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Awareness levels of breast cancer among female university and medical college students in Sylhet city of Bangladesh

Awareness levels of breast cancer among female university and medical college students in Sylhet... INTRODUCTIONBreast cancer is in number second in the most occurring cancers list among humans and in the first place among women. In 2018, the percentage of breast cancer among newly diagnosed cases in both genders was 12.3%, and in women, it was 25.4% (excluding non‐melanoma skin cancer).1 In Belgium, the age‐standardized incidence rate of breast cancer was 113.2, which is the highest per 100 000 women, and this rate was 17.0 in Bangladesh.2 The incidence rate of breast cancer has an increasing trend, and it will increase in the future, as some prediction tools suggest.3–5 In Bangladesh, clinical data warehousing is not rich,6 but the information collected by different international organizations depicts that the incident rate is increasing speedily in Bangladesh. Moreover, the mortality rate is increasing because of the absence of breast cancer awareness in women, faulty screening tests, outdated medical treatment, and people not having faith in the medical procedure.7,8 In many developing countries, the picture of breast cancer patients depicts that doctors detect most breast cancer cases in the last stage of cancer because patients do not know the early warning signs and screening approaches of breast cancer. An early test of cancer leads to early detection of breast cancer and increases the chance of survival. Simple screening approaches like breast self‐examination and clinical breast examination are helpful to detect breast cancer, and knowledge of these approaches among people can compel authorities to employ early detection programs in a region.9The common warning signs of breast cancer are a lump in the breast or under the armpit, pulling in the breast, pain in the breast/nipple, puckering/dimpling breast skin, bleeding or discharge from the nipple, rash in the nipple or breast skin, redness of breast skin, and changes in the size of the breast due to swelling.10,11 The exact reason/factor behind unusual changes in the breast still can not be stated.12 Nevertheless, clinical and observational researchers pointed out some like being a woman, early menstruation, diet, late menopause, infertility, family history of cancer, overweight, smoking and alcohol consumption, physically inactive, not breastfeeding, trauma.13–22 To detect any abnormalities in the breast as early as possible, doctors suggest three screening approaches, and those are (a) breast self‐examination (BSE), (b) clinical breast examination (CBE), and (c) mammogram. Along with these, CT scans/sonography and biopsy are also used to confirm the abnormalities to be signs of breast cancer.23–26 Treatment of breast cancer depends on the type and stage of this cancer. Most breast cancer cases require surgical treatment‐ breast‐conserving surgery, mastectomy. Along with these surgeries, surgeons perform other necessary surgeries to remove cancer cells entirely, and doctors prescribe therapies either before or after the surgery.27The knowledge about the risk factors, early warning signs, screening methods and therapeutic methods can be varied respective to a person's educational level, economic status, family history of breast cancer and marital status.28 Also, several campaigns/interventions are showing fruitful results in improving the knowledge about breast cancer and encouraging women to practice screening approaches in their lives.29,30Many studies suggested the strong relation of level of awareness with the early detection of breast cancer,31,32 and most people had no interest in being conscious about screening approaches for breast cancer.32 However, developed countries provided that healthcare experts could explain the need for screening approaches to general people and increase the number of women attending the screening sessions.33,34 Several studies10,11,35–45 in the world aimed to discover the awareness levels of breast cancer among women. As far as we know, there is no such study conducted in Bangladesh that measured the awareness levels about risk factors, early warning signs, screening approaches, and therapeutic methods among women. Most of the studies conducted in Bangladesh only focused on obtaining the percentages of different factors influencing breast cancer.This study aims to find out the current awareness level about breast cancer among university‐level female students. Moreover, to identify which factors affect the awareness level of students. As we know, they have more access to various mediums to know the details of this than other sections of the population. Hopefully, this study will help policymakers plan intervention strategies to make women more aware of various aspects of breast cancer.METHODOLOGYWe conducted a cross‐sectional study on undergraduate and graduate‐level students in Sylhet city in the northeastern part of Bangladesh. There are six universities and five medical colleges, among which two universities and one medical college are public institutions in this city. Due to limited resources and lack of cooperation, the study population was female students of one university and one medical college. We considered students of five academic years (1st year, 2nd year, 3rd year, 4th year, Master's) of all departments from the university. Similarly, we included Medical College students of five academic years (1st year, 2nd year, 3rd year, 4th year, 5th year) and intern doctors.There were two groups in the population, and between them, one group had medical knowledge, and the other group had no such knowledge. The group with medical knowledge included female students of medical college, and the group with no such knowledge included the female students of the university. The calculation of sample sizes of the two groups followed the following procedure.We applied simple random sampling to collect a comparable and representative sample from each group without equal respondents in two groups. To get the required number of samples, we considered the level of significance, d = 0.05, Z‐score for 95% confidence interval, z = 1.96, and N = Population size.As we had no idea about the proportions aware of breast cancer, we selected p = 0.05, and so, q = 1 – p = .05. When estimating the sample size, the population size for the group having medical knowledge was N = 535 and for the other group receiving no medical knowledge was N = 3160. For calculating the total number of respondents included in the sample from two assemblies, we used the following equations46:n0=z2pqd2andn=Nn0N+n0Thus, the sample size for the group having medical knowledge for our study was 224, and the sample size of the other group was 343.We developed a semi‐structured questionnaire with various information about breast cancer and took different vital questions from the Breast Module of the Cancer Awareness Measure, developed by Cancer Research UK, King's College London, and University College London in 2009. Moreover, the questions of the last five sections were based on the American Cancer Society27 and different published articles.10,11,47 This questionnaire contained six sections, each one named with its proper heading indicating its topic. These sections had questions about socio‐demographic information, breast cancer risk factors (RF), early warning signs (EWS) of breast cancer, screening approaches (SA) and therapeutic methods (TM) of breast cancer, and barriers to seeking medical help related to breast. The first section contained socio‐demographic variables: age, height, weight, the institution of graduation, marital status, attending any breast cancer‐related educational campaigns or programs, seeing breast cancer‐promoting ads, and personal breast‐related problems. The second section had questions on risk factors, and the third section had questions on early warning signs of breast cancer. The fourth section had questions on screening methods, and the fifth section comprised Likert scale questions on different reasons for not taking medical help. Furthermore, the sixth section included questions for assessing the knowledge about therapeutic methods of breast cancer. All the questions used for the assessment of awareness levels were recorded as “Yes” and “No” options.We collected data from the halls of female students, which the educational institutions provide. We included students of different academic years randomly from February 2, 2019 to March 15, 2019. Data collectors went room to room and described the objective of the study. A student received a questionnaire if she was interested in participating voluntarily; otherwise was not bothered. We completed the data collection procedure by taking the necessary time allowing flexibility to the respondents.Data processing steps included data entry, data editing, and necessary adjustment for data analysis. For data processing steps, we used Statistical Package for Social Sciences (SPSS) version 22.0. We edited data on some sections‐ where respondents gave unfitting or meaningless answers and some places to get consistent results among respondents.We did descriptive analyses and stated mean (±SD) for numerical variables and percentage for categorical variables. We considered the structure of the dataset as a latent structure as we selected variables from the sections of risk factors, early warning signs, screening approaches and therapeutic methods, which are categorical variables with two categories‐ “Yes” and “No”. We wanted to find out distinct classes with similar understanding/knowledge among individuals and the chance of participants being in different classes. Furthermore, we analyzed this by applying latent class analysis (LCA) method to each section of the dataset individually to fulfill the aim. LCA was developed for this setting where multiple categorical variables describe one idea and a hidden categorical variable that influences those multiple variables. Participants were assessed based on having adequate or low knowledge about items of each section, and the correct answer for each question was finalized before applying the LCA. Then to measure the extent of effects of factors on the awareness levels about breast cancer, we used latent class regression (LCR), the extended version of LCA. LCR uses the constructed categories by the LCA as the dependent variable for running logistic regression. For factors, obtained coefficients can be converted into odds ratio (OR) to interpret them simply as the participant's chance of being in another category than the reference category. In this study, we used six factors that somehow connected to the awareness level of breast cancer. These factors are the age of respondents, marital status, personal breast problem history, ads promoting awareness about breast cancer, educational program/campaign, and relative with breast cancer. We used the statistical modeling program Mplus version 7.0 to run this part of the analysis.RESULTSAwareness levels of medical studentsThe mean (±SD) age of participants of the medical college was 21.61(1.56) years, and mean (±SD) height and weight were 1.58 (±0.05) meters and 53.04 (±9.10) kg, respectively. Among 224 medical students, the majority of them (97.32%) were single, 76.34% were never attending any programs/campaigns related to breast cancer, and a total of 75% of students saw ads that promoted awareness of breast cancer. In addition, 91.96% of students had no family history