal breast fndings were signifcantly correlated with the use of contraception, age at frst marriage, and number of pregnancies similar to the study of Bk et al. [27].Early marriage, particularly before the age of 18, has been identifed as a potential risk factor for breast cancer in the Eastern Region of Saudi Arabia [4].Tis is consistent with the broader association between marital status and cancer diagnosis, with unmarried individuals being more likely to be diagnosed at a later stage [28].Similarly, parity, or the number of pregnancies, is linked to a short-term increase in breast cancer risk, followed by a long-term decrease [29].Tese fndings suggest that hormonal risk factors may be contributing.Tis suggests that more research is necessary to determine how these are related to one another.
In addition to suggesting clinical and cytological diagnoses for reported breast abnormalities, this study ofered 100 women the chance to learn about breast abnormalities.Te fndings of the study have shown the burden of breast abnormalities and unfulflled diagnostic needs across the country.Tis warrants the need of change in breast screening protocols as routine mammography screening in a resource-limited country with a young population is neither sensitive nor afordable.Te data of the study will serve as a policy guide to improve breast diagnostic and treatment.
Our study also had some limitations.Te data were collected by self-report which can introduce biases as participants may not accurately recall or report their experiences, leading to underreport or overreport of the symptoms.Tis can result in inaccurate prevalence estimates.Since the sample size is relatively small, so the result cannot be generalized as it might not accurately represent the true prevalence or association; hence, it is recommended to conduct further studies using larger samples at various areas.We were not able to incorporate all the factors that could have infuenced the association between the variables.
Despite the limitations, the fndings of this study highlighted that there is a critical need for reinforcing breast cancer screening protocols and resource allocation in health system.

Conclusion
Our study has identifed a high prevalence of breast abnormalities that require immediate action.It is very important to prioritize education and awareness programs aimed at promoting early detection of breast abnormalities.
Policymakers must tailor screening protocols to address the unique needs of diferent demographic groups and ensure the timely availability of diagnostic services, including clinical and radiological examinations, particularly in underserved areas.Te study's fndings ofer constructive insights for healthcare practitioners in Nepal.By utilizing these insights, healthcare providers can tailor their approaches to identify and manage breast abnormalities among women more effectively.Trough prioritizing awareness campaigns, early detection eforts, and improved access to diagnostic services, healthcare providers can signifcantly enhance breast health outcomes and reduce the burden of breast abnormalities in the population.Given the limitations of routine mammography screening in resource-limited settings with a predominantly young population, policymakers should explore alternative screening modalities that are more sensitive, cost-efective, and feasible in the Nepalese context.Tis may include the integration of breast self-examination and clinical breast examination into primary healthcare services.It is absolutely necessary to invest in healthcare infrastructure, training of healthcare personnel, and strengthening referral systems to ensure timely follow-up and treatment for women with abnormal breast fndings.
Analysis.Data were entered in Microsoft excel version 2019 and data analysis was performed on IBM Statistical Package for the Social Sciences (SPSS) version 21. 2 Te Breast Journal Descriptive analysis was done by calculating frequency and percentages of categorical variables.Te chi-square test was employed for the comparison of nominal variables, while the independent sample t-test and paired sample t-test were utilized for the comparison of nominal and continuous variables.
3.3.Characteristics of the Complaints.Of the total participants, 19% complained about the abnormal breast.Out of which 31.7% reported lumps, 26.31% reported discharge, another 26.31% reported pain, and the remaining 15.7% reported soreness as shown in Table

Table 2 :
Behavioral characteristics of the study participants (n � 100).

Table 3 :
Characteristics of the complaints.

Table 4 :
Relationship between the complaints and sociodemographic and characteristics of the respondents.
Te bold values are statistically signifcant data.

Table 5 :
Factors associated with the complaints.