Breast cancer is a leading cause of mortality among women in the United Arab Emirates (UAE). Many young women in the UAE have poor knowledge about breast cancer screening, including risk factors and warning signs/symptoms. We investigated awareness about breast cancer and breast self-examination (BSE) as a screening tool among female students at the University of Sharjah, UAE. This study used a cross sectional survey design. Participants were 241 undergraduate female students (aged ≥18 years) from three University of Sharjah campuses. Data were collected from March to April 2017 using a self-administered questionnaire. The questionnaire covered: sociodemographic characteristics; knowledge about breast cancer, risk factors, and warning signs/symptoms; and knowledge and practice of BSE. Data were analyzed using descriptive statistics and Pearson’s chi-square tests. About 38.6% of participants were from the Medical campus, 37.3% were from the Women’s campus, and 24% were from the Fine Arts and Design campus. Most (99%) participants had heard of breast cancer. About 50% were knowledgeable about the risk factors, but only 38% were knowledgeable about warning signs/symptoms. The most commonly identified risk factors were family and personal histories of breast cancer, and the most commonly identified warning sign/symptom was breast lump. There was a significant association between knowledge about risk factors and campus type. Participants from the Medical campus were more knowledgeable about risk factors than participants from the other two campuses. Overall, 68.5% of participants had heard of BSE, but few participants actually performed BSE. Reasons for not performing BSE included “forgetting” and “not knowing how.” Although most participants were aware of breast cancer, knowledge about risk factors and warning signs/symptoms was relatively poor. Knowledge about performing BSE was particularly low. This highlights the importance of increasing awareness about breast cancer and BSE among young women in the UAE. Breast cancer claims the lives of hundreds of thousands of women each year and affects countries at all levels of modernization . In 2018, there were 2.1 million newly diagnosed breast cancer cases among women, accounting for almost one in four cancer cases among women . The World Health Organization (WHO) reported that an estimated 627,000 women died from breast cancer in 2018, representing approximately 15% of all cancer deaths among women . Breast cancer is the second most common cancer in the world and the most frequent cancer among women, with an estimated 1.67 million new breast cancer cases diagnosed in 2012 . Globally, breast cancer represents about 12% of all new cancer cases, and 25% of all cancer cases in women . Despite the high incidence rate, around 89% of women in Western countries diagnosed with breast cancer are still alive 5 years after diagnosis, with this high survival rate attributed to early detection and treatment . Cancer that is diagnosed at an early stage when it is not too large and has not yet spread is more likely to be treated successfully . It is estimated that one-third of all cancers can be prevented, and a further third of all cancers may be cured if diagnosed at an early stage .Breast cancer is also the most common cancer type in the United Arab Emirates (UAE), accounting for almost 60% of all cancer cases seen at Dubai Hospital . In the Middle East and Gulf region, the incidence of breast cancer is rising and affecting a younger population compared with Western countries . According to the WHO, the incidence of cancer in the Middle East region (including the UAE) is increasing, with the number of cases expected to double by 2030 . The Health Department of Abu Dhabi reported that in the UAE alone, there are 4,500 new cases of cancer each year, with breast, colorectal, and lung cancers being most common . Reports from medical institutions under the UAE Ministry of Health indicated that 39 women died of breast cancer in the UAE in 2013 . This is supported by Health Authority of Abu Dhabi statistics that show breast cancer is the leading type of cancer causing death among women in the UAE . However, the average age at diagnosis of breast cancer among UAE women is about 10 years younger than women in Europe and the United States (45–55 years vs. 55–65 years) . Given these statistics, it is particularly concerning that a study conducted in Ajman, UAE, reported a high proportion of female university students had inadequate knowledge about breast cancer . This suggests that raising breast cancer awareness could contribute to reducing the number of breast cancer cases among young women in the UAE. Breast self-examination (BSE), clinical breast examination, and mammography are commonly recommended screening methods . BSE is a screening technique for early breast cancer detection that can be performed by women at home. This is a simple, inexpensive, easy, and effective technique that allows women to examine their breast tissue for any physical or visual changes. BSE increases women’s chances for treatment, thereby increasing the survival rate in women . BSE can help screen for tumors, cysts, and other abnormalities in the breasts. The American Cancer Society recommends BSE for early detection of breast cancer as it assists women to become familiar with the appearance and sense of their breasts, and helps them to detect any changes in their breasts as soon as possible . In resource constrained settings such as Nigeria, BSE has been reported to be culturally and religiously acceptable, friendly, and incurring no cost . If detected early, breast cancer can be treated in the early stages of the disease, meaning BSE is something all women should prioritize. Despite advances in treatment, detecting breast cancer as early as possible is important to maximize the potential for good health outcomes. Organizations concerned with breast health education suggest that all women should start performing BSE regularly as soon as their breasts are fully developed. For example, the Maurer Foundation suggests BSE should be performed at least once a month from age 18 years . Such regular examination means women become familiar with their own breasts and are therefore more likely to detect any changes.Awareness about breast cancer is an important factor that has a major impact on the incidence and outcomes of the disease . For example, if female university students have sufficient knowledge about breast cancer, they can help prevent cancer in themselves and contribute to reducing the incidence of breast cancer in their community. To date, knowledge about breast cancer and practice of BSE has not been assessed among the female student population of the University of Sharjah, UAE. Therefore, we aimed to assess the awareness of breast cancer and BSE among female students at the University of Sharjah. In particular, the objectives of this study were to:1) Assess knowledge regarding risk factors and warning signs and symptoms of breast cancer and the practice of BSE among female students at the University of Sharjah; and 2) Assess the association between campus type  and knowledge of risk factors and warning signs/symptoms of breast cancer.Study design, setting, and populationWe used a cross sectional survey to explore the level of awareness about breast cancer and BSE among female students at three University of Sharjah campuses  in the UAE. The target population was undergraduate female students aged ≥18 years from the three campuses. We excluded students who were male, female students younger than 18 years, students attending other campuses, and female students who were non-English speakers. The sample size was calculated as 300 female students following a purposive sampling method. However, because of limited time and resources, 250 questionnaires were distributed to female students who agreed to participate in this study. In total, 241 responses were received. Data collection A questionnaire was developed for this study based on questionnaires used in similar previous studies conducted in Egypt , Nigeria , North-East London , and Turkey . The questionnaire comprised three sections: participants’ sociodemographic characteristics (Section 1); knowledge about breast cancer, risk factors, and early warning signs and symptoms (Section 2); and knowledge about and practice of BSE (Section 3). Data collection took place between March 2017 and April 2017.Demographic information collected included age, campus , academic year, and marital status. Fourteen questions were used to investigate participants’ knowledge of risk factors and signs/symptoms. Participants who correctly answered seven or more of these 14 questions were considered knowledgeable; those who correctly answered six or fewer questions were considered non-knowledgeable. In addition, the questionnaire included 10 questions about the warning signs and symptoms of breast cancer. Participants who correctly identified five or more warning signs/symptoms were considered knowledgeable, and those who correctly identified four or fewer were considered non-knowledgeable. The final part of the questionnaire assessed participants’ knowledge about the purpose of BSE , how often BSE should be performed , and when BSE should be performed . In addition, this section evaluated whether participants performed BSE, reasons for not performing BSE, how often BSE was performed (for those that performed BSE), and if participants were confident about detecting changes in their breasts. Data analysisAfter data collection, data were organized, coded, and tabulated using SPSS version 22  and Microsoft Office Excel. The statistical analyses included descriptive statistics and Pearson’s chi-square tests.Ethical considerationsEthical approval to conduct this study was obtained from the University of Sharjah Research Ethics Committee. Participation in this study was voluntary and verbal consent was obtained from all students who agreed to participate. Participants received an information sheet and a full explanation of the purpose of the study. They were assured that their participation would be anonymous and identifying information would not be collected. All data collected were kept confidential and only used for research purposes.Participants’ characteristicsIn total, 241 female students