of breast cancer, and 62.05% did not practice breast self‐examination (Table 1).1TABLEDescriptive information about medical studentsVariablesCategoriesN (%)/Mean (±SD)Age in years21.61 (1.56)Height in inch62.10 (2.01)Weight in kg53.04 (9.10)BMIUnderweight41 (18.30)Normal128 (57.14)Overweight31 (13.84)Pre‐obese21 (9.38)Obese T‐12 (0.89)Obese T‐21 (0.45)Marital statusSingle218 (97.32)Married6 (2.68)Attending program/campaignYes53 (23.66)No171 (76.34)Seen awareness related AdsYes168 (75.00)No56 (25.00)TraumaYes25 (11.16)No199 (88.84)Know TMYes156 (69.60)No68 (30.36)Men_BCYes176 (78.57)No48 (21.43)Personal breast problem historyYesBreast lump1 (0.45)12 (5.36)Inflammation1 (0.45)Itching1 (0.45)Mastalgia1 (0.45)Unequal size1 (0.45)Pain6 (2.68)Rash in breast skin1 (0.45)No212 (94.64)Member with breast cancerYesMother3 (1.33)18 (8.04)Aunt9 (4.02)Sister1 (0.45)Cousin3 (1.33)Grandmother2 (0.89)No206 (91.96)DietYesBalanced Diet1 (0.45)26 (11.61)Less calorie food1 (0.45)Not mentioned12 (5.36)Not specific one1 (0.45)OMAD4 (1.79)Vegetarian7 (3.13)No198 (88.39)ExerciseYesDaily26 (11.61)119 (53.13)Sometimes78 (34.82)Rarely17 (7.59)No105 (46.88)Taught to do BSEYesParents5 (2.23)131 (58.48)Teacher90 (40.18)Friend8 (3.57)Ads1 (0.45)NGO agent/organization2 (0.89)Book4 (1.79)Internet18 (8.04)Magazine1 (0.45)TV/Newspaper2 (0.89)No93 (41.52)Practice BSEYesWeekly2 (0.89)85 (37.95)Monthly39 (17.42)Occasionally29 (12.95)Rarely15 (6.70)No139 (62.05)Ever done mammogramYes5 (2.23)NoNot old enough47 (20.98)219 (97.77)Financial constraint5 (2.23)Not interested84 (37.50)Others83 (37.05)Total224 (100.00)LCA produced two latent classes for medical students and calculated the percentage of being in a class to give one of two answers to breast cancer risk factors. Table 2 shows the prevalence of the correct answers to the questions about specific breast cancer screening approaches in constructed classes. After observing different percentages in these classes, the classes can be easily labeled based on awareness levels. Here, class‐1 contained 86.3% of participants and included students with relatively high knowledge about breast cancer risk factors, and class‐2 included 13.7% of participants having low knowledge level. Thus, in class‐2, the chances of answering “Yes” to questions about risk factors were relatively low. However, for not breastfeeding, the case was much high; even so, the chance was lower than that for class‐1. Furthermore, in the meantime, for class‐1, the percentage of answering “Yes” to any of the 11 questions was high enough.2TABLEAwareness (%) of medical students about RF into latent classes and size of classesRisk factors (RF)Class‐1 (high awareness)Class‐2 (low awareness)YesNoYesNoEarly Menarche53.3%46.7%19.2%80.8%Diet58.0%42.0%22.7%77.3%Late menopause73.2%26.8%31.0%69.0%Family history of breast cancer93.3%6.7%67.5%32.5%Infertility78.1%21.9%29.2%70.8%Being overweight/obese86.7%13.3%53.4%46.6%Smoking96.2%3.8%0.0%100.0%Alcohol consumption94.5%5.5%4.4%95.6%Not breast feeding94.3%5.7%70.7%29.3%Trauma65.2%34.8%29.0%71.0%Not being physically active73.0%27.0%48.4%51.6%Class size86.3%13.7%Through applying LCA on the responses of different early warning signs of breast cancer of medical students, we evaluate respondents' knowledge level about these warning signs. We found two classes, among which one class includes those respondents who have high awareness about these, and the other includes respondents with low awareness (Table 3). The class‐1 included most of the respondents, with 69.8%. From the correct answers to the questions about warning signs, we found two classes where class‐1 included respondents with high awareness and class‐2 had individuals with insufficient knowledge. We observed that the chance of answering “Yes” to questions about early warning signs in class‐1 was relatively high. In addition to this, the percentage of answering “Yes” was 100% for “lump or thickening in the breast” in class‐1. Whereas in class‐2, the chance of answering “Yes” was relatively low for each question, but for lump or thickening in the breast, something other than milk in the nipple, and pain in breasts/armpit, the chances were high.3TABLEAwareness (%) of medical students about EWS into latent classes and size of classesEarly warning signs (EWS)Class‐1 (high awareness)Class‐2 (low awareness)YesNoYesNoPulling in of nipple77.8%22.2%19.9%80.1%Pain in breasts/armpit82.6%17.4%60.4%39.6%Puckering/dimpling breast skin92.5%7.5%28.6%71.4%Bleeding or discharge something other than milk in nipple94.7%5.3%62.1%37.9%Lump or thickening in breast100.0%0.0%77.8%22.2%Nipple rash57.3%42.7%30.2%69.8%Redness of breast skin59.2%40.8%40.7%59.3%Lump or thickening under armpit90.1%9.9%55.0%45.0%Change in size of breast84.5%15.5%54.6%45.4%Class size69.8%30.2%The percentage of having accurate knowledge about screening approaches and practicing those approaches to detect breast cancer as early as possible among medical students was portrayed (Table 4). Applying LCA to answers given by medical students provides two classes representing awareness levels. Class‐1 having 70.2% of respondents, consisted of individuals with high awareness, and class‐2 had 29.8% of respondents with low awareness. In class‐2, the chance of answering “Yes” to “practice BSE” was meager, and the percentage of answering “Yes” for this question in class‐1 was about half. The chances of answering “Yes” in class‐2 were relatively low for other questions than in class‐1, but the values were not that small.4TABLEAwareness (%) of medical students about SA into latent classes and size of classesScreening approaches (SA)Class‐1 (high awareness)Class‐2 (low awareness)YesNoYesNoKnow about breast self‐examination (BSE)100.0%0.0%53.6%46.4%Practice BSE51.0%49.0%7.3%92.7%Clinical breast‐examination (CBE)86.7%13.3%41.5%58.5%Mammogram93.7%6.3%43.0%57.0%Biopsy93.1%6.9%57.9%42.1%CT scan/sonography76.3%23.7%61.5%38.5%Class size70.2%29.8%From the data of medical students, after applying LCA, we discovered two distinct latent classes and the percentage of correct answers to questions about therapeutic methods given by respondents in each latent group (Table 5). Class‐1 represented individuals having high awareness, and class‐2 represented those with low awareness about breast cancer. The size of class‐1 and class‐2 was 51.2% and 48.8%, respectively. The chance of answering “yes” to “Surgery or removal of the whole or part breast” was 100% for class‐1, while for class‐2, it was 18.6%. Although the chances of answering “Yes” to “Alternative medicine” were low for both classes, the opportunity was meager for class‐1.5TABLEAwareness (%) of medical students about TM into latent classes and size of classesTherapeutic methods (TM)Class‐1 (high awareness)Class‐2 (low awareness)YesNoYesNoSurgery or removal of whole or part of breast100.0%0.0%18.6%81.4%Chemical or radiotherapy98.3%1.7%11.3%88.7%Depends on disease stage98.3%1.7%11.3%88.7%Alternative medicine1.7%98.3%4.6%95.4%Class size51.2%48.8%The classes of LCA were used in the logistic regression of LCR and the second class was the reference category. After applying LCR, we discovered that for risk factors of breast cancer, the age of respondents had a significant positive effect on being a respondent in the high awareness group (OR = 1.63; 95% CI = [1.21, 2.21]). Furthermore, having a family history of breast cancer also positively affected being in the high awareness group, but the impact was not significant (OR = 3.16; 95% CI = [0.30, 33.33]). Also, we could see that other factors had no positive or significant effect on being in class‐1. Determinants having a negative impact, but not notable were personal breast problem history (OR = 0.34), being married (OR = 0.35), educational program/campaign related to breast cancer (OR = 0.52), and ads that promote awareness about breast cancer (OR = 0.63). For early warning signs of breast cancer, the age of respondents significantly affected the respondents to be in high awareness class (OR = 1.57; 95% CI = [1.16, 2.13]). Having seen ads that promote breast cancer awareness positively affected being in high awareness class, but the impact was not significant (OR = 2.05; 95% CI = [0.89, 4.70]). OR portrayed that Respondents having relatives with breast cancer tended to be in the high awareness class, and the association had not been found significant (OR = 1.43; 95% CI = [0.39, 5.25]). Moreover, being married (OR = 0.18), personal breast problem history (OR = 0.68), and program/campaign related to breast cancer (OR = 0.94) had a negative effect, although the impacts were not significant (Table 6).6TABLEOdds ratio (OR) and 95% confidence interval of OR for the effects of different factors on awareness level about different aspects of breast cancer of medical studentsIndependent variablesDifferent aspects of breast cancerRisk factors OR (95% CI)Early warning signs OR (95% CI)Screening approaches OR (95% CI)Therapeutic methods OR (95% CI)Age1.63a (1.21, 2.21)1.57a (1.16, 2.13)2.66a (1.64, 4.31)1.88a (1.46, 2.42)Marital statusb (married)0.35 (0.05, 3.53)0.18 (0.02, 1.42)0.02 (0.00, 0.25)0.30 (0.07, 1.38)Program campaign0.52 (0.20, 1.32)0.94 (0.35, 2.50)1.86 (0.59, 5.88)1.64 (0.76, 3.53)Ads0.63 (0.22, 1.79)2.05 (0.89, 4.70)1.80 (0.68, 4.76)1.62 (0.80, 3.28)Personal breast problem history0.34 (0.08, 1.48)0.68 (0.17, 2.72)2.38 (0.21, 26.81)0.79 (0.16, 3.80)Member with cancer3.16 (0.30, 33.33)1.43 (0.39, 5.25)0.35 (0.06, 1.95)0.79 (0.25, 2.45)Note: Class‐2 (low level) is reference class.ap‐value <.05.bReference category is single.Same as earlier aspects, the age of respondents had a positive and highly significant effect on respondents being in high awareness class (OR = 2.66; 95% CI = [1.64, 4.31]) in case of screening approaches of breast cancer. Along with this, factors having positive effect but not significant, in order of importance, were personal breast problem history (OR = 2.38; 95% CI = [0.21, 26.81]), program/campaign related to breast cancer (OR = 1.86; 95% CI = [0.59, 5.88]) and ads that promote breast cancer awareness (OR = 1.80; 95% CI = [0.68, 4.76]). It was also evident that being married had a significantly negative impact on an individual in high awareness class. Having a family member/relative with breast cancer had a negative impact but was not significant. As we can see, like other parts, the age of respondents had a significantly positive effect on individuals being in high awareness class (OR = 1.88; 95% CI = [1.46, 2.42]) for therapeutic methods of breast cancer. On the other hand, programs/campaigns related to breast cancer (OR = 1.64) and ads promoting awareness of breast cancer (OR = 1.62) positively but not significantly impacted individuals in high awareness class. Moreover, being married (OR = 0.30), personal breast history problem (OR = 0.79), having a relative with breast cancer (OR = 0.79) had a negative but not significant effect on individuals being in class‐1 (Table 6).Awareness levels of university studentsThe mean (±SD) age of university female student participants was 22.59 (±1.55) years, and the mean (±SD) height and weight of them were 1.56 (±0.06) meters and 51.24 (±8.39) kg. Among 343 female university students, 93.88% were single, and 88.92% of students never attended any breast cancer‐related campaign or programs, but 63.56% had seen ads promoting breast cancer awareness. Around 13% of students had a family history of breast cancer, but only 18.37% practiced breast self‐examination (BSE) (Table 7).7TABLEDescriptive information about university studentsVariablesCategoriesN (%)/Mean (SD)Age in years—22.59 (1.55)Height in