Key words: KAP on Breast Cancer Screening and Management, PHHC

Cancer of the breast is the most common cancer among women. The burden of breast cancer has increased steadily, almost doubling, in terms of estimated new cases annually over a 20 year span. Breast cancer was third in frequency in men and women taken as a group, and by far it is the most prevalent cancer in women with more than one million cases and nearly 600,000 deaths occurring worldwide annually [1]. The incidence rates are increasing in all countries with available statistics, and since women are at risk from the ages of late 30's, the impact of the disease is magnified.[2] The highest mortality rate (ASR) in Arabic countries was in Lebanon (ASR = 23.4), and in Gulf countries was in Bahrain (ASR = 17.7). In Saudi Arabia, 677 deaths from breast cancer were reported and it has a mortality rate of 10, which makes breast cancer the second leading cause of all cancer- related death.

Studies of the etiology of breast cancer have failed to identify feasible primary prevention strategies suitable for use in the general population, so, reducing mortality from breast cancer through early detection has become a high priority.[2] Breast cancer is a progressive disease, and small tumors are more likely to be early stage disease, have a better prognosis, and are more successfully treated. [3] In a retrospective study to determine the effectiveness of screening mammography in a community medical setting, the result showed that among the patients who did not have previous screening mammography, 65.7% were diagnosed with "advanced" breast cancer (stages II, III, IV), while only 39.9% who had previous screening mammography were diagnosed with advanced breast cancer (p < 0.001).[4]

The value of CBE as a screening tool for breast cancer cannot be specifically determined due to lack of randomized trials demonstrating CBE's independent contributions to reduced mortality.[5] Several studies have evaluated the proportion of cancers identified by CBE that were not detected by mammography. The highest levels were in older studies and/or where mammography sensitivity was lower than that attained by current technology.[6-10]

Several studies showed that physicians' ordering of screening depended on: levels of confidence and comfort, and knowledge of breast screening guidelines,[11] their colleague's mammography practices, the adequacy of insurance coverage, and how often they had spent an unreasonable time explaining mammography results, [12] beliefs of physicians and patient preference for a female provider,[13] and physicians being younger, female, and internists.[1]

Some studies on BC screening knowledge among medical practitioners showed: medical students reported needing additional training in clinical breast examination and recommended more curricular time devoted to education about breast cancer screening is needed,[14] although they agreed with published guidelines for screening mammography use, practitioners tended to have relatively low levels of knowledge about breast cancer risk factors, and the effectiveness of other breast cancer screening methods, and tended to over-estimate their breast cancer screening knowledge and skills.[15]

In another study, no significant difference was found between the physicians who received and those who did not receive coaching and supportive interventions over the course of the academic year. A difference was noted on compliance with BSE by those who received training evidencing more compliance.[16]

The present research assessed the effects of breast cancer early detection training program on the knowledge, attitudes, and practice of female PHHC physicians.

This is a non-randomized quasi experimental design, with 45 PHCCs' female physicians in Al Khobar, and Al Qatif cities (experimental group) and 41 PHHCs' female physicians in Al Dammam City (control group) during the period: Oct 2003- Feb 2004 participating. The workshop consisted of 5 lecture sessions using power point presentations about epidemiology and burden of breast cancer, risk factors of breast cancer, evidence-based screening programs and screening guidelines, breast cancer management, and follow up of survivors of breast cancer, resource speaker-sharing of her case and group discussion afterwards, group discussion and problem solving sessions on how to deal with breast lumps in PHHC and the physicians' future view of breast clinic in the PHHCs, practical sessions designed to improve the participants' examination skills, distribution of instructional materials in the form of a manual on breast cancer detection program which included the workshop's time table, rationale, aim objectives, topics, methods, approaches, updated content materials and health education materials, and evaluation.

The dependent variables of the study were the PHHC's physicians' knowledge, attitudes, and practice (KAP) on breast cancer screening and the independent variables were PHHC's physicians' demographic characteristics and workshop attended. Each participant in the control group carried out the examination of the models then completed the questionnaire under supervision of the investigator. The experimental group attended the workshop which consisted of: distribution of instructional materials, five lecture sessions of 10 to 30-minutes, a case study and group discussions of a patient who was invited, and group discussion and problem solving sessions. A 55-minute videotape was used as a guide to the clinician through step-by-step exercises. During the lecture sessions and problem solving sessions, the Mamma Care model of clinical learning system was used.

A 3-part structured questionnaire (demographic data, general knowledge, and early detection) based on fundamental knowledge of breast cancer and early detection was used as a data gathering tool. The knowledge measurement is composed of 65 close-ended items with two choices (agree/disagree). A 30-item like type of 5 choices questions were used to assess the attitudes of physicians. The Mamma Care program models were used to assess the ability of the physicians in detecting lumps and evaluating the nature of breast tissues.

Another part of the assessment tool was the practice part totaling 16 points which assessed the lumps using two breast models with 5 lumps. The cut-off points of Knowledge and Practice are: Poor < 60% , Good 61-80 %, Excellent >80%. The cut-off points of attitudes were determined after taking the mean of all the respondents.

A pilot study was conducted using the tools of data collection to assess the reliability of the research tool, which was found to be highly reliable (Cronbach a coefficient of 0.80). Face validity and content validity were also established with the aid of experts on the field in Saudi Arabia. The Statistical Package for Social Science (SPSS) version 10 was used for data entry and analysis and decided to use a p value of <0.05 level of significance (with 95% confidence interval). The study followed strict ethical considerations.