participated in this study; 93 (38.6%) from the Medical campus, 90 (37.3%) from the Women’s campus, and 58 (24.1%) from the Fine Arts and Design campus. Most participants were aged 18–23 years (95.4%) and were single (95.4%). The majority of participants were non-UAE nationals (79.7%), and 29.9% were in their second year of study .Knowledge about breast cancerMost (99.2%) participants had heard of breast cancer. The main source of information about breast cancer was social media (74.7%), such as Facebook, Twitter, and Instagram . A familKnowledge about risk factors and warning signs and symptomsAround half of the participants (49.8%) were knowledgeable about breast cancer risk factors. The risk factors most commonly identified correctly were a family history of breast cancer (84.2%), followed by personal history (82.2%). Chest radiation and smoking were also correctly identified as risk factors by more than half of the participants . Obesity and advanced age at full term pregnancy were the two least-identified risk factors (25.7% for both) .The majority of participants were non- knowledgeable about the warning signs and symptoms of breast cancer (61.8%), and only 38.2% had adequate knowledge. The warning signs and symptoms most commonly identified correctly were breast lump (80.1%), change in breast size and shape (74.7%), and pain in the breast or armpit (73.3%). Rash or ulcer on the nipple and arm swelling were the least-identified breast cancer warning signs and symptoms  .There was a significant association between knowledge about risk factors and campus (P=0.000). More participants attending the Medical campus were knowledgeable about breast cancer risk factors (55.0%), followed by the Women’s campus (30.0%) . InteresKnowledge and practice of BSEIn total, 166 (68.9%) participants had heard of BSE. The Medical campus had the highest percentage of participants who had heard about BSE (45.2%), followed by the Women’s (32.5%) and Fine Arts and Design (22.3%) campuses . The maiOnly 62 participants (37.3%) had a correct understanding of what BSE involved; 58.4% had correct knowledge regarding the recommended frequency of performing BSE and 42.8% knew about the right timing for performing BSE . Most paOur results indicated that overall, 213 (88.4%) participants agreed that awareness of breast cancer and BSE should be increased. We found that 38% of participants thought that providing free training courses at the University would be the best method to increase awareness of breast cancer and BSE. In addition, 34% thought that more awareness campaigns would be a good method to increase awareness, and 28% indicated mandatory educational courses regarding breast cancer and BSE would be desirable.Breast cancer is the most common type of cancer among women in the UAE. Women in the UAE are likely to develop this disease a decade earlier than women in Western countries. Breast cancer awareness and regular practice of BSE facilitate early detection of breast cancer, which improves the chances of survival and better health outcomes. Few studies have investigated knowledge about breast cancer and BSE among female university students in the UAE, and this is the first study conducted among female students at the University of Sharjah. Our study provides useful insights to help address this knowledge gap.We found that most participants (98.8%) had heard of breast cancer, with social media being the most common source of information. This finding was consistent with a study conducted among female students in Egypt that showed mass media (TV and radio) was the main source of information about breast cancer for 89.1% of participants . Similarly, a study in Yemen reported mass media was the main source of information for 81.6% of participants . This may be explained by the similar levels of mobile technology penetration in Egypt and the UAE. Furthermore, our sample was a group of University students, who tend to be technology savvy. In our study, around half of the participants were knowledgeable about risk factors and warning signs and symptoms of breast cancer. The most frequently identified risk factor was personal history of breast cancer (82.9%), which was consistent with a study conducted in Turkey among high school students (68.7%) . We also found that students from the Medical campus were more knowledgeable about breast cancer risk factors compared with those from the Women’s and Fine Arts and Design campuses. However, this may be attributable to the topics studied in the Medical campus. This finding was also consistent with a study conducted among medical and non-medical students in Southern Punjab, Pakistan  that reported medical students’ knowledge about risk factors was significantly better than that of non-medical students, although the overall level of knowledge was insufficient.Less than half of our participants (40%) were knowledgeable about the warning signs and symptoms of breast cancer. This suggests that the level of knowledge about warning signs and symptoms was insufficient. This was consistent with the study by Sudhanthra and Relton (2014), which reported less than 35% of participants were aware of the early warning signs of breast cancer. Among our participants, “breast lump” was the most commonly identified warning sign/symptom, which was consistent with previous findings . In our study, participants from the Women’s campus were more knowledgeable about the warning signs and symptoms of breast cancer than those from the fine Arts and Design campus. However, this finding may be explained by response bias, as the Women’s campus had a higher percentage of participants than the Fine Arts and Design campus. As expected, students from the Medical campus were more knowledgeable than those from the other two campuses. Over two-thirds (69.4%) of the participants in this study had heard about BSE, which was similar to the Egyptian study that reported 63.4% of participants had heard about BSE . In our study, the highest percentage of participants who had heard about BSE was from the Medical campus, which again may be attributable to their medical background. However, relatively few (40.7%) participants had a correct understanding of what BSE entailed. Similarly, a study conducted among women in Ondo state, Nigeria Makanjuola et al., (2013) reported that only 22% of participants understood what BSE was. We found that almost two-thirds (59.3%) of students that had heard of BSE had correct knowledge regarding the recommended frequency (monthly) and right timing (after menstruation) to perform BSE. However, the study among female university students in Egypt reported that only 8.8% of students knew the appropriate time to perform BSE .A concerning finding in our study was that few (28.8%) participants performed BSE, and most of these participants rarely performed BSE. This finding was consistent with that of a study among female university students in Jordan that reported 11% of participants performed BSE . The two most common reasons for not performing BSE given by participants in our study were “forgetting” and “do not know how to perform BSE.” The study involving Egyptian students reported similar reasons for not performing BSE, such as “did not know how to perform BSE” and “lack of interest” . An encouraging finding from our study was that most students agreed that awareness about breast cancer and BSE should be increased, with popular methods of increasing awareness being free university-based training courses and more overall awareness campaigns.This study had some limitations that should be considered. We used a purposive sampling method; therefore, our study sample may not be representative of all female students at the University of Sharjah. In addition, our findings cannot be generalized to all female students at the University of Sharjah or more widely to female university students elsewhere, because potential participants did not have a random chance of being selected. Furthermore, the required sample size for this study was calculated at 300 participants, but only 250 participants were approached because of time constraints. In conclusion, we found that the level of awareness about breast cancer and BSE varied among female students at the three campuses, with awareness being higher in the Medical campus than in the Women’s and Fine Arts and Design campuses. Although a majority of participants knew about BSE, only 28.81% actually performed the technique. This signals a need for prompt interventions to raise awareness about breast cancer and BSE among female students at the University of Sharjah. Comparisons with similar studies conducted in other countries indicate that the need to raise awareness about breast cancer among female university students is likely to be relevant globally.Female university students need to be more aware of breast cancer and encouraged to practice BSE regularly to detect abnormalities in their breasts and identify breast cancer at an early stage. Appropriate educational interventions, such as elective courses that cover key aspects of women’s health, may be important for female university students. Providing free BSE training courses may also be an effective way to raise awareness. This study generated new information and insights about the level of awareness about breast cancer and BSE among university students, thereby creating opportunities for further research. It is recommended that further studies conducted in this area use a probability sampling technique to improve the representativeness of the study population and generalizability of the findings, and provide more robust results.No external funding was received for this study.