inch—61.40 (2.30)Weight in kg—51.24 (8.39)Marital statusSingle322 (93.88)Married21 (6.12)BMI statusUnderweight76 (22.16)Normal185 (53.94)Overweight44 (12.83)Pre‐obese33 (9.62)Obese T‐15 (1.46)Attend program/campaignYes38 (11.08)No305 (88.92)AdsYes218 (63.56)No125 (36.44)Member with breast cancerNo299 (87.17)Yes44 (12.83)Mother6 (1.75)Aunt21 (6.12)Sister1 (0.29)Cousin8 (2.33)Others6 (1.75)Grandmother6 (1.75)Personal breast problemYesPain17 (4.96)27 (7.87)Rash in breast skin5 (1.46)Mastitis1 (0.29)Soreness1 (0.29)Discharge something from nipple1 (0.29)Dimpling in Breast skin1 (0.29)Breast tumor1 (0.29)No316 (92.13)SmokingYes6 (1.75)No337 (98.25)AlcoholYes4 (1.17)No339 (98.83)DietYes24 (7.00)No319(93.00)ExerciseYesDaily21 (6.12)114 (33.24)Sometimes70 (20.41)Rarely23 (6.71)No229 (66.76)TraumaYes99 (28.86)No244 (71.14)Men_BCYes148 (43.15)No195 (56.85)Practice BSEYesMonthly15 (4.37)63 (18.37)Occasionally31 (9.04)Rarely17 (4.96)No280 (81.63)Taught to do BSEYesParents11 (3.21)106 (30.90)Sister2 (0.58)Cousin1 (0.29)Aunt1 (0.29)Teacher13 (3.79)Doctor17 (4.96)Nurse1 (0.29)Friend21 (6.12)Internet34 (9.91)Newspaper3 (0.87)TV1 (0.29)Health related program1 (0.29)No237 (69.10)Ever done MamYes1 (0.29)NoNot old enough9 (2.62)342 (99.71)Do not know it283 (82.51)Not interested30 (8.75)Financial constraint5 (1.46)Didn't face any problem2 (0.58)Didn't find abnormalities1 (0.29)Didn't think about it2 (0.58)Not needed10 (2.92)Know TMYes117 (34.11)No226 (65.89)Total343 (100.00)Table 8 shows the percentage of the correct answer to questions about different risk factors given by university students in terms of two latent classes. Class‐2 included individuals with high knowledge about risk factors defined as high awareness class and class‐1 with less knowledgeable individuals. Here, class‐2 contained 73% of study participants, whereas class‐1 had 27%. In class‐1, the percentage of answering “Yes” to each question was lower than in class‐2. Although the percentages of answering “Yes” to questions were higher than class‐1 for some questions, the chances were not high enough such as for Early Menarche, the chance of answering “Yes” was only 33.8% (Table 8).8TABLEAwareness (%) of university students about RF into latent classes and size of classesRisk factors (RF)Class‐1 (Low awareness)Class‐2 (High awareness)YesYesYesNoEarly Menarche12.3%33.8%33.8%87.7%Diet7.0%31.8%31.8%93.0%Late menopause23.5%51.2%51.2%76.5%Family history of breast cancer35.3%76.4%76.4%64.7%Infertility16.0%65.2%65.2%84.0%Being overweight/obese29.7%60.5%60.5%70.3%Smoking6.9%91.0%91.0%93.1%Alcohol consumption0.0%88.3%88.3%100.0%Not breast feeding45.3%86.3%86.3%54.7%Trauma17.2%30.8%30.8%82.8%Not being physically active26.6%50.5%50.5%73.4%Class size27.0%73.0%The LCA assessed the awareness level of university students about early warning signs of breast cancer which provided two latent classes. Regarding the percentage of correct answers to early warning signs in two classes, we could see that class‐1 included individuals with low awareness about warning signs of breast cancer with 33.2% of the study population, and class‐2 contained high aware individuals (66.8%). In class‐1, the probability of answering “Yes” for any of the nine questions was very low, while in class‐2, the probabilities were high enough. For instance, the chance of correct answer for “something other than milk in nipple” was 81.8% in class‐2 while 11% in class‐1 (Table 9).9TABLEAwareness (%) of university students about EWS into latent classes and size of classesEarly warning signs (EWS)Class‐1 (low awareness)Class‐2 (high awareness)YesNoYesNoPulling in of nipple7.4%92.6%40.9%59.1%Pain in breasts/armpit22.3%77.7%81.5%18.5%Puckering/dimpling breast skin7.8%92.2%69.9%30.1%Bleeding or discharge something other than milk in nipple11.0%89.0%81.8%18.2%Lump or thickening in breast4.3%95.7%68.6%31.4%Nipple rash7.0%93.0%48.1%51.9%Redness of breast skin9.3%90.7%51.7%48.3%Lump or thickening under armpit1.3%98.7%56.5%43.5%Change in size of breast11.2%88.8%69.1%30.9%Class size33.2%66.8%Table 10 shows the percentages of correct answers to the questions about screening approaches in terms of the latent class, and from this prevalence, we could understand that class‐1 contained students with low awareness level and class‐2 consisted of individuals with low awareness level. From the class size, we found that only 35.9% of individuals had a high level of knowledge, and 64.1% had a low level of knowledge about screening approaches for breast cancer. The probability of practicing BSE was 0% in class‐1, while the chance was 51.1% in class‐2. However, the chance of answering “yes” for “CT scan/sonography” was only 35% in class‐2, and in class‐1, the chance was lower than that (Table 10).10TABLEAwareness (%) of university students about SA into latent classes and size of classesScreening approaches (SA)Class‐1 (low awareness)Class‐2 (high awareness)YesNoYesNoKnow about breast self‐examination (BSE)15.6%84.4%94.7%5.3%Practice BSE0.0%100.0%51.1%48.9%Clinical breast‐examination (CBE)8.4%91.6%62.1%37.9%Mammogram2.2%97.8%41.6%58.4%Biopsy36.7%63.3%61.2%38.8%CT scan/sonography17.2%82.8%35.0%65.0%Class size64.1%35.9%The LCA identified distinct classes from study participants of the university regarding the prevalence of correct answers to therapeutic methods. From the percentage of the correct answers in two latent classes, we found that class‐1 contained most of the participants (75.3%) who had a low level of knowledge about therapeutic methods, while class‐2 included individuals with a high level of knowledge (24.7%). For Surgery/removal of whole or part of the breast, the correct answers were 100% in class‐2, while 8.6% in class‐1 (Table 11).11TABLEAwareness (%) of university students about TM into latent classes and size of classesTherapeutic methods (TM)Class‐1 (low awareness)Class‐2 (high awareness)YesNoYesNoSurgery or removal of whole or part of breast8.6%91.4%100.0%0.0%Chemical or radiotherapy2.8%97.2%92.9%7.1%Depends on disease stage0.4%99.6%97.9%2.1%Alternative medicine0.8%99.2%1.2%98.8%Class size75.3%24.7%LCR indicated the impacts of six factors on individuals of the university being in high awareness class. In LCR, latent classes were dependent variables, and class‐1 (low awareness) was the reference class like logistic regression. The obtained coefficients of six factors were easy to interpret as OR of belonging in other classes rather than reference one. The coefficients associated with factors for the aspect “risk factors” of breast cancer showed that being married (OR = 1.82; 95% CI = [0.51, 6.44]), personal breast problem history (OR = 1.77; 95% CI = [0.57, 5.53]), ads promoting awareness about breast cancer (OR = 1.36; 95% CI = [0.76, 2.45]), relative with breast cancer (OR = 1.14; 95% CI = [0.46, 2.83]) and age (OR = 1.05; 95% CI = [0.86, 1.30]) had positive but not significant impact on individuals being in high awareness group rather than reference one while educational program/campaign (OR = 0.90; 95% CI = [0.36, 2.21]) had negative but insignificant effect. All six factors had an insignificant impact on differentiating class‐2 from class‐1. From the results, for the early warning signs, it was clear that ads promoting awareness about breast cancer had a significant positive impact on participants being in high awareness class than reference class (OR = 5.85; 95% CI = [3.20, 10.67]). Though educational program/campaign had more positive impact but the impact was not significant (OR = 10.14; 95% CI = [0.06, 1705.14]). Other factors had not any significant effect on distinguishing the latent classes. The factors with significant positive effect on the level of awareness about screening approaches of breast cancer were personal breast problem history (OR = 6.33; 95% CI = [2.06, 19.46]), promotional ads of breast cancer awareness (OR = 4.31; 95% CI = [2.24, 8.31]), educational program/campaign (OR = 3.38; 95% CI = [1.31, 8.76]) and age (OR = 1.20; 95% CI = [1.01, 1.44]). From the results for therapeutic methods, educational program/campaign had positive significant impact on differentiating two classes (OR = 2.49; 95% CI = [1.26, 4.94]) while being married (OR = 2.17; 95% CI = [0.89, 5.29]), ads promoting awareness (OR = 1.61; 95% CI = [0.93, 2.81]) and relatives with Breast Cancer (OR = 1.79; 95% CI = [0.90, 3.57]) had positive effects which were not much significant (Table 12).12TABLEOdds ratio (OR) and 95% confidence interval of OR for the effects of different factors on awareness level about different aspects of breast cancer of university studentsIndependent variablesDifferent aspects of breast cancerRisk factors OR (95% CI)Early warning signs OR (95% CI)Screening approaches OR (95% CI)Therapeutic methods OR (95% CI)Age1.05 (0.86, 1.30)1.06 (0.86, 1.31)1.20a (1.01, 1.44)1.05 (0.90, 1.23)Marital statusb (married)1.82 (0.51, 6.44)0.90 (0.32, 2.49)1.43 (0.48, 4.25)2.17 (0.89, 5.29)Program campaign0.90 (0.36, 2.21)10.14 (0.06, 1705.14)3.38a (1.31, 8.76)2.49a (1.26, 4.94)Ads1.36 (0.76, 2.45)5.85a (3.20, 10.67)4.31a (2.24, 8.31)1.61 (0.93, 2.81)Personal breast problem history1.77 (0.57, 5.53)2.27 (0.72, 7.21)6.33a (2.06, 19.46)1.79 (0.79, 4.07)Member with cancer1.14 (0.46, 2.83)1.01 (0.37, 2.75)1.50 (0.66, 3.43)1.79 (0.90, 3.57)Note: Class‐1 is reference class.ap‐value <.05.bReference category is single.DISCUSSIONBreast cancer awareness is paramount to diagnose it early and is the most common cancer among women (excluding skin cancer). Being aware of this cancer can reduce the chance of developing breast cancer. Many organizations worldwide are focusing more on the awareness part of breast cancer. They are organizing various campaigns, online tutorials, booklets to teach people of all ages about the importance of early detection and factors that might influence the development of breast cancer. Early detection of breast cancer helps specialists destroy the cancer cell as early as possible, and the treatment of cancer becomes less costly with a higher possibility of recovery. This investigation explored the level of awareness about the risk factors, early warning signs, screening modalities, and therapeutic approaches taken by medics of breast cancer among university and medical students. It also helped to know different factors which could influence their curiosity to be familiar with other aspects of this cancer.The current study gives information on the awareness levels about different parts of breast cancer among university and medical students. The knowledge about breast cancer risk factors among university and medical students is high. However, a relatively small number of university students identified trauma, diet, and early menarche as risk factors of breast cancer. In contrast, the least number of medical students did the same for early menarche and diet. Furthermore, a cross‐sectional study on Iranian adult women provided low awareness about breast cancer risk factors.11 Another cross‐sectional research on university students of UAE displayed relatively low knowledge about different risk factors before the awareness program, which changed at the end of the study.35 Finally, another survey of medical and non‐medical program university students in Angola revealed the same results, depicting the low level of awareness.36 Thus, our findings on risk factors are inconsistent with some studies.11,35–38 Our analysis also revealed that the awareness level about early warning signs of breast cancer was high among university and medical students but not high enough among medical students. It is presumed that medical students will have proficient