The sample group of the study, shown in Table 1, was composed of 75 or 96% of the 78 PHC female physicians who were available at the time of the study. The findings, that 65% of the physicians were Saudi having mean and median ages of 35.93±7.23 and 36 age of years, respectively, indicate that a good number of younger Saudi female physicians are working in the 3 cities of Al Dammam, Al Khobar and Al Qatif. The respondents' mean ages, duration of medical practices in general and PHCCs in particular, are lower than what is in literature.9,10,11,12 Most of the physicians in the study (95%) did not undergo post graduate training as compared to literature wherein 46% are family physicians. The 5 physicians (5%) in the study who had master's degree in pediatrics (3), obstetrics (1), and gynecology (1) were also working as general physicians.

The average scores of the female physicians on the indicators of knowledge before intervention shown in Figure 1 were as follows: epidemiology of BC was 78%, BC in Saudi Arabia was 60%, presentation was 47%, BC management was 83%, recommendation follow-up in BC survivors was 74%, BC risk factors was 69%, and BC screening guidelines was 73%. The total score on knowledge in Figure 2 was 64%, total score on attitudes was 68%, total score on examination of BC was 40%, and overall total score was 36%.

In general, there were significant statistical differences after the educational program shown in Table 1 in the knowledge, attitude, and practice of physicians regarding BC detection and management. There were significant statistical changes after the education program in the physicians' knowledge regarding BC epidemiology shown in Table 2 in seven items: the burden of breast cancer increase in western countries (p =0.016), increases in BC incidence rate are seen in an area that previously had low rates (p<0.001), low success of BC treatments (p =0.016), the female BC age (ASR) in Saudi Arabia was 14.1 per 100000 (p< 0.001) BC rate was the highest rate of all types of cancer (p< 0.001), The highest BC ASR in Riyadh and Eastern Region (p< 0.001), and the nature of BC in Saudi Arabia is not the same as in the western countries (p< 0.001).

There were significant statistical changes in other knowledge parameters, shown in Table 3: in BC presentation, BC management, BC recommendation for primary care follow up in breast cancer survivors, BC risk factors, BC screening tests, and BC screening guidelines.

In BC presentation, only in the parameter obvious skin changes in the breast as late BC presentation, no change had occurred since the doctors got correct responses before the workshop. In other BC presentation parameters, the improvements in correct responses are significant at p<0.001.

In BC management, the doctors showed improvement in correct responses in new adjuvant chemotherapy is the standard of Rx for localized and advanced BC at p< 0.01, while in the other parameter not much improvement occurred because almost all doctors gave the right answer at the start and after the study they all gave the correct answers. In recommendation for primary care follow up for breast cancer survivors, great improvement at p <0.001 were achieved in correct responses in routine laboratory testing CBC, LFT, blood chemistry annually. The doctors got high correct scores before the workshop in the other parameters of recommendation for primary care follow up for breast cancer survivor.

In Knowledge of BC high risk factors, significant gains in correct answers were found in the following factors: age (p= .003), paternal and maternal relatives (p= .039), FH of ovarian cancer (p= .039), FH of BC at age <45 (p= .006), race (p< .001), late menarche (p= .013), nulparous (p= .016), parous having few children with a late age at 1st and subsequent birth (p < .001), early age at menopause (p = .021), prior breast pathology (p< .001), rapid growth and great adult height (p< .001), total fat and saturated animal fat intake (p = .008), meat intake (p < .001), alcohol (p = .004), endogenous free estrogen (p< .001), oral contraception (p = .004), postmenopausal estrogen-progesterone therapy (p< .001), frequent chest x-ray or fluoroscopy (p< .008), electromagnetic fields (p< .001), and stress (p< .001).

There were significant statistical changes after the education program in the doctor's BC screening tests except on the following items: mammography sensitivity is 77-95% and specificity of 94-97% and ultrasonography is not to be used for routine screening. Significant changes were achieved after the program in the following items of BC screening guidelines: BCE by professional advice to all women ³ 20 years (p< .001), mammography is the only screening method that proves to decrease BC mortality and morbidity (p< .001), because mammography and BCE is variable sensitive, BSE has been advised also to women > 20 yrs old (p= .013). The correct responses of doctors before the program in other items were already high.

There were significant statistical changes after the education program in the physician's attitude toward breast cancer (Table 4). The total attitude score improved significantly and improved significantly on items: Women will attend BC screening program if the PHC doctor will advice them to go (p= .013), treatment modality of BC depends on the histological types and stage of the disease not the patient choice (p< .001), and the patient should be referred to psychiatry after diagnosis of BC (p= .007).

The physicians' practice responses totally improved (p< .001), as shown in Table 5: Each item improved significantly too as follows: Comparing the nature of the two breasts (p=.014), total score of nodular lump examination (p< .001), and total score of soft examination (p< .001). They also significantly improved in identifying all kind of both soft and nodular lumps as shown in Table 6.

Like other studies in literature 17,18,19,20 the findings of the study show that intervention programs to improve the KAP of physicians increase their KAP significantly and therefore significant increase in their utilizing of BC early detection screening is to be expected.

From the results of the study, the following are stated: (1) Before intervention was given, the physicians had good knowledge about breast cancer and early detection but scored low regarding practice of BC early detection and had a negative attitude of it too, and (2) After the educational program, there were significant positive changes in physicians KAP.

The conclusions showed that programs for the improvement of BC KAP should be part of the medical curriculum and for those who had not taken some programs in their undergraduate medical training, BC KAP intervention programs should be part of PHC physicians' CME. A replication of this study to be conducted to all PHC physicians would an interesting thing to do.