Significant number of women present with advanced-stage breast cancer in Ghana. These women usually depend on family caregivers for their multi-dimensional needs. Yet, there are gaps in research about what motivates family caregivers to assume the caring role and their experiences with caregiving within the Ghanaian context.To explore and describe the caregiving motivations and experiences among family caregivers of patients living with advanced breast cancer.In-depth, semi-structured qualitative interviews were conducted with 15 family caregivers who were providing unpaid care for women living with advanced breast cancer. Colaizzi’s thematic analysis was used to analyze the data.Family relationship normally prescribed the caregiving role among family caregivers. Due to the lack of home-based palliative services in Ghana, findings suggest that family caregivers are the main managers of advanced breast cancer-related symptoms in the home. These findings are discussed under three major themes: (i) motivation for assuming the caregiving role; (ii) meeting self-care and psychosocial needs of the patient; and (iii) symptom management and monitoring.Socio-cultural values influence the role of family caregivers in Ghana. This presents opportunities for health professionals and relevant stakeholders to develop a culturally-appropriate intervention to support informal caregivers in their home-based care for women living with advanced breast cancer in Ghana. In Ghana, breast cancer is currently the leading cause of cancer deaths among women . It has However, in the Ghanaian context, the home-based model of care is just emerging and the most commonly practiced model is the out-patient palliative care model since the treatment trend for breast cancer as well as palliative care is gradually transitioning to out-based settings . FurtherPrevious studies have reported that in the home-setting, caregivers are often responsible for providing treatment decision-making, symptom management, physical as well as emotional support ,14. TradPrior research has highlighted that factors such as social norms and cultural values may influence caregivers’ choices to accept the caregiving role –21. For Given the high symptom burden and the challenging needs of Ghanaian women diagnosed with advanced breast cancer , it is v.To explore and describe the caregiving motivations and experiences among family caregivers of patients living with advanced breast cancerAn exploratory descriptive phenomenological approach was used to explore and describe the motivations and experiences of participants . PhenomeCaregivers of women diagnosed with advanced breast cancer in the Ashanti Region, Ghana, were the target population for this study. To be recruited, participants satisfied the following inclusion criteria: (i) ≥ 18 years and above; (ii) family caregiver of a patient diagnosed with advanced breast cancer (Stage III & IV) for at least three months; (iii) providing unpaid care services to the patient; and lastly (iv) could speak either English or Twi. Caregivers of patients diagnosed with early-stage breast cancer were excluded from this study.A purposive sampling technique was used. This helped the researchers to enroll participants who had experienced the phenomenon under study and met the inclusion criteria into the study –27. A toThe head of the oncology unit gave formal permission to the authors for the study. This permission was granted after giving an introductory letter that specified the purpose of the study and a copy of the ethical approval to the head of the unit. There were pre-data collection interactions with the staff to discuss the study. Three nurses (“recruitment links”) at the oncology unit were identified to aid in recruiting participants. Subsequently, the nurses were met to discuss the recruitment process, detailing the selection criteria. They were provided with the recruitment tool bearing the researchers’ contact details. The nurses presented potential participants with study information sheets. For prospective participants who were unable to read and understand, the “recruitment nurses” read and translated the content of the information sheets to them.The first author was contacted when potential participants were identified and their phone numbers were provided by the recruitment nurses. Potential participants were then contacted confidentially via phone to assess their suitability for the study by the first author and a final screening was done to determine their eligibility for the study based on the inclusion criteria. The recruitment process came to an end after the 15th interview following data saturation .A semi-structured interview guide  was usedBefore the actual study, the guiding questions were piloted at a private oncology center in Kumasi with two family caregivers who were not involved in the final study. This center has similar geographical, socio-economic and cultural features with KATH. The outcome of the pilot study was used to address practical concerns of the guiding questions accordingly. However, the results of these pilot interviews were not included in the main results of this study.Pre-interview demographic information was collected before the main interview. A clinical psychologist was consulted to offer counseling services to participants who needed emotional support after sharing their experience. However, none of the participants used this service. Eleven (11) participants had the main interview conducted in their homes while four (4) participants preferred to be interviewed at the hospital. Non-participants were not allowed to the venue for the interviews. Further probes and paraphrasing were used to understand the participants’ caregiving motivations and experiences. The mean duration of the interviews was 80 minutes (ranging from 45 to 115 minutes). Interviews were audio-recorded with participants’ consent. Interviews were conducted in English (n = 1) and Twi (n = 14). No repeat interviews were conducted.The researchers listened and transcribed the audiotapes concurrently to help explore the topic in successive interviews. The first author kept field notes for each interview. These field notes recorded the participants’ non-verbal cues, concerns, and researchers’ reflections. After each interview, member checks were done with each participant by summarizing the responses to ensure an accurate representation of the participants’ views. This maximized the credibility of the study. Also, transcripts were returned to four participants to read through to ensure it reflected their views.Data was analyzed using Colaizzi’s rigorous and robust method of analysis to find, understand, describe, and depict  the motiStep 1. All the interviews were transcribed verbatim by the first author in their respective languages; Twi (14) and English (1). Two independent translators fluent in both the Twi and English languages translated the 14 anonymized “Twi” transcripts using the process of back-back translation while maintaining confidentiality. The transcripts for all the 15 participants were independently read repeatedly by the first author (GK) and the second author (ABBM) to make sense of the caregiving motivations and experiences among the family caregivers of patients living with advanced breast cancer.Step 2. To generate data that directly pertain to caregiving motivations and experiences among family caregivers of patients living with advanced breast cancer, significant recurring statements or phrases were extracted from participants’ transcripts as codes.Step 3. Formulated Meanings were then created from the significant statements or phrases to describe and illuminate the meanings hidden in the various contexts of the phenomenon under study. Subsequently, themes were generated based on the multiple statements that conveyed similar meanings.Step 4. Step 1 to step 3 were then repeated for all the 15 transcripts to identify the experiences that were common to all participants. All the formulated meanings were then categorized into clusters of themes based on their similarities and relationships.Step 5. A database was created to compile all the exhaustive descriptions that were generated in step 1 to step 4.Step 6. The results were then summarized and incorporated into a rich and exhaustive description of the caregiving motivations and experiences of participants. The field notes were also used to corroborate the themes developed.Step 7. To ensure the credibility of the findings, transcripts were returned to four (4) participants to confirm whether their realities were truly captured. However, no new or pertinent data were obtained.The researchers assigned participants with numbers to protect their anonymity. For confidentiality, the anonymized transcripts were saved on a password-protected computer and copied on a pen drive to prevent data loss.We ensured the trustworthiness of the study by applying the principles of credibility, dependability, confirmability, transferability, and authenticity ,31. MembAccording to Fontana, reflexivity is a pillar of ‘critical’ qualitative research . Also, iGK (first author) conducted all the interviews due to her ability to speak and write in both the ‘Twi’ and English languages. The interviewer is a female nurse who works at the Department of Obstetrics and Gynecology of KATH. Nevertheless, she is not related to any of the participants and had no direct influence on the study setting and results. To ensure authenticity, data were analyzed inductively  to descrThe study obtained ethical approvals from the Ethics Review Board  and the Research and Development Unit, KATH also approved and registered the study (RD/CR18/235). The purpose of the study, its benefits and risks were explained to the participants during the recruitment stage for them to willingly decide to participate in the study. Although there were no direct or indirect benefits for study participants, they were educated that their participation will contribute to improved caregiving to women diagnosed with advanced breast cancer. Participants consented to participate in the study by writing. Participants were assured of their anonymity in future publications and reports. All data will be destroyed after 5 years of this study.A sample of 15 family caregivers was recruited into the study. Participants were aged between 25 to 73 years. Participants consisted of seven (7) men and eight (8) women. Eleven (11) of the participants cared for patients living with stage III breast cancer whereas four (4) of the participants cared for women with stage IV breast cancer. The detailed characteristics of the participants are shown in In Ghana, hospital-based palliative care for cancer patients is regrettably inadequate, thereby creating an avenue for family members and significant others to assume the caregiving role for advanced breast cancer women. The current study affords unique insights into caregiving motivations and experiences of family caregivers of women living with advanced breast cancer. Three major themes that emerged from the study were motivation for assuming the caregiving role, meeting self-care and psychosocial needs of patients, and symptom management and monitoring as summarized in This theme describes the motive that guided participants’ decision to become the primary caregivers of women living with advanced breast cancer. The underlying sub-themes under this theme were: (1) caregiving as a family and socio-cultural obligation; and (2) caregiving as a means of reciprocity.Participants in this study cited that the family’s obligation to care for its ill individuals was the main reason that underpinned their decision to accept the caregiving role. The family, a recognized institution in Ghana , is usua“She is my mother, my family… it is actually my socio-cultural responsibility to take care of her… That is the reason I am the one taking care of her” .