knowledge about the different diseases, and from that assumption, the awareness level is compared. On the other hand, nipple rash and redness of breast skin had a lower percentage of the correct answer to be recognized as an early warning sign by medical students and the same for pulling in of nipple, redness of breast skin, and lump or lump thickening under armpit by university students. Some earlier studies provided lower levels of knowledge about early warning signs than our research.11,36–39 That could be due to the education level48 and the availability of sources of breast cancer information for the study participants. Our research discovered adequate knowledge about screening approaches of breast cancer among medical students and insufficient knowledge among university students. Although having high knowledge about screenings, only about half of medical students had been practicing BSE. On the other hand, practicing BSE was least commonly done by university students because of insufficient knowledge. Other than that, the knowledge about mammogram and CT scan/sonography is much low among them. Several studies regarding this topic showed almost similar insufficient knowledge for university students about screening approaches among participants.11,39,42 Surprisingly, participants of the university who had high knowledge about screening methods had inadequate knowledge about mammogram and CT scan/sonography. Among medical students who knew the procedure of BSE‐ most of them learned about this process from their teacher/professor, which is quite normal for medical students. This source does not exist for university students, and most of the university students acquired knowledge of this procedure from the internet and mixed sources. Those sources taught them about this process, and they are also actively doing their part. However, we found that different educational programs or campaigns must be held more in various areas or institutions to familiarize women with BSE better.Our study aimed to discover the awareness about widely‐known curative methods of breast cancer, and the result displayed that awareness level is very low for university students. Surprisingly, the level is also low for medical students. Those university and medical students who had high knowledge about curative procedures gave a high rate of correct answers for each option. A study in India among women of a rural district found low knowledge about therapeutic methods43 also among the Iranian adult women.11 The literature review revealed few published papers about the knowledge of therapeutic procedures to make a proper comparison. Our findings might be the result of the therapeutic methods being complicated and not known to general people. Also, the therapeutic methods are available for medical students to be informed about after a specific time in their degree period, which can justify this result for medical students. From the overall findings of the level of awareness about four sections of breast cancer, on average, we found high awareness among students compared to other published studies on different groups of populations.The levels of awareness among participants are varied because of their personal information, and necessary steps can change most of the reasons. For medical students, one common influential factor was the respondent's age, and it is evident that the final year students had better knowledge about the aspects of breast cancer than the first‐year students. Alternatively, for university students, age did not effectively influence the awareness levels, which is usual as they will not get any extra course regarding this topic at any level of their education.We found a significant but negative association between marital status and awareness about screening approaches among medical students. A study on Jordanian nurses showed no significant association between marital status and performing BSE,49 and another study on Saudi adult women showed an insignificant effect of marital status on the knowledge of breast cancer.45 On the other hand, a significant association existed between awareness level of screening approaches and marital status, a family member with breast cancer, educational qualification among women in Riyadh.41 A study showed a strong association in Australian women between knowledge and practice of screening approach and factors like marital status, personal history of the breast problem, and age. However, it was found that women over 65 years were not interested in doing BSE, and women of the reproductive age group were concerned about examining their breasts.50 Our findings might be the consequences of having a low number of married students and different age groups. At the same time, other articles argued in favor of influential association by indicating that married people are usually more worried about their health condition because they have more chance of getting affected by the different refractory disease.In university students, we found a positive and significant association between age, attending program/campaign, ads promoting awareness about breast cancer, personal breast problem history, and awareness level about screening approaches. Personal breast problem history is an essential factor for awareness about screening approaches because it is evident that after feeling any pain or seeing any unusual changes in the breast, women tend to see doctors. Furthermore, from there, women got to find out different screening methods. It also indicates that students are concerned about their health symptoms and always consult doctors if they find any unusual changes. Moreover, a significant association existed between attending programs/campaigns and awareness levels about therapeutic methods for university students. University students showed that ads promoting awareness about breast cancer could help them get accurate knowledge about breast cancer early warning signs. However, we could not find any significant factors among university students for the knowledge of breast cancer risk factors. In Bangladesh, there are a few ads promoting awareness about any part of breast cancer, and the number of such ads must be increased covering every aspect of breast cancer. Along with this, in each educational institution, programs/campaigns that give details about breast cancer should be organized every year.As awareness about breast cancer is necessary among women, especially aged 15–49 years, the main strong point of this study is that we want to know the extent of knowledge about this among students in Bangladesh who have more access to materials of the necessary information and this type of study was already done in many other countries but not any significant research in Bangladesh. Besides, the statistical technique used in the current study provides fair and trustworthy results about the levels of awareness and effective factors that vary the awareness level about breast cancer.The limitation of this study is that only two educational institutes of one city of Bangladesh were used for participants to investigate the awareness levels. This study can be extended by considering more undergraduate and graduate students or more women aged 15–49 years from every district in Bangladesh. This study is conducted using simple random sampling, and further study can be run by using other random sampling techniques and more samples. Cluster sampling procedure may also be used to investigate the breast cancer patients in different divisions in Bangladesh. Also, to get an in‐depth understanding of the factors that influence the awareness among women, mixed‐method research approaches are possible to employ.CONCLUSIONThe current study revealed a moderately low awareness level about the screening approaches and therapeutic methods among university students and relatively high awareness among medical students. However, the awareness level concerning breast cancer risk factors was moderate among medical and university students. The results exposed the fact that female students having personal breast problem history, attending programs related to breast cancer, seeing informative ads on breast cancer tended to have a high awareness of breast cancer. Educational programs about breast cancer in every educational institute, events at the community level to raise awareness among women, and voluntarily learning about breast cancer from online events, web pages, and tutorials using technology could be practical steps to take.ACKNOWLEDGMENTSWe want to acknowledge the principal and academic staff of Sylhet Women's Medical College for their support throughout the data collection process. We appreciate the help of study participants for their voluntary participation and the assistance of Shahnaj Sultana Sathi and Mitu Akter in the data collection process. The author(s) received no financial support/specific grant for the research, authorship, and publication of this article from any funding agency in the public, commercial, or not‐for‐profit sectors.CONFLICT OF INTERESTThe authors declare no conflicts of interest.AUTHOR CONTRIBUTIONAll authors had full access to the dataset used in this study and took full responsibility for the analysis, the accuracy, and the representation of the data. Mst. Farzana Akter: conceptualization, data curation, formal analysis, investigation, methodology, validation, visualization, and writing‐original draft. Mohammad Ohid Ullah: conceptualization, methodology, supervision, validation, writing‐review & editing.ETHICS STATEMENTThe study was approved by the ethical/research (Thesis) committee 2018 (Session 2016–2017) [Regi/161(council)/1/2233] of the Department of Statistics department, Shahjalal University of Science and Technology, Sylhet, Bangladesh. The objective of this study was clarified verbally to the students, and they signed a written consent form that was included on the top of the questionnaire. They had been assured that their identity would not be linked with the research materials, and they would not be identified or identifiable in any report.DATA AVAILABILITY STATEMENTThe data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.REFERENCESWorldwide cancer data. World Cancer Research Fund, 2018. Available from: https://www.wcrf.org/dietandcancer/cancer-trends/worldwide-cancer-data.Global Cancer Observatory, 2019. Available from: http://gco.iarc.fr/.Poirier AE, Ruan Y, Walter SD, et al. The future burden of cancer in Canada: long‐term cancer incidence projections 2013–2042. Cancer Epidemiol. 2019;59:199‐207.Zaheer S, Shah N, Maqbool SA, Soomro NM. 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Available from: https://www.cancer.org/cancer/breast-cancer.html.Alam NE, Islam MS, Ullah H, et al. Evaluation of knowledge, awareness and attitudes towards breast cancer risk factors and early detection among females in Bangladesh: A hospital based cross‐sectional study. PLOS One. 2021;16(9):e0257271.Anastasi N, Lusher J. The impact of breast cancer awareness interventions on breast screening uptake among women in the United Kingdom: A systematic review. J Health Psychol. 2019;24(1):113‐124.Glynn RW, Kelly JC, Coffey N, Sweeney KJ, Kerin MJ. The effect of breast cancer awareness month on internet search activity ‐ a comparison with awareness campaigns for lung and prostate cancer. BMC Cancer. 2011;11(1):442.Cruz‐Castillo AB, Hernández‐Valero MA, Hovick SR, Campuzano‐González ME, Karam‐Calderón MA, Bustamante‐Montes LP. A study on the knowledge, perception and use of breast cancer screening methods and quality of care among women from Central Mexico. 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Breast cancer awareness among women in eastern China: a cross‐sectional study. BMC Public Health. 2014;14(1004). doi:10.1186/1471-2458-14-1004Kan'an A. Evaluation of breast cancer (BC) awareness among female university students in Zarqa University. Jordan Eur J Breast Health. 2018;14(4):199‐204.Salaudeen AG, Akande T, Musa O. Knowledge and attitudes to breast cancer and breast self examination among female undergraduates in a state in Nigeria. Eur J Soc Sci. 2009;1:7.Linsell L, Burgess CC, Ramirez AJ. Breast cancer awareness among older women. Br J Cancer. 2008;99(8):1221‐1225.Alam AA. Knowledge of breast cancer and its risk and protective factors among women in Riyadh. Ann Saudi Med. 2006;26(4):272‐277.Montazeri A, Vahdaninia M, Harirchi I, et al. Breast cancer in Iran: need for greater women awareness of warning signs and effective screening methods. Asia Pac Fam Med. 2008;7(1):6.Gangane N, Ng N, Sebastian MS. 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Factors associated with breast cancer awareness and breast self‐examination in Fiji and Kashmir India – a cross‐sectional study. BMC Cancer. 2020;20(1):1078.Hadayat A. Breast self‐examination and risk factors of breast cancer: awareness of jordanian nurses. Health Sci J. 2013;7(3):303‐314.Yelland MJ, Rice DE, Ward AE, Bain C, Siskind V, Schofieid F. A profile of Australian women practicing breast self‐examination. Asia Pac J Public Health. 1991;5(4):307‐312. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Cancer Reports Wiley