“As our culture demands, I have to take care of her. It is just my duty as her (patient) family member” .The cultural orientation of Ghana towards the female gender also assigns the caring role for homes, children and sick relatives specifically to mothers and older daughters –40. Henc“Hmmm..! As the eldest daughter, it is my cultural duty to take care of her. I have no other option than to take care of her” .“I am a woman and her mother and it is my cultural duty to take care of her” .In the absence of female family members who are the predominant caregivers, some men also assumed the caregiving roles for women diagnosed with advanced breast cancer. In the Ghanaian cultural context, spouses offer vital support to their partners in all life situations including sickness, and this includes the essential role played by men in the medical decision-making of their wives . In this“Oh! She is my wife… if I don’t take care for her, who will? It is just my social obligation as a husband to take care of her” .A brother of one of the patients also said:“When she was diagnosed of the disease (breast cancer) she had no one to take care of her, hence, as a brother, it is culturally expected that I take care of her. There are no women around, hence I have to do it” .Some participants were primarily motivated by reciprocity to assume the caregiving role. Participants cited that caregiving was a means of repayment of a good deed the participant had initially obtained from the patient. This is shown in the following narratives:“It is unusual for someone who is not your family member to take care of you when you are sick, but she (patient) did it passionately when I was admitted at the hospital. So now that she is sick, it is my turn to repay her for what she did for me” .“She used to support me by lending me money when she was working. So now that she is sick, I have to also support her till she recovers from this illness. I am just paying her back for all the support she has been giving me” .This theme explores the participants’ experiences in supporting the patients to meet their daily needs. Further, this theme describes the support that is provided by participants in meeting the spiritual and psychosocial needs of patients living with advanced breast cancer. Four sub-themes emerged under this theme: (i) assisting with activities of daily living; (ii) spiritual support; (iii) emotional support, and (iv) financial support.Participants described that patients with advanced breast cancer were unable to perform physical activities such as bathing, cooking, and grooming due to symptoms such as a wound, weakness, lymphedema, and treatment side effects. Hence, as part of their caregiving role, participants assisted patients with their daily activity needs.“I fetch and boil water for her every day. I also groom her every day because she becomes very weak whenever she goes for therapy (chemotherapy)” .“She cannot wash her dirty cloths because her hand is always swollen and heavy (lymphedema). So, I am the one who does all her laundry” .This sub-theme addresses the support that was offered by participants to patients to meet their spiritual needs. Generally, spirituality and religion are said to play key roles among cancer patients , and thi“I pray for her and share healing messages in the Bible with her. This has really helped her to have some inner peace now” .“Now she (patient) does not cry anymore because I always encourage her that God is on the throne and that He will heal her. I pray and share God’s words with her. These have really increased her faith in God” .Other participants also cited that they ensured that patients had access to their spiritual leaders and benefited from spiritual services such as the Holy Communion in the home. This is because spiritual leaders are key stakeholders during illnesses including breast cancer diagnosis in Ghana . Two par“I always remind the church leaders every month about the Holy Communion. I make sure that they always bring her bread and wine in the house” .“Sometimes, I arrange pastoral visits for her. The Osofo (Reverend) comes in to pray with her .Participants described that advanced breast cancer disease affected patients emotionally. Emotional support was therefore perceived as being critical in aiding patients cope with advanced breast cancer disease. Hence, in this regard, participants described that they provided words of encouragement as shown in the following narrations:“She was always thinking about the disease, but I encourage her with cheerful and hopeful messages to relieve her emotional distress” .“I always make sure that I communicate with her and encourage her to forget about the breast cancer so that she can be happy all the time” .Participants consoled the patients any time they cried or became worried about their condition by keeping a positive attitude. This is corroborated as below:“Although I worry a lot about her condition every day, I try to be cheerful when I am with her. I get time to listen to her and console her when she is lonely” .Participants also narrated that they provided financial support to cover for treatment cost since there is limited coverage of breast cancer treatment by the National Health Insurance Scheme (NHIS). The Ghana NHIS provides partial coverage for the treatment cost of breast cancer , therefo“At the hospital, all the little money on me has been spent on her treatment because the NHIS covers only the folder and some of the infusions but all the other medications, I have to buy them” .“The National Health Insurance Scheme (NHIS) does not cover all the cost of the treatment. So, the little I get, I spend it all on my mother’s drugs and living expenses” .Participants also cited that they also provided financial assistance for other non-treatment costs such as transportation for access to medical care.“I provide money for everything including transportation to the hospital. Where we live, if we take a taxi to the hospital, they charge GHC 120 (≈23 USD) for our round trip” .“Aside money for her drugs, I always buy food supplements (Forever Living) to meet her nutritional needs. Although expensive, I manage to buy it for her” .This theme describes the experiences of participants in the management of symptoms of advanced breast cancer and its related treatment side effects. Ghana, a country that lacks resources, is also burdened with inadequate cancer care centers , inapproIn this study, the sub-themes generated under this theme are (i) home-based wound care; (ii) drug administration and pain management; (iii) management of breast cancer-related lymphedema; and (iv) continuous evaluation of symptoms and patient advocacy.Participants cited that they were the sole agents in the management of malignant wounds in the home setting. Participants described that they resorted to the services of traditional healers, socio-culturally acceptable in the Ghanaian health care system , in mana“We went to an herbalist who gave us a mixture of charcoal and clay to apply on the wound to help with the bleeding. It really helped with the bleeding and helped in removing the sloughs. So I use it for the dressing at home” .“I sent her to an herbal center at Asokwa. The herbal doctor usually grinds some green leaves for us to apply on the wound at home and it has really reduced the mal-odor” .Participants cited that in the home setting, they used prescribed analgesics to manage patients’ cancer-related pains. Nonetheless, participants narrated that these prescribed analgesics were not adequately alleviating the breast cancer-related pains. Hence, participants modified the prescribed dosages of these analgesics to aid in relieving breast cancer-related pains.“Per the doctor’s instruction, she was supposed to take 100 mg tramadol 2 times daily and 1 gram paracetamol three times daily. But the pain was still unbearable so I had to give her more than the prescribed medicine. Now, I give her 200mg tramadol to relieve her pain and also help her to sleep” .“One tablespoon (10mg) Morphine 3 times daily is what they (doctors) prescribed for her. But, normally, she complains of pain in the breast. The breast is ulcerated so she really feels the pain. So I administer two tablespoons (20mg) to her in the house anytime she complains of pain. I don’t stick to the prescribed dosage because it just couldn’t relieve her pain” .Others also used non-medical means to control the patients’ pains:“Where we were staying, we had no fan. So whenever she cried and complained of pain, I fan her to reduce the pain and further promote her comfort” .“Sometimes when she complains of pain, I intentionally play her favorite program on TV for her to watch and it really helps to take her mind off the pain” .Further, participants described some adverse effects of prescribed opioids such as addiction, sedation, and hallucinations. Hence, to avoid the occurrence of these side effects, they administered the prescribed dosages only in situations when patients suffered from extreme pain.“Sometimes, she (patient) can ask for the whole bottle of morphine because of the unbearable pain. But I always say no to her request. The doctor says you can experience side effects such as constipation and addiction when you take too much of the morphine” .Due to this, I do not administer the drug daily per the prescription … I administer the drug to her when the pain is too much .The majority of the participants made it known that they were also in charge of managing lymphedema and its related symptoms. Participants used different strategies to reduce the lymphedema as described below:“Her arm is always heavy so I usually apply bandages and put the arm in a sling for her. Now the weight has started reducing gradually” .“When her arm becomes swollen, I make sure I elevate the affected arm by putting the arm on pillows. This has helped in decreasing the swollen arm” .Participants also cited that they used various approaches such as traditional approaches in managing breast cancer-related lymphedema in the home setting.“Her arm was always swollen and I sent her to an herbalist who put some herbs in a horn and blew it on the swollen arm” .“I usually mix charcoal with clay and apply it on her (patient) swollen hand and by the next day, the hand will be better. So, that is what I have been using for the hand” .This sub-theme describes participants’ experiences in monitoring treatment-related side effects such as vomiting and subsequently communicating with health professionals about these treatments induced side effects. This is evident in the following quotes:“After the first cycle of chemotherapy, they told us she will vomit and also have diarrhea. But the vomiting was too much for three consecutive days. So, I called the doctor and told him about it and he said it is the side effect of the chemotherapy. But I told the doctor that the vomiting was too much. So, he told us to send her to the nearest hospital” .“I don’t know whether it was because of the drugs she was taking. She was always complaining “my stomach, my stomach”. When she complains of the stomach pains, she usually feels like vomiting so I called the doctor and told him about what was happening” .The motivations identified for providing care to the women with advanced breast cancer included family and socio-cultural obligation and reciprocity. Family and socio-cultural obligation reflect the cultural norm that is embedded in the Ghanaian society which views the family as the key provider of support during terminal illnesses such as breast cancer .Participants described that caregiving was entrenched in the Ghanaian cultural values; hence, the decision to care was viewed as an automatic obligation. This finding supports earlier evidence that describes caregiving as a communal family activity that is shaped by cultural norms . FurtherStudy findings showed that, in addition to a motivation for caregiving, caregivers also assisted with the daily needs of patients such as bathing, grooming, and cooking. The progressive nature of advanced breast cancer and its treatment resulted in declining functional status which resulted in patients being unable to perform daily living activities such as grooming, groceries, and bathing. Our findings correspond with earlier research works which posit that caregivers of women diagnosed with advanced breast cancer provided support with activities of daily living , 49.Further, findings in the study highlighted the experiences of caregivers in symptom management such as the management of pain, lymphedema, wound, and evaluation of symptoms. In the management of wounds, participants narrated that they used herbal products, charcoal, and coal to manage wound symptoms such as odor, bleeding, and discharge. This finding could be explained by the fact that there is a lack of home-based palliative care services and wound care specialists in the Ghanaian health system , consequIn addition, in the management of pain, participants also cited that they normally altered the prescribed pain medications to improve the comfort of patients. This finding indicates that caregivers should be given support that can aid them in addressing their breast cancer pain management concerns. Further, findings in the current study showed various dimensions in which caregivers provided support to patients. Caregivers were the main providers of emotional support by offering patients with words of encouragement. Previous authors confirmed that emotional support from the family is important for women with advanced breast cancer due to the emotional and psychological impact on women . ProvidiIn the Ghanaian health structure, it is recognized that breast cancer and other women cancers are fully covered under the National Health Insurance Scheme (NHIS). However, it is perceived that the NHIS only provides partial subsidizations for breast cancer treatment, making patients and their family members the main financial providers of treatment costs . This peThe present study has illuminated the caregiving motivations and experiences of caregivers of women living with advanced breast cancer in Ghana. Through the narratives of family caregivers, it was identified that socio-cultural obligations and reciprocity were key motivating factors in the choice of family members and friends to accept the caregiving role. Further, family caregivers were the key agents for the management of symptoms such as a malignant wound, pain, and lymphedema in the home due to a lack of formal support services. This finding has significant implication for policy intervention. The non-existence of integrative palliative care services in the Ghanaian socio-cultural context requires the healthcare structure to work on instituting and improving integrative palliative care services. Also the use of a collaborative-based home model for the direct provision of palliative care services is paramount. This will, in turn, require home-based support programs to assist caregivers in their caring role especially in the area of symptom management, and direct governmental social intervention programs (e.g. transportation to treatment facilities and drugs for patients) to resource-limited caregiving families of women with advanced breast cancer. The National Health Insurance Scheme should be expanded to fully cover breast cancer treatment to women and their families since the current partial subsidization of breast cancer treatment is a challenge.Some limitations of the current study need to be addressed. First, findings from the study reported on caregivers of women with advanced-stage breast malignancy. Hence, these findings may not apply to caregivers of women living with the early-stage disease. The focus of this study was also limited to a single site. Majority of the participants in this present study were women and therefore, the degree to which findings from this study are generalized to male caregivers should be done carefully. Therefore, it is essential for studies to specifically explore the experiences family caregivers of early-stage breast cancer as well as male caregivers in breast cancer caregiving to foster a comprehensive understanding of the phenomenon.We recruited a diverse sample of caregivers with different characteristics such as age (ranging from 25 to 73 years), gender, religion, socioeconomic status and duration of caregiving. This allowed a full exploration of the experiences of family caregivers with diverse backgrounds. Further, the key strength of this study is its rigor. For instance, the credibility of the study was determined by using member checking to validate the study findings. We are also the first to report on the caregiving motivations and experiences among family caregivers of patients living with advanced breast cancer in the socio-cultural context of Ghana.Most women in Ghana are usually diagnosed with advanced-stage disease.There is a gap in research about what motivates caregivers to assume the caregiving role and their home care experiences with caregiving.Family members usually support women with advanced breast cancer in the home setting.This study identifies socio-cultural obligation and reciprocity as reasons for accepting the caregiving role.The lack of home-based palliative care services in the Ghanaian health system structure makes caregivers the key agents of management of breast cancer-related symptoms.Caregivers provide multi-dimensional forms of support for patients diagnosed with advanced breast cancer.S1 File(DOCX)Click here for additional data file.S2 File(DOCX)Click here for additional data file.S1 Table(DOCX)Click here for additional data file. 13 Dec 2019PONE-D-19-26686Caregiving motivations and experiences among family caregivers of patients living with advanced breast cancer in Ghana.PLOS ONEDear Dr Mensah,Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.Please respond to the comments by reviewer 2.  In your discussion I suggest it might be better to cite research supporting your findings of family support rather than the Iranian study.https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.We would appreciate receiving your revised manuscript by Jan 27 2020 11:59PM. 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Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: YesReviewer #2: Yes**********2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: N/AReviewer #2: N/A**********3. Have the authors made all data underlying the findings in their manuscript fully available?PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.The Reviewer #1: NoReviewer #2: Yes**********4. Is the manuscript presented in an intelligible fashion and written in standard English?PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.Reviewer #1: YesReviewer #2: Yes**********5. Review Comments to the AuthorPlease use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. Reviewer #1: Thank you for the opportunity to review this well planned and executed investigation into caregiving motivations and experiences among family caregivers of patients living with advanced breast cancer.Specific comments follow:It is unclear in Data analysis whether the procedure you took is the Colaizzi approach – could you clarify this. Colaizzi is difficult to find on line therefore it needs more clarification and preferably a more recent reference in addition. Also, the reference needs to show it is an edited book but consider using a more up to date reference for your methodology and relate more what you did to the reference you are using.Line 55 – Word form - WoundLine 58 – article required before treatment – also subject verb agreement – head noun in that sentence is treatment trend (is)Line 64 add “as well as”Line 72 researches (Count noun?)Line 80 Delete article an and add an article in line 116Line 118 delete s off interestsLine 151 count vs non-count noun -informationLine 197 – add a reference to confirmability claimLine 204 a reference for and more detail of ‘voice-centered data analysis’ -Table S1? Where is it?Line 336 replace these for thisLine 345 cited that?Line 443 – delete an ‘only’Line 475 – 78 Not sure what you are saying here. Sense?Discussion - could do with being a bit sharper and to the point.Line 526- I’m not sure the contrast with the Iranian participants adds anything because we aren’t told why this is differentLine 538 – sense?Line 542 – incomplete sentence and is it an irony?Line 560 – which home based model are you referring to? Have you explained it elsewhere in the paper?Reviewer #2: This article makes an important contribution to family and socio-cultural factors in breast cancer caregiving in Ghana. The paper still needs a bit more proofreading, but is otherwise satisfactory in all major respects and I would recommend publication.