Awareness levels of breast cancer among female university and medical college students in Sylhet city of Bangladesh

Akter, Mst. Farzana; Ullah, Mohammad Ohid
Cancer Reports , Volume 5 (11) – Nov 1, 2022
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Abstract

INTRODUCTIONBreast cancer is in number second in the most occurring cancers list among humans and in the first place among women. In 2018, the percentage of breast cancer among newly diagnosed cases in both genders was 12.3%, and in women, it was 25.4% (excluding non‐melanoma skin cancer).1 In Belgium, the age‐standardized incidence rate of breast cancer was 113.2, which is the highest per 100 000 women, and this rate was 17.0 in Bangladesh.2 The incidence rate of breast cancer has an increasing trend, and it will increase in the future, as some prediction tools suggest.3–5 In Bangladesh, clinical data warehousing is not rich,6 but the information collected by different international organizations depicts that the incident rate is increasing speedily in Bangladesh. Moreover, the mortality rate is increasing because of the absence of breast cancer awareness in women, faulty screening tests, outdated medical treatment, and people not having faith in the medical procedure.7,8 In many developing countries, the picture of breast cancer patients depicts that doctors detect most breast cancer cases in the last stage of cancer because patients do not know the early warning signs and screening approaches of breast cancer. An early test of cancer leads to early detection of breast cancer and increases the chance of survival. Simple screening approaches like breast self‐examination and clinical breast examination are helpful to detect breast cancer, and knowledge of these approaches among people can compel authorities to employ early detection programs in a region.9The common warning signs of breast cancer are a lump in the breast or under the armpit, pulling in the breast, pain in the breast/nipple, puckering/dimpling breast skin, bleeding or discharge from the nipple, rash in the nipple or breast skin, redness of breast skin, and changes in the size of the breast due to swelling.10,11 The exact reason/factor behind unusual changes in the breast still can not be stated.12 Nevertheless, clinical and observational researchers pointed out some like being a woman, early menstruation, diet, late menopause, infertility, family history of cancer, overweight, smoking and alcohol consumption, physically inactive, not breastfeeding, trauma.13–22 To detect any abnormalities in the breast as early as possible, doctors suggest three screening approaches, and those are (a) breast self‐examination (BSE), (b) clinical breast examination (CBE), and (c) mammogram. Along with these, CT scans/sonography and biopsy are also used to confirm the abnormalities to be signs of breast cancer.23–26 Treatment of breast cancer depends on the type and stage of this cancer. Most breast cancer cases require surgical treatment‐ breast‐conserving surgery, mastectomy. Along with these surgeries, surgeons perform other necessary surgeries to remove cancer cells entirely, and doctors prescribe therapies either before or after the surgery.27The knowledge about the risk factors, early warning signs, screening methods and therapeutic methods can be varied respective to a person's educational level, economic status, family history of breast cancer and marital status.28 Also, several campaigns/interventions are showing fruitful results in improving the knowledge about breast cancer and encouraging women to practice screening approaches in their lives.29,30Many studies suggested the strong relation of level of awareness with the early detection of breast cancer,31,32 and most people had no interest in being conscious about screening approaches for breast cancer.32 However, developed countries provided that healthcare experts could explain the need for screening approaches to general people and increase the number of women attending the screening sessions.33,34 Several studies10,11,35–45 in the world aimed to discover the awareness levels of breast cancer among women. As far as we know, there is no such study conducted in Bangladesh that measured the awareness levels about risk factors, early warning signs, screening approaches, and therapeutic methods among women. Most of the studies conducted in Bangladesh only focused on obtaining the percentages of different factors influencing breast cancer.This study aims to find out the current awareness level about breast cancer among university‐level female students. Moreover, to identify which factors affect the awareness level of students. As we know, they have more access to various mediums to know the details of this than other sections of the population. Hopefully, this study will help policymakers plan intervention strategies to make women more aware of various aspects of breast cancer.METHODOLOGYWe conducted a cross‐sectional study on undergraduate and graduate‐level students in Sylhet city in the northeastern part of Bangladesh. There are six universities and five medical colleges, among which two universities and one medical college are public institutions in this city. Due to limited resources and lack of cooperation, the study population was female students of one university and one medical college. We considered students of five academic years (1st year, 2nd year, 3rd year, 4th year, Master's) of all departments from the university. Similarly, we included Medical College students of five academic years (1st year, 2nd year, 3rd year, 4th year, 5th year) and intern doctors.There were two groups in the population, and between them, one group had medical knowledge, and the other group had no such knowledge. The group with medical knowledge included female students of medical college, and the group with no such knowledge included the female students of the university. The calculation of sample sizes of the two groups followed the following procedure.We applied simple random sampling to collect a comparable and representative sample from each group without equal respondents in two groups. To get the required number of samples, we considered the level of significance, d = 0.05, Z‐score for 95% confidence interval, z = 1.96, and N = Population size.As we had no idea about the proportions aware of breast cancer, we selected p = 0.05, and so, q = 1 – p = .05. When estimating the sample size, the population size for the group having medical knowledge was N = 535 and for the other group receiving no medical knowledge was N = 3160. For calculating the total number of respondents included in the sample from two assemblies, we used the following equations46:n0=z2pqd2andn=Nn0N+n0Thus, the sample size for the group having medical knowledge for our study was 224, and the sample size of the other group was 343.We developed a semi‐structured questionnaire with various information about breast cancer and took different vital questions from the Breast Module of the Cancer Awareness Measure, developed by Cancer Research UK, King's College London, and University College London in 2009. Moreover, the questions of the last five sections were based on the American Cancer Society27 and different published articles.10,11,47 This questionnaire contained six sections, each one named with its proper heading indicating its topic. These sections had questions about socio‐demographic information, breast cancer risk factors (RF), early warning signs (EWS) of breast cancer, screening approaches (SA) and therapeutic methods (TM) of breast cancer, and barriers to seeking medical help related to breast. The first section contained socio‐demographic variables: age, height, weight, the institution of graduation, marital status, attending any breast cancer‐related educational campaigns or programs, seeing breast cancer‐promoting ads, and personal breast‐related problems. The second section had questions on risk factors, and the third section had questions on early warning signs of breast cancer. The fourth section had questions on screening methods, and the fifth section comprised Likert scale questions on different reasons for not taking medical help. Furthermore, the sixth section included questions for assessing the knowledge about therapeutic methods of breast cancer. All the questions used for the assessment of awareness levels were recorded as “Yes” and “No” options.We collected data from the halls of female students, which the educational institutions provide. We included students of different academic years randomly from February 2, 2019 to March 15, 2019. Data collectors went room to room and described the objective of the study. A student received a questionnaire if she was interested in participating voluntarily; otherwise was not bothered. We completed the data collection procedure by taking the necessary time allowing flexibility to the respondents.Data processing steps included data entry, data editing, and necessary adjustment for data analysis. For data processing steps, we used Statistical Package for Social Sciences (SPSS) version 22.0. We edited data on some sections‐ where respondents gave unfitting or meaningless answers and some places to get consistent results among respondents.We did descriptive analyses and stated mean (±SD) for numerical variables and percentage for categorical variables. We considered the structure of the dataset as a latent structure as we selected variables from the sections of risk factors, early warning signs, screening approaches and therapeutic methods, which are categorical variables with two categories‐ “Yes” and “No”. We wanted to find out distinct classes with similar understanding/knowledge among individuals and the chance of participants being in different classes. Furthermore, we analyzed this by applying latent class analysis (LCA) method to each section of the dataset individually to fulfill the aim. LCA was developed for this setting where multiple categorical variables describe one idea and a hidden