**********what does this mean?). If published, this will include your full peer review and any attached files.6. PLOS authors have the option to publish the peer review history of their article  digital diagnostic tool,  15 Jan 2020Reviewer #11. We thank the reviewer for the important suggestion raised on clarifying the Colaizzi’s approach used for data analysis. The comment has been addressed and highlighted in green font of the revised manuscript, now page 9-10, line 189-217 to provide more clarification on how the Colaizzi’s approach was used. 2. We thank the reviewer for this important comment. We have addressed this comment in page 3, line 55. 3. This comment has now been addressed in the revised manuscript in page 4, now line 734. We thank the reviewer for the observation made. We have added as well as in the revised manuscript page 4, now line 84. 5. This comment has been addressed in page 4, now line 93 of the revised manuscript.6. We thank the reviewer for the observation made. We have deleted the article “an” now in page 5, line 101 of revised manuscript. 7. The article “a” have been added to page 7, now line 137 and the sentence has been reconstructed to make it more meaningful. 8. We thank the reviewer for the observation made. We have deleted s off interests in page 7, now line 139 of the revised manuscript. 9. This comment has been addressed in the revised manuscript in page 8, now line 172. 10. We thank the reviewer for this comment. We have addressed this comment, and added a reference to the confirmability claim in page 11, now line 236 of the revised manuscript.11. We thank the reviewer for this comment. This comment has been addressed and a reference and a more meaningful statement of data analysis has been added in page 11, line 242-244 of the revised manuscript. 12. We thank the reviewer for this comment. Table S1 is in the additional file that was submitted with the manuscript and has been highlighted in page 12, now line 263 of the revised manuscript 13. We thank the reviewer for the important observation. We have addressed this in page 17, now line 364 of the revised manuscript. 14. This has been well elaborated in page 17, now line 371-374 of the revised manuscript. 15. We thank the reviewer for pointing this out. We agree with the comment. Therefore we have addressed in page 20, now line 460-461 of the revised manuscript.16. We thank the reviewer for this comment. We have reconstructed the statement into a more meaningful statement in page 21, now line 489 -491 of the revised manuscript.17. We appreciate the reviewer’s comments. As suggested by the reviewer, we have been sharper in the ‘discussion’ section in page 22-24, now line 504-562 of the revised manuscript. 18. We thank the reviewer for this suggestion. the Iranian example has been removed and the statement has been amended as suggested in Page 23, now line 543-546 .19. We thank the reviewer for the important input. We have reconstructed the sentence into a complete statement to make it more meaningful in page 27, line 554-55720. We thank the reviewer for the important input. The Home based model have been introduced and well elaborated in the ‘introduction section ’. This has given a context to the home-based care model presented in the “conclusion section” page 25, now line 573 of the revised manuscript .Reviewer #2We thank the reviewer for this valuable feedback. As suggested by the reviewer, we have accordingly proofread the revised manuscript.AttachmentResponse to reviewer final copy.pdfSubmitted filename: Click here for additional data file. 12 Feb 2020Caregiving motivations and experiences among family caregivers of patients living with advanced breast cancer in Ghana.PONE-D-19-26686R1Dear Dr. Mensah,We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.Within one week, you will receive an e-mail containing information on the amendments required prior to publication. 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Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes**********3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: N/A**********4. Have the authors made all data underlying the findings in their manuscript fully available?PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.The Reviewer #1: No**********5. Is the manuscript presented in an intelligible fashion and written in standard English?PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.Reviewer #1: No**********6. Review Comments to the AuthorPlease use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. Reviewer #1: Still some errors in the text - I've highlighted a few here, but text needs careful reading mainly for small grammar errors - subject/verb agreement, word form error , preposition use etc. Otherwise authors have addressed previous comments. Our findings correspond with earlier research works which posit that caregivers of women527 provided support with daily activities .Caregivers were the main providers of emotional support544 by offering patients with words of encouragement. this further move other women cancers?**********what does this mean?). If published, this will include your full peer review and any attached files.7. PLOS authors have the option to publish the peer review history of their article (If you choose “no”, your identity will remain anonymous but your review may still be made public.Do you want your identity to be public for this peer review? 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Exposures to cancer risk factors such as smoking and alcohol are not mutually independent. We aimed to identify risk factor exposure patterns and their associations with sociodemographic characteristics and cancer incidence. We considered 120,771 female and, separately, 100,891 male participants of the Australian prospective cohort 45 and Up Study. Factor analysis grouped 36 self-reported variables into 8 combined factors each for females  and males . Associations with cancer incidence were investigated using multivariable logistic regression . After multiple-testing correction, we identified 10 associations between combined factors and cancer incidence for females and 6 for males, of which 14 represent well-known relationships  1.16  1.08–1.25), males ‘smoking’ factor OR 1.15 (95% CI 1.07–1.23)), providing evidence for the validity of this approach. The catalogue of associations between exposure patterns, sociodemographic characteristics, and cancer incidence can help inform design of future studies and targeted prevention programmes. However, exposures to these lifestyle factors are not independent of each other—for example, there are known links between exposures to raised Body Mass Index (BMI), lack of exercise, and poor diet, and thus it is unlikely that these exposures will have isolated effects on health2. It is therefore important to establish the relationships between different risk factors, identify exposure patterns and their sociodemographic associations, and examine the joint associations of exposure patterns with cancer incidence, so that cancer risks can be better understood and addressed.Lifestyle factors such as smoking, alcohol intake, diet and physical activity play a major role in the aetiology of different cancers6), and separately, to reproductive variables (e.g.7). Factor analysis is related to latent profile models, which have also been applied to lifestyle information (e.g.8). The main difference is that latent profile models assume latent variables are categorical (e.g. present or absent) and correspondingly seek to divide individuals into discrete separate groups based on their lifestyle (e.g. “High risk” versus “Low risk”). By contrast, factor analysis considers continuous latent variables and returns a continuous score for each individual and each latent factor (e.g. continuous risk behaviour level), retaining more granular risk information which facilitates the later examination of dose–response relationships.Factor analysis is a statistical approach that condenses multiple individual lifestyle risk variables into a smaller set of so-called “latent factors” (labelled “combined factors” in this paper) which capture variation in individual lifestyle risk variables. A number of previous cancer risk studies have applied factor analysis to diet and nutrition variables  in a large Australian cohort. We investigated relationships between these risk variables and applied factor analysis to identify “combined factors” reflecting exposure patterns. To understand the variation in these factors across different population groups, we examined the associations between the combined factors and ancestry, health and socioeconomic characteristics.We then systematically tested the associations between the combined factors and the incidence of several major cancers  as well as all invasive cancers combined. Finally, we tested for possible interaction effects between the combined factors on cancer incidence.9. Briefly, a random sample of New South Wales (NSW) residents aged ≥ 45 years from the Medicare Australia enrolment database held by Services Australia (formerly the Department of Human Services) was invited to participate in the study. The database provides near complete coverage of the population. Individuals aged 80 and over, as well as those living in regional and remote areas, were oversampled by a factor of two during recruitment. About 18% of those invited participated, with participants comprising about 11% of the NSW population aged 45 years and over. Participants completed a baseline questionnaire between January 2006 and December 2009 (78% completed the baseline questionnaire in 2008). All participants gave written informed consent for follow-up and linkage of their information to routine health databases.We used data from The Sax Institute’s 45 and Up Study, a longitudinal study of 267,153 Australian residents, described in detail elsewherehttp://www.cherel.org.au/) using a best practice approach to linkage while preserving privacy10. The NSWCR has high standards of data completeness and quality, and the data are accepted by the International Agency for Research on Cancer for publication in Cancer Incidence in Five Continents11.The 45 and Up Study data include: (1) reimbursements for subsidised outpatient and medical services and some in-hospital procedures covered by the Medicare Benefits Schedule (MBS); (2) inpatient care in public and private hospitals in NSW from the Admitted Patient Data Collection (APDC); (3) emergency department presentation records from the NSW Emergency Department Data Collection (EDDC); (4) cancer diagnoses (excluding non-melanoma skin cancer) from the population-wide NSW Cancer Registry (NSWCR); and (5) death records from the NSW Registry of Births, Deaths and Marriages (RBDM). Individual records were linked to the health database (1) by the Sax Institute using a unique identifier that was provided to Services Australia. NSW Health data for (2) to (5) were provided by the NSW Ministry of Health and Cancer Institute NSW, and individual records were probabilistically linked by the Centre for Health Record Linkage in NSW  used in the analysis was obtained at baseline from the Medicare Australia enrolment database or information from the participant that the incorrect baseline questionnaire had been sent. We note that the usual gender terminology refers to “women” or “men”, but have used the terms contained in the Medicare Australia data and the 45 and Up Study data .The study questionnaire is available at The conduct of the 45 and Up Study was approved by the University of New South Wales Human Research Ethics Committee. The work in this paper was approved as part of a larger research programme by the NSW Population and Health Services Research Ethics Committee , and was performed in accordance with all relevant guidelines and regulations.We excluded 45 participants with probable linkage errors , and those with cancer history at baseline , retaining 120,771 females and 100,891 males Fig. . All ana13 (downloaded from http://www.komkon.org/~tacik/stata/).As some variables were continuous (e.g. BMI), others categorical (e.g. never/former/current smoker), pairwise correlations between all variables were calculated as polychoric correlations based on pairwise complete observations, using the Stata package polychoricTo identify “combined factors” representing risk factor exposure patterns, we carried out a factor analysis based on the matrix of correlations between cancer risk variables, applying the Stata function “factormat”. Considering a scree plot, we retained 8 factors each for females and for males . For females, the discovery and validation datasets were analogously split into 12 subsets each. Information was then imputed within each subset. This procedure was repeated 10 times, to yield 10 fully imputed datasets. We checked that imputation of the missing data did not change the mean or range of any variables.Missing data for cancer risk variables were imputed using a a nonparametric random forest method, applying the function “missForest” in the R package “missForest”15 with option method = “Thurstone”. This method calculates the regression based weights as W = R−1F, where R is the correlation matrix and F is the factor loading matrix16. The factor scores are then obtained as S = ZW, where Z is the matrix of standardised observed variables. For each participant and each combined factor, the score was calculated as the mean of the scores from the 10 imputations -1/2, where R and F are as defined above and U is the diagonal matrix of uniquenesses16. Based on the individual across-imputation mean scores, the correlations between the Thurstone and Anderson methods were extremely high (Pearson r 0.985–0.999), so scores based on the Thurstone method were used in subsequent analyses.As there are different approaches for obtaining factor scores, each seeking to minimise a particular estimate of error, as a sensitivity analysis, we also calculated scores using the method = “Anderson” option. This method calculates weights such that the factor scores are uncorrelated as W = UCancer incidence data for 2006–2013 were obtained from linkage to the NSW Cancer Registry .We tested the association between each combined factor and age at baseline, as well as key health, ancestry, and socioeconomic characteristics  using logistic regression. In each logistic regression analysis, cases were participants newly diagnosed with cancer after recruitment , while all other participants were included as non-cases. We applied the function “glm” in R with option family = “binomial” to estimate odds ratios (ORs) and the function “confint.default” to obtain 95% confidence intervals.17, self-reported health rating, and number of GP visits in the 2 years prior to baseline We also adjusted for self-reported pre-baseline cancer screening: mammographic screening for breast and all cancers for females, prostate-specific antigen (PSA) testing for prostate and all cancers for males, and bowel screening for bowel and all cancers for males and females. For analyses of melanoma risk, we further adjusted for skin colour, tannability, and average daily hours outdoors.P < 0.00125 in the main analysis (Bonferroni correction for 40 tests per gender), also requiring P < 0.05 in both sensitivity analyses.We conducted two sensitivity analyses: testing all combined factors jointly; excluding all individuals with cancer diagnosed in the first year after the individual’s baseline questionnaire. Statistical significance was defined as We also verified that the estimates for the factor effects from logistic regression were not substantially different when additionally adjusted for highest educational qualification, income, and the relative socio-economic disadvantage index for areas .18). As with the logistic regression approach, we tested each combined factor separately. In a sensitivity analysis, we also tested all combined factors jointly. Significance was defined as P < 0.00125 in the main analysis, with a further requirement of P < 0.05 in the sensitivity analysis. These analyses were done using the function “crr”18 in the R package “cmprsk”, with 95% confidence intervals for estimates obtained using the function “summary.crr”.To further verify the results, we also carried out a survival analysis using competing risks regression for cancer incidence with death as the competing risk .Second, to further investigate an interaction between ‘alcohol’ and ‘menopausal hormone therapy (MHT)’ combined factors, we also tested for interactions between each of the two original alcohol variables with each of the two original MHT variables, using the same approach as for the combined factors. When analysing the original variables, we carried out tests based on the original data with exclusion of missing values. We verified that similar results were obtained when using across-imputation means from missForest imputation of missing data. Finally, we carried out a stratified analysis of breast cancer risk by baseline MHT status (never/former/current use) for all females and, separately, for post-menopausal females. In each stratum, we separately tested associations between breast cancer incidence and each of the ‘alcohol’ combined factor and both original alcohol variables.We calculated pairwise correlations between 33 variables for females and 28 variables for males (Supplementary Table The highest correlations were observed between variables in the same domain (e.g. smoking behaviour: years smoked and number of cigarettes per week). We also observed correlations between smoking behaviour and consumption of alcohol (positive), fruit (negative), and breakfast cereal (negative). While most of these correlations were relatively weak, some of them were almost as strong as correlations between related variables such as fruit and vegetable consumption, or red meat and processed meat consumption.Most correlations were similar for females and males (see Supplementary Note for description of differences).For females, factor analysis identified 8 “combined factors” that capture the variation in the original 33 variables and reflect exposure patterns. We labelled each combined factor based on the original risk variables with the strongest absolute loadings Fig. : ‘smokinEight combined factors were also identified for males Fig. b, labellCombined factors with the same label for females and males may have different loading contributions from the original risk variables, due to differences in strengths of correlations. For example, for males, there was a stronger correlation between red meat and alcohol consumption, therefore a larger loading of red meat in the ‘alcohol’ combined factor Fig. .The associations between each of the combined factors and age, ancestry, health, participation in cancer screening, family history of cancer, and socioeconomic characteristics are shown in Fig. We detected associations between the self-reported health rating and most of the combined factors, even when accounting for all other characteristics . In particular, we identified associations between poorer health rating and higher ‘smoking’, ‘urology & health’ and ‘meat & BMI’ factor scores, as well as lower ‘alcohol’, ‘vigorous exercise’, ‘moderate exercise’, ‘age at childbirth’, ‘standing/sitting’, ‘fruit & vegetables’ factor scores.We detected several associations with self-reported ancestry, including lower ‘smoking’ and ‘alcohol’ factor scores with Chinese ancestry; lower ‘smoking’ and higher ‘fruit & vegetables’ factor scores with Australian ancestry; higher ‘alcohol’ and, for females, higher ‘smoking’ factor scores with Irish ancestry; and lower ‘alcohol’ factor scores with Greek ancestry.Married/de-facto/living-with-partner