categorical variable that influences those multiple variables. Participants were assessed based on having adequate or low knowledge about items of each section, and the correct answer for each question was finalized before applying the LCA. Then to measure the extent of effects of factors on the awareness levels about breast cancer, we used latent class regression (LCR), the extended version of LCA. LCR uses the constructed categories by the LCA as the dependent variable for running logistic regression. For factors, obtained coefficients can be converted into odds ratio (OR) to interpret them simply as the participant's chance of being in another category than the reference category. In this study, we used six factors that somehow connected to the awareness level of breast cancer. These factors are the age of respondents, marital status, personal breast problem history, ads promoting awareness about breast cancer, educational program/campaign, and relative with breast cancer. We used the statistical modeling program Mplus version 7.0 to run this part of the analysis.RESULTSAwareness levels of medical studentsThe mean (±SD) age of participants of the medical college was 21.61(1.56) years, and mean (±SD) height and weight were 1.58 (±0.05) meters and 53.04 (±9.10) kg, respectively. Among 224 medical students, the majority of them (97.32%) were single, 76.34% were never attending any programs/campaigns related to breast cancer, and a total of 75% of students saw ads that promoted awareness of breast cancer. In addition, 91.96% of students had no family history of breast cancer, and 62.05% did not practice breast self‐examination (Table 1).1TABLEDescriptive information about medical studentsVariablesCategoriesN (%)/Mean (±SD)Age in years21.61 (1.56)Height in inch62.10 (2.01)Weight in kg53.04 (9.10)BMIUnderweight41 (18.30)Normal128 (57.14)Overweight31 (13.84)Pre‐obese21 (9.38)Obese T‐12 (0.89)Obese T‐21 (0.45)Marital statusSingle218 (97.32)Married6 (2.68)Attending program/campaignYes53 (23.66)No171 (76.34)Seen awareness related AdsYes168 (75.00)No56 (25.00)TraumaYes25 (11.16)No199 (88.84)Know TMYes156 (69.60)No68 (30.36)Men_BCYes176 (78.57)No48 (21.43)Personal breast problem historyYesBreast lump1 (0.45)12 (5.36)Inflammation1 (0.45)Itching1 (0.45)Mastalgia1 (0.45)Unequal size1 (0.45)Pain6 (2.68)Rash in breast skin1 (0.45)No212 (94.64)Member with breast cancerYesMother3 (1.33)18 (8.04)Aunt9 (4.02)Sister1 (0.45)Cousin3 (1.33)Grandmother2 (0.89)No206 (91.96)DietYesBalanced Diet1 (0.45)26 (11.61)Less calorie food1 (0.45)Not mentioned12 (5.36)Not specific one1 (0.45)OMAD4 (1.79)Vegetarian7 (3.13)No198 (88.39)ExerciseYesDaily26 (11.61)119 (53.13)Sometimes78 (34.82)Rarely17 (7.59)No105 (46.88)Taught to do BSEYesParents5 (2.23)131 (58.48)Teacher90 (40.18)Friend8 (3.57)Ads1 (0.45)NGO agent/organization2 (0.89)Book4 (1.79)Internet18 (8.04)Magazine1 (0.45)TV/Newspaper2 (0.89)No93 (41.52)Practice BSEYesWeekly2 (0.89)85 (37.95)Monthly39 (17.42)Occasionally29 (12.95)Rarely15 (6.70)No139 (62.05)Ever done mammogramYes5 (2.23)NoNot old enough47 (20.98)219 (97.77)Financial constraint5 (2.23)Not interested84 (37.50)Others83 (37.05)Total224 (100.00)LCA produced two latent classes for medical students and calculated the percentage of being in a class to give one of two answers to breast cancer risk factors. Table 2 shows the prevalence of the correct answers to the questions about specific breast cancer screening approaches in constructed classes. After observing different percentages in these classes, the classes can be easily labeled based on awareness levels. Here, class‐1 contained 86.3% of participants and included students with relatively high knowledge about breast cancer risk factors, and class‐2 included 13.7% of participants having low knowledge level. Thus, in class‐2, the chances of answering “Yes” to questions about risk factors were relatively low. However, for not breastfeeding, the case was much high; even so, the chance was lower than that for class‐1. Furthermore, in the meantime, for class‐1, the percentage of answering “Yes” to any of the 11 questions was high enough.2TABLEAwareness (%) of medical students about RF into latent classes and size of classesRisk factors (RF)Class‐1 (high awareness)Class‐2 (low awareness)YesNoYesNoEarly Menarche53.3%46.7%19.2%80.8%Diet58.0%42.0%22.7%77.3%Late menopause73.2%26.8%31.0%69.0%Family history of breast cancer93.3%6.7%67.5%32.5%Infertility78.1%21.9%29.2%70.8%Being overweight/obese86.7%13.3%53.4%46.6%Smoking96.2%3.8%0.0%100.0%Alcohol consumption94.5%5.5%4.4%95.6%Not breast feeding94.3%5.7%70.7%29.3%Trauma65.2%34.8%29.0%71.0%Not being physically active73.0%27.0%48.4%51.6%Class size86.3%13.7%Through applying LCA on the responses of different early warning signs of breast cancer of medical students, we evaluate respondents' knowledge level about these warning signs. We found two classes, among which one class includes those respondents who have high awareness about these, and the other includes respondents with low awareness (Table 3). The class‐1 included most of the respondents, with 69.8%. From the correct answers to the questions about warning signs, we found two classes where class‐1 included respondents with high awareness and class‐2 had individuals with insufficient knowledge. We observed that the chance of answering “Yes” to questions about early warning signs in class‐1 was relatively high. In addition to this, the percentage of answering “Yes” was 100% for “lump or thickening in the breast” in class‐1. Whereas in class‐2, the chance of answering “Yes” was relatively low for each question, but for lump or thickening in the breast, something other than milk in the nipple, and pain in breasts/armpit, the chances were high.3TABLEAwareness (%) of medical students about EWS into latent classes and size of classesEarly warning signs (EWS)Class‐1 (high awareness)Class‐2 (low awareness)YesNoYesNoPulling in of nipple77.8%22.2%19.9%80.1%Pain in breasts/armpit82.6%17.4%60.4%39.6%Puckering/dimpling breast skin92.5%7.5%28.6%71.4%Bleeding or discharge something other than milk in nipple94.7%5.3%62.1%37.9%Lump or thickening in breast100.0%0.0%77.8%22.2%Nipple rash57.3%42.7%30.2%69.8%Redness of breast skin59.2%40.8%40.7%59.3%Lump or thickening under armpit90.1%9.9%55.0%45.0%Change in size of breast84.5%15.5%54.6%45.4%Class size69.8%30.2%The percentage of having accurate knowledge about screening approaches and practicing those approaches to detect breast cancer as early as possible among medical students was portrayed (Table 4). Applying LCA to answers given by medical students provides two classes representing awareness levels. Class‐1 having 70.2% of respondents, consisted of individuals with high awareness, and class‐2 had 29.8% of respondents with low awareness. In class‐2, the chance of answering “Yes” to “practice BSE” was meager, and the percentage of answering “Yes” for this question in class‐1 was about half. The chances of answering “Yes” in class‐2 were relatively low for other questions than in class‐1, but the values were not that small.4TABLEAwareness (%) of medical students about SA into latent classes and size of classesScreening approaches (SA)Class‐1 (high awareness)Class‐2 (low awareness)YesNoYesNoKnow about breast self‐examination (BSE)100.0%0.0%53.6%46.4%Practice BSE51.0%49.0%7.3%92.7%Clinical breast‐examination (CBE)86.7%13.3%41.5%58.5%Mammogram93.7%6.3%43.0%57.0%Biopsy93.1%6.9%57.9%42.1%CT scan/sonography76.3%23.7%61.5%38.5%Class size70.2%29.8%From the data of medical students, after applying LCA, we discovered two distinct latent classes and the percentage of correct answers to questions about therapeutic methods given by respondents in each latent group (Table 5). Class‐1 represented individuals having high awareness, and class‐2 represented those with low awareness about breast cancer. The size of class‐1 and class‐2 was 51.2% and 48.8%, respectively. The chance of answering “yes” to “Surgery or removal of the whole or part breast” was 100% for class‐1, while for class‐2, it was 18.6%. Although the chances of answering “Yes” to “Alternative medicine” were low for both classes, the opportunity was meager for class‐1.5TABLEAwareness (%) of medical students about TM into latent classes and size of classesTherapeutic methods (TM)Class‐1 (high awareness)Class‐2 (low awareness)YesNoYesNoSurgery or removal of whole or part of breast100.0%0.0%18.6%81.4%Chemical or radiotherapy98.3%1.7%11.3%88.7%Depends on disease stage98.3%1.7%11.3%88.7%Alternative medicine1.7%98.3%4.6%95.4%Class size51.2%48.8%The classes of LCA were used in the logistic regression of LCR and the second class was the reference category. After applying LCR, we discovered that for risk factors of breast cancer, the age of respondents had a significant positive effect on being a respondent in the high awareness group (OR = 1.63; 95% CI = [1.21, 2.21]). Furthermore, having a family history of breast cancer also positively affected being in the high awareness group, but the impact was not significant (OR = 3.16; 95% CI = [0.30, 33.33]). Also, we could see that other factors had no positive or significant effect on being in class‐1. Determinants having a negative impact, but not notable were personal breast problem history (OR = 0.34), being married (OR = 0.35), educational program/campaign related to breast cancer (OR = 0.52), and ads that promote awareness about breast cancer (OR = 0.63). For early warning signs of breast cancer, the age of respondents significantly affected the respondents to be in high awareness class (OR = 1.57; 95% CI = [1.16, 2.13]). Having seen ads that promote breast cancer awareness positively affected being in high awareness class, but the impact was not significant (OR = 2.05; 95% CI = [0.89, 4.70]). OR portrayed that Respondents having relatives with breast cancer tended to be in the high awareness class, and the association had not been found significant (OR = 1.43; 95% CI = [0.39, 5.25]). Moreover, being married (OR = 0.18), personal breast problem history (OR = 0.68), and program/campaign related to breast cancer (OR = 0.94) had a negative effect, although the impacts were not significant (Table 6).6TABLEOdds ratio (OR) and 95% confidence interval of OR for the effects of different factors on awareness level about different aspects of breast cancer of medical studentsIndependent variablesDifferent aspects of breast cancerRisk factors OR (95% CI)Early warning signs OR (95% CI)Screening approaches OR (95% CI)Therapeutic methods OR (95% CI)Age1.63a (1.21, 2.21)1.57a (1.16, 2.13)2.66a (1.64, 4.31)1.88a (1.46, 2.42)Marital statusb (married)0.35 (0.05, 3.53)0.18 (0.02, 1.42)0.02 (0.00, 0.25)0.30 (0.07, 1.38)Program campaign0.52 (0.20, 1.32)0.94 (0.35, 2.50)1.86 (0.59, 5.88)1.64 (0.76, 3.53)Ads0.63 (0.22, 1.79)2.05 (0.89, 4.70)1.80 (0.68, 4.76)1.62 (0.80, 3.28)Personal breast problem history0.34 (0.08, 1.48)0.68 (0.17, 2.72)2.38 (0.21, 26.81)0.79 (0.16, 3.80)Member with cancer3.16 (0.30, 33.33)1.43 (0.39, 5.25)0.35 (0.06, 1.95)0.79 (0.25, 2.45)Note: Class‐2 (low level) is reference class.ap‐value <.05.bReference category is single.Same as earlier aspects, the age of respondents had a positive and highly significant effect on respondents being in high awareness class (OR = 2.66; 95% CI = [1.64, 4.31]) in case of screening approaches of breast cancer. Along with this, factors having positive effect but not significant, in order of importance, were personal breast problem history (OR = 2.38; 95% CI = [0.21, 26.81]), program/campaign related to breast cancer (OR = 1.86; 95% CI = [0.59, 5.88]) and ads that promote