status was associated with lower ‘smoking’ and higher ‘fruit & vegetable’ factor scores, but also lower ‘vigorous exercise’ factor scores. For females, it was also associated with higher ‘alcohol’ and ‘parity & breastfeeding’ factor scores.Characteristics reflecting higher socioeconomic advantage  were generally associated with lower ‘smoking’ and higher ‘alcohol’ factor scores, as well as higher ‘age at childbirth’ and lower ‘parity & breastfeeding’ factor scores for females.After correction for multiple testing and conducting several sensitivity analyses, we detected 10 associations between combined factors and cancer incidence for females and 6 for males Fig. .Figure 421, and bowel cancer22 for both females and males (Supplementary Note). There is conflicting or no prior evidence for the associations identified in this analysis between MHT use and lung cancer24 and age at childbirth and lung cancer, likely due to residual confounding (Supplementary Note).Of the 16 associations, 14 reflect well-known risk factors for cancer, such as the association of the ‘smoking’ factor with all cancers, lung cancer26.Notably, some associations between combined factors and cancer incidence possibly reflect multiple mechanisms: for example, the factor ‘parity & breastfeeding’, which was associated with breast cancer incidence, has positive loadings for number of children, time breastfed, and negative loading for age at first childbirth, all of which are known to be associated with breast cancerSeveral additional associations were only suggestive and did not pass multiple testing correction . Several of these represent previously reported relationships (Supplementary Note).We found a possible interaction between ‘age at childbirth’ and ‘MHT’ factors for lung cancer incidence for females [adjusted odds ratio (OR) 1.17  1.02–1.33); Supplementary Table 27. Moreover, current MHT users also reported higher alcohol intake, and the confidence intervals for odds ratios overlapped between strata, hence these results are interpreted as suggestive only.We also found a possible interaction effect between ‘alcohol’ and ‘MHT’ factors for breast cancer incidence [adjusted OR 1.06 (95% CI 1.00–1.12), p = 0.046; Supplementary Table 30, we examined the association between BMI and breast cancer risk stratified by MHT status  in this study has a range of important applications, from studies of cancer risk, to microsimulation modelling and the design of interventions.31. For future studies focused on specific single exposures, the correlations with other exposures provided in this study will allow better identification and examination of possible confounders. Similarly, the atlas of associations between combined factors and sociodemographic characteristics can also help to identify possible confounders for future studies of cancer risk.Correlation between cancer risk exposures can lead to confounding in studies of cancer incidence, leading to e.g. possibly spurious associations between smoking and breast cancer due to confounding by alcohol consumption34 or only one risk factor36. The next step would be to create more holistic models with realistic constellations of multiple exposures, such as both smoking and alcohol intake for bowel cancer. This again requires information on correlations between these exposures, such as provided by this study.Knowledge of relationships between risk factor exposures is also crucial for microsimulation modelling, which simulates millions of individuals in a population to forecast future disease burden and the effects of interventions. For cancer risk, current models typically only simulate an overall underlying cancer risk, e.g.37, targeting correlated behaviours might improve success. For example, one study found that a joint intervention for smoking and alcohol intake temporarily reduced smoking better than an intervention for smoking alone38, and that smoking lapses often occurred with alcohol use39. Moreover, the atlas of associations between cancer-relevant risk behaviours and sociodemographic characteristics provides information for the design of targeted intervention approaches to include social determinants, suggesting which population groups have higher exposure to given risk factors. For example, we found that remoteness of residence was associated with both higher ‘alcohol’ and ‘meat & BMI’ combined factor scores for males, suggesting potential interventions to reduce alcohol intake, meat consumption, or obesity levels might be targeted to remote regions.In another key area of application, information on relationships between risk factor exposures also underlies the development of comprehensive intervention programmes that help people modify their lifestyles. While targeting multiple, possibly uncorrelated behaviours simultaneously can reduce the completion rate of interventions40. Previous meta-analyses have shown that alcohol consumption affects sex hormone levels including oestradiol41, and the increase in circulating oestradiol levels with alcohol consumption is thought to affect the formation or growth of cancerous cells42. Notably, a small double-blind, placebo-controlled crossover study found that alcohol consumption led to a threefold increase in circulating oestradiol for females taking MHT, with no significant change in those not taking MHT43. However, residual confounding remains a possibility. Hence larger follow-up studies will be crucial to confirm whether an interaction effect is present, and if so, whether it relates to a specific MHT type.In addition to dependencies between cancer risk factor exposures, it is possible that the effects of some exposures on cancer risk may not be independent. Very large sample sizes are necessary to reliably detect interactions, hence the results in this study are provided to generate hypotheses for testing in future work. We found a possible interaction between alcohol consumption and MHT status on breast cancer risk, with the highest risk for alcohol consumption for females taking MHT at recruitment (i.e. a departure from a multiplicative model). Alcohol is known to increase breast cancer risk for both pre- and post-menopausal females, with likely complex causal mechanismsP < 0.05), several reflect relationships that have also been reported previously, including associations between the ‘vigorous exercise’ factor and breast cancer44 incidence for females and incidence of all cancers45 for males (decreasing risks with higher scores), and between the ‘alcohol’ factor and bowel46 and prostate cancer47 incidence for males (increasing risks with higher scores). Some associations have contradictory evidence from past studies and should thus be considered as potential false-positives due to chance or confounding. For example, some cohort studies have also reported increased melanoma incidence with MHT use , although a small clinical trial did not find a significant effect49. It is possible that the association depends on MHT type, data for which were not available in this study.Some of the associations identified between combined factors and cancer incidence can also serve to generate new hypotheses to be followed up in more targeted studies. As expected and noted above, almost all (14/16) of the most significant associations reflect well-known cancer risk factors (Supplementary Note). Of the nominally significant associations ; investigating this was beyond the remit of this study. We also note that the correlations between risk factor exposures and the associations between risk factor exposure patterns and sociodemographic characteristics may be different in other countries. However, representativeness is not required for reliable relative risk estimates from internal comparisons, e.g. when testing associations between combined factors and cancer incidence50. Second, the data on cancer risk exposures and sociodemographic characteristics were self-reported, which could lead to biases due to participants’ recall. While past work has shown that e.g. self-reported use of medications for chronic conditions agreed well with administrative data51, this might not extend to lifestyle behaviours, especially exposures or characteristics that are possibly stigmatised. Moreover, for some risk behaviours, the question related to usual behaviour around the time of recruitment . Thus, information on cumulative lifetime risk exposure was only available for some of the risk factors. Third, this study was limited to available data, for example, it is known that cancer risk differs by MHT type52, but this information was not available. Fourth, we used the number of GP visits in the 2 years prior to baseline as a covariate in the analyses of cancer risk. As data to capture GP visits was only available from June 2004, this variable would not be captured correctly for the approximately 14% of participants who were recruited prior to June 2006. However, the second covariate used for health at recruitment  was captured for everyone. Finally, while it would be of interest to identify the exact contributions of the original exposure variables to the associations between combined factors and cancer incidence, these in-depth follow-up analyses are beyond the scope of the current study.This study has several limitations. First, the 45 and Up Study participants were limited to those aged at least 45 years. While we did not see different correlations between original risk variables by 10-year age groups (data not shown), these correlations cannot necessarily be generalised to those below 45 years of age. The generalisability is also limited by sampling bias of participants, who are known to be healthier and of lower social disadvantage than the general populationIn summary, this study provides a large-scale, systematic analysis of cancer risk exposures in a large-scale population cohort. The identified relationships between risk variables can be used to inform a wide variety of future studies, and design interventions targeting multiple correlated behaviours. Further information for targeting such approaches is provided by the associations between combined factors and sociodemographic characteristics. This study also shows the potential of factor analysis as an approach for identifying associations between exposure patterns and cancer risk.Supplementary Information 1.Supplementary Information 2.