breast cancer awareness (OR = 1.80; 95% CI = [0.68, 4.76]). It was also evident that being married had a significantly negative impact on an individual in high awareness class. Having a family member/relative with breast cancer had a negative impact but was not significant. As we can see, like other parts, the age of respondents had a significantly positive effect on individuals being in high awareness class (OR = 1.88; 95% CI = [1.46, 2.42]) for therapeutic methods of breast cancer. On the other hand, programs/campaigns related to breast cancer (OR = 1.64) and ads promoting awareness of breast cancer (OR = 1.62) positively but not significantly impacted individuals in high awareness class. Moreover, being married (OR = 0.30), personal breast history problem (OR = 0.79), having a relative with breast cancer (OR = 0.79) had a negative but not significant effect on individuals being in class‐1 (Table 6).Awareness levels of university studentsThe mean (±SD) age of university female student participants was 22.59 (±1.55) years, and the mean (±SD) height and weight of them were 1.56 (±0.06) meters and 51.24 (±8.39) kg. Among 343 female university students, 93.88% were single, and 88.92% of students never attended any breast cancer‐related campaign or programs, but 63.56% had seen ads promoting breast cancer awareness. Around 13% of students had a family history of breast cancer, but only 18.37% practiced breast self‐examination (BSE) (Table 7).7TABLEDescriptive information about university studentsVariablesCategoriesN (%)/Mean (SD)Age in years—22.59 (1.55)Height in inch—61.40 (2.30)Weight in kg—51.24 (8.39)Marital statusSingle322 (93.88)Married21 (6.12)BMI statusUnderweight76 (22.16)Normal185 (53.94)Overweight44 (12.83)Pre‐obese33 (9.62)Obese T‐15 (1.46)Attend program/campaignYes38 (11.08)No305 (88.92)AdsYes218 (63.56)No125 (36.44)Member with breast cancerNo299 (87.17)Yes44 (12.83)Mother6 (1.75)Aunt21 (6.12)Sister1 (0.29)Cousin8 (2.33)Others6 (1.75)Grandmother6 (1.75)Personal breast problemYesPain17 (4.96)27 (7.87)Rash in breast skin5 (1.46)Mastitis1 (0.29)Soreness1 (0.29)Discharge something from nipple1 (0.29)Dimpling in Breast skin1 (0.29)Breast tumor1 (0.29)No316 (92.13)SmokingYes6 (1.75)No337 (98.25)AlcoholYes4 (1.17)No339 (98.83)DietYes24 (7.00)No319(93.00)ExerciseYesDaily21 (6.12)114 (33.24)Sometimes70 (20.41)Rarely23 (6.71)No229 (66.76)TraumaYes99 (28.86)No244 (71.14)Men_BCYes148 (43.15)No195 (56.85)Practice BSEYesMonthly15 (4.37)63 (18.37)Occasionally31 (9.04)Rarely17 (4.96)No280 (81.63)Taught to do BSEYesParents11 (3.21)106 (30.90)Sister2 (0.58)Cousin1 (0.29)Aunt1 (0.29)Teacher13 (3.79)Doctor17 (4.96)Nurse1 (0.29)Friend21 (6.12)Internet34 (9.91)Newspaper3 (0.87)TV1 (0.29)Health related program1 (0.29)No237 (69.10)Ever done MamYes1 (0.29)NoNot old enough9 (2.62)342 (99.71)Do not know it283 (82.51)Not interested30 (8.75)Financial constraint5 (1.46)Didn't face any problem2 (0.58)Didn't find abnormalities1 (0.29)Didn't think about it2 (0.58)Not needed10 (2.92)Know TMYes117 (34.11)No226 (65.89)Total343 (100.00)Table 8 shows the percentage of the correct answer to questions about different risk factors given by university students in terms of two latent classes. Class‐2 included individuals with high knowledge about risk factors defined as high awareness class and class‐1 with less knowledgeable individuals. Here, class‐2 contained 73% of study participants, whereas class‐1 had 27%. In class‐1, the percentage of answering “Yes” to each question was lower than in class‐2. Although the percentages of answering “Yes” to questions were higher than class‐1 for some questions, the chances were not high enough such as for Early Menarche, the chance of answering “Yes” was only 33.8% (Table 8).8TABLEAwareness (%) of university students about RF into latent classes and size of classesRisk factors (RF)Class‐1 (Low awareness)Class‐2 (High awareness)YesYesYesNoEarly Menarche12.3%33.8%33.8%87.7%Diet7.0%31.8%31.8%93.0%Late menopause23.5%51.2%51.2%76.5%Family history of breast cancer35.3%76.4%76.4%64.7%Infertility16.0%65.2%65.2%84.0%Being overweight/obese29.7%60.5%60.5%70.3%Smoking6.9%91.0%91.0%93.1%Alcohol consumption0.0%88.3%88.3%100.0%Not breast feeding45.3%86.3%86.3%54.7%Trauma17.2%30.8%30.8%82.8%Not being physically active26.6%50.5%50.5%73.4%Class size27.0%73.0%The LCA assessed the awareness level of university students about early warning signs of breast cancer which provided two latent classes. Regarding the percentage of correct answers to early warning signs in two classes, we could see that class‐1 included individuals with low awareness about warning signs of breast cancer with 33.2% of the study population, and class‐2 contained high aware individuals (66.8%). In class‐1, the probability of answering “Yes” for any of the nine questions was very low, while in class‐2, the probabilities were high enough. For instance, the chance of correct answer for “something other than milk in nipple” was 81.8% in class‐2 while 11% in class‐1 (Table 9).9TABLEAwareness (%) of university students about EWS into latent classes and size of classesEarly warning signs (EWS)Class‐1 (low awareness)Class‐2 (high awareness)YesNoYesNoPulling in of nipple7.4%92.6%40.9%59.1%Pain in breasts/armpit22.3%77.7%81.5%18.5%Puckering/dimpling breast skin7.8%92.2%69.9%30.1%Bleeding or discharge something other than milk in nipple11.0%89.0%81.8%18.2%Lump or thickening in breast4.3%95.7%68.6%31.4%Nipple rash7.0%93.0%48.1%51.9%Redness of breast skin9.3%90.7%51.7%48.3%Lump or thickening under armpit1.3%98.7%56.5%43.5%Change in size of breast11.2%88.8%69.1%30.9%Class size33.2%66.8%Table 10 shows the percentages of correct answers to the questions about screening approaches in terms of the latent class, and from this prevalence, we could understand that class‐1 contained students with low awareness level and class‐2 consisted of individuals with low awareness level. From the class size, we found that only 35.9% of individuals had a high level of knowledge, and 64.1% had a low level of knowledge about screening approaches for breast cancer. The probability of practicing BSE was 0% in class‐1, while the chance was 51.1% in class‐2. However, the chance of answering “yes” for “CT scan/sonography” was only 35% in class‐2, and in class‐1, the chance was lower than that (Table 10).10TABLEAwareness (%) of university students about SA into latent classes and size of classesScreening approaches (SA)Class‐1 (low awareness)Class‐2 (high awareness)YesNoYesNoKnow about breast self‐examination (BSE)15.6%84.4%94.7%5.3%Practice BSE0.0%100.0%51.1%48.9%Clinical breast‐examination (CBE)8.4%91.6%62.1%37.9%Mammogram2.2%97.8%41.6%58.4%Biopsy36.7%63.3%61.2%38.8%CT scan/sonography17.2%82.8%35.0%65.0%Class size64.1%35.9%The LCA identified distinct classes from study participants of the university regarding the prevalence of correct answers to therapeutic methods. From the percentage of the correct answers in two latent classes, we found that class‐1 contained most of the participants (75.3%) who had a low level of knowledge about therapeutic methods, while class‐2 included individuals with a high level of knowledge (24.7%). For Surgery/removal of whole or part of the breast, the correct answers were 100% in class‐2, while 8.6% in class‐1 (Table 11).11TABLEAwareness (%) of university students about TM into latent classes and size of classesTherapeutic methods (TM)Class‐1 (low awareness)Class‐2 (high awareness)YesNoYesNoSurgery or removal of whole or part of breast8.6%91.4%100.0%0.0%Chemical or radiotherapy2.8%97.2%92.9%7.1%Depends on disease stage0.4%99.6%97.9%2.1%Alternative medicine0.8%99.2%1.2%98.8%Class size75.3%24.7%LCR indicated the impacts of six factors on individuals of the university being in high awareness class. In LCR, latent classes were dependent variables, and class‐1 (low awareness) was the reference class like logistic regression. The obtained coefficients of six factors were easy to interpret as OR of belonging in other classes rather than reference one. The coefficients associated with factors for the aspect “risk factors” of breast cancer showed that being married (OR = 1.82; 95% CI = [0.51, 6.44]), personal breast problem history (OR = 1.77; 95% CI = [0.57, 5.53]), ads promoting awareness about breast cancer (OR = 1.36; 95% CI = [0.76, 2.45]), relative with breast cancer (OR = 1.14; 95% CI = [0.46, 2.83]) and age (OR = 1.05; 95% CI = [0.86, 1.30]) had positive but not significant impact on individuals being in high awareness group rather than reference one while educational program/campaign (OR = 0.90; 95% CI = [0.36, 2.21]) had negative but insignificant effect. All six factors had an insignificant impact on differentiating class‐2 from class‐1. From the results, for the early warning signs, it was clear that ads promoting awareness about breast cancer had a significant positive impact on participants being in high awareness class than reference class (OR = 5.85; 95% CI = [3.20, 10.67]). Though educational program/campaign had more positive impact but the impact was not significant (OR = 10.14; 95% CI = [0.06, 1705.14]). Other factors had not any significant effect on distinguishing the latent classes. The factors with significant positive effect on the level of awareness about screening approaches of breast cancer were personal breast problem history (OR = 6.33; 95% CI = [2.06, 19.46]), promotional ads of breast cancer awareness (OR = 4.31; 95% CI = [2.24, 8.31]), educational program/campaign (OR = 3.38; 95% CI = [1.31, 8.76]) and age (OR = 1.20; 95% CI = [1.01, 1.44]). From the results for therapeutic methods, educational program/campaign had positive significant impact on differentiating two classes (OR = 2.49; 95% CI = [1.26, 4.94]) while being married (OR = 2.17; 95% CI = [0.89, 5.29]), ads promoting awareness (OR = 1.61; 95% CI = [0.93, 2.81]) and relatives with Breast Cancer (OR = 1.79; 95% CI = [0.90, 3.57]) had positive effects which were not much significant (Table 12).12TABLEOdds ratio (OR) and 95% confidence interval of OR for the effects of different factors on awareness level about different aspects of breast cancer of university studentsIndependent variablesDifferent aspects of breast cancerRisk factors OR (95% CI)Early warning signs OR (95% CI)Screening approaches OR (95% CI)Therapeutic methods OR (95% CI)Age1.05 (0.86, 1.30)1.06 (0.86, 1.31)1.20a (1.01, 1.44)1.05 (0.90, 1.23)Marital statusb (married)1.82 (0.51, 6.44)0.90 (0.32, 2.49)1.43 (0.48, 4.25)2.17 (0.89, 5.29)Program campaign0.90 (0.36, 2.21)10.14 (0.06, 1705.14)3.38a (1.31, 8.76)2.49a (1.26, 4.94)Ads1.36 (0.76, 2.45)5.85a (3.20, 10.67)4.31a (2.24, 8.31)1.61 (0.93, 2.81)Personal breast problem history1.77 (0.57, 5.53)2.27 (0.72, 7.21)6.33a (2.06, 19.46)1.79 (0.79, 4.07)Member with cancer1.14 (0.46, 2.83)1.01 (0.37, 2.75)1.50 (0.66, 3.43)1.79 (0.90, 3.57)Note: Class‐1 is reference class.ap‐value <.05.bReference category is single.DISCUSSIONBreast cancer awareness is paramount to diagnose it early and is the most common cancer among women (excluding skin cancer). Being aware of this cancer can reduce the chance of developing breast cancer. Many organizations worldwide are focusing more on the awareness part of breast cancer. They are organizing various campaigns, online tutorials, booklets to teach people of all ages about the importance of early detection and factors that might influence the development of breast cancer. Early detection of breast cancer helps specialists destroy the cancer cell as early as possible, and the treatment of cancer becomes less costly with a higher possibility of recovery. This investigation explored the level of awareness about the risk factors, early warning signs, screening modalities, and therapeutic approaches taken by medics of breast cancer among university and medical students. It also helped to know different factors which could influence their curiosity to be familiar with other aspects of this cancer.The current study gives information on the awareness levels about different parts of breast cancer among university and medical students. The knowledge about breast cancer risk factors among university and medical students is high. However, a relatively small number of university students identified trauma, diet, and early menarche as risk factors of breast cancer. In contrast, the least number of medical students did the same for early menarche and diet. Furthermore, a cross‐sectional study on Iranian adult women provided low awareness about breast cancer risk factors.11 Another cross‐sectional research on university students of UAE displayed relatively low knowledge about different risk factors before the awareness program, which changed at the end of the study.35 Finally, another survey of medical and non‐medical program university students in Angola revealed the same results, depicting the low level of awareness.36 Thus, our findings on risk factors are inconsistent with some studies.11,35–38 Our analysis also revealed that the awareness level about early warning signs of breast cancer was high among university and medical students but not high enough among medical students. It is presumed that medical students will have proficient knowledge about the different diseases, and from that assumption, the awareness level is compared. On the other hand, nipple rash and redness of breast skin had a lower percentage of the correct answer to be recognized as an early warning sign by medical students and the same for pulling in of nipple, redness of breast skin, and lump or lump thickening under armpit by university students. Some earlier studies provided lower levels of knowledge about early warning signs than our research.11,36–39 That could be due to the education level48 and the availability of sources of breast cancer information for the study participants. Our research discovered adequate knowledge about screening approaches of breast cancer among medical students and insufficient knowledge among university students. Although having high knowledge about screenings, only about half of medical students had been practicing BSE. On the other hand, practicing BSE was least commonly done by university students because of insufficient knowledge. Other than that, the knowledge about mammogram and CT scan/sonography is much low among them. Several studies regarding this topic showed almost similar insufficient knowledge for university students about screening approaches among participants.11,39,42 Surprisingly, participants of the university who had high knowledge about screening methods had inadequate knowledge about mammogram and CT scan/sonography. Among medical students who knew the procedure of BSE‐ most of them learned about this process from their teacher/professor, which is quite normal for medical students. This source does not exist for university students, and most of the university students acquired knowledge of this procedure from the internet and mixed sources. Those sources taught them about this process, and they are also actively doing their part. However, we found that different educational programs or campaigns must be held more in various areas or institutions to familiarize women with BSE better.Our study aimed to discover the awareness about widely‐known curative methods of breast cancer, and the result displayed that awareness level is very low for university students. Surprisingly, the level is also low for medical students. Those university and medical students who had high knowledge about curative procedures gave a high rate of correct answers for each option. A study in India among women of a rural district found low knowledge about therapeutic methods43 also among the Iranian adult women.11 The literature review revealed few published papers about the knowledge of therapeutic procedures to make a proper comparison. Our findings might be the result of the therapeutic methods being complicated and not known to general people. Also, the therapeutic methods are available for medical students to be informed about after a specific time in their degree period, which can justify this result for medical students. From the overall findings of the level of awareness about four sections of breast cancer, on average, we found high awareness among students compared to other published studies on different groups of populations.The levels of awareness among participants are varied because of their personal information, and necessary steps can change most of the reasons. For medical students, one common influential factor was the respondent's age, and it is evident that the final year students had better knowledge about the aspects of breast cancer than the first‐year students. Alternatively, for university students, age did not effectively influence the awareness levels, which is usual as they will not get any extra course regarding this topic at any level of their education.We found a significant but negative association between marital status and awareness about screening approaches among medical students. A study on Jordanian nurses showed no significant association between marital status and performing BSE,49 and another study on Saudi adult women showed an insignificant effect of marital status on the knowledge of breast cancer.45 On the other hand, a significant association existed between awareness level of screening approaches and marital status, a family member with breast cancer, educational qualification among women in Riyadh.41 A study showed a strong association in Australian women between knowledge and practice of screening approach and factors like marital status, personal history of the breast problem, and age. However, it was found that women over 65 years were not interested in doing BSE, and women of the reproductive age group were concerned about examining their breasts.50 Our findings might be the consequences of having a low number of married students and different age groups. At the same time, other articles argued in favor of influential association by indicating that married people are usually more worried about their health condition because they have more chance of getting affected by the different refractory disease.In university students, we found a positive and significant association between age, attending program/campaign, ads promoting awareness about breast cancer, personal breast problem history, and awareness level about screening approaches. Personal breast problem history is an essential factor for awareness about screening approaches because it is evident that after feeling any pain or seeing any unusual changes in the breast, women tend to see doctors. Furthermore, from there, women got to find out different screening methods. It also indicates that students are concerned about their health symptoms and always consult doctors if they find any unusual changes. Moreover, a significant association existed between attending programs/campaigns and awareness levels about therapeutic methods for university students. University students showed that ads promoting awareness about breast cancer could help them get accurate knowledge about breast cancer early warning signs. However, we could not find any significant factors among university students for the knowledge of breast cancer risk factors. In Bangladesh, there are a few ads promoting awareness about any part of breast cancer, and the number of such ads must be increased covering every aspect of breast cancer. Along with this, in each educational institution, programs/campaigns that give details about breast cancer should be organized every year.As awareness about breast cancer is necessary among women, especially aged 15–49 years, the main strong point of this study is that we want to know the extent of knowledge about this among students in Bangladesh who have more access to materials of the necessary information and this type of study was already done in many other countries but not any significant research in Bangladesh. Besides, the statistical technique used in the current study provides fair and trustworthy results about the levels of awareness and effective factors that vary the awareness level about breast cancer.The limitation of this study is that only two educational institutes of one city of Bangladesh were used for participants to investigate the awareness levels. This study can be extended by considering more undergraduate and graduate students or more women aged 15–49 years from every district in Bangladesh. This study is conducted using simple random sampling, and further study can be run by using other random sampling techniques and more samples. Cluster sampling procedure may also be used to investigate the breast cancer patients in different divisions in Bangladesh. Also, to get an in‐depth understanding of the factors that influence the awareness among women, mixed‐method research approaches are possible to employ.CONCLUSIONThe current study revealed a moderately low awareness level about the screening approaches and therapeutic methods among university students and relatively high awareness among medical students. However, the awareness level concerning breast cancer risk factors was moderate among medical and university students. The results exposed the fact that female students having personal breast problem history, attending programs related to breast cancer, seeing informative ads on breast cancer tended to have a high awareness of breast cancer. Educational programs about breast cancer in every educational institute, events at the community level to raise awareness among women, and voluntarily learning about breast cancer from online events, web pages, and tutorials using technology could be practical steps to take.ACKNOWLEDGMENTSWe want to acknowledge the principal and academic staff of Sylhet Women's Medical College for their support throughout the data collection process. We appreciate the help of study participants for their voluntary participation and the assistance of Shahnaj Sultana Sathi and Mitu Akter in the data collection process. The author(s) received no financial support/specific grant for the research, authorship, and publication of this article from any funding agency in the public, commercial, or not‐for‐profit sectors.CONFLICT OF INTERESTThe authors declare no conflicts of interest.AUTHOR CONTRIBUTIONAll authors had full access to the dataset used in this study and took full responsibility for the analysis, the accuracy, and the representation of the data. Mst. Farzana Akter: conceptualization, data curation, formal analysis, investigation, methodology, validation, visualization, and writing‐original draft. Mohammad Ohid Ullah: conceptualization, methodology, supervision, validation, writing‐review & editing.ETHICS STATEMENTThe study was approved by the ethical/research (Thesis) committee 2018 (Session 2016–2017) [Regi/161(council)/1/2233] of the Department of Statistics department, Shahjalal University of Science and Technology, Sylhet, Bangladesh. 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Journal

Cancer Reports – Wiley

Published: Nov 1, 2022

Keywords: breast cancer; cancer education; epidemiology; women's cancer

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