Metabolic syndrome (MetS) has been suggested to be a risk factor for many cancers, including breast cancer. However, it remains unclear whether MetS predicts poor prognosis in women with breast cancer. A meta-analysis was performed to summarize the association between MetS and clinical outcome in women with breast cancer.Cohort studies were identified by search of PubMed and Embase databases. A random-effect model incorporating the potential heterogeneity was applied to pool the results. Subgroup analyses according to the ethnicity and study design were performed.Nine cohort studies with 17,892 women with breast cancer were included. Pooled results showed that MetS was significantly associated with an increased risk of breast cancer recurrence . Subgroup analyses showed that MetS was independently associated with increased recurrence of breast cancer in Caucasians , but not in Asians , and MetS was associated with a trend of increased risk of breast cancer recurrence in both the prospective and retrospective studies. Although we failed to show a significant association between MetS and breast cancer related deaths , MetS was associated with increased risk of all-cause deaths in these patients .MetS may predict the risk of cancer recurrence and mortality in women with breast cancer, particularly in Caucasians. Despite of the improvements in the prevention and management of cancer, breast cancer remains a common malignancy in women, and about 1.4 million women are diagnosed with breast cancer annually . MetabolThe meta-analysis was designed and performed in accordance with the MOOSE   and CochElectronic databases of PubMed and Embase were systematically searched using the combination of the following terms: (1) “metabolic syndrome” OR “insulin resistance syndrome” OR “syndrome X”; (2) “breast cancer”; and (3) “survival” OR “prognosis” OR “mortality” OR “death” OR “recurrence” OR “surgery” OR “operation”. The search was limited to human studies without restriction of the publication language. The reference lists of original and review articles were also analyzed manually. The final literature search was performed on August 24, 2019.Studies were included if they met the following criteria: (1) published as full-length article; (2) designed as cohort studies with the minimal follow-up duration of 1 year; (3) included women with breast cancer; (4) MetS was identified as exposure of interest at baseline; (5) documented the incidence of at least one of the outcomes during follow-up, including the primary outcome of breast cancer recurrence, and the secondary outcomes of breast cancer related deaths and all-cause deaths; and (6) reported the adjusted risk ratios  and their corresponding 95% confidence intervals (CIs) for the above outcomes comparing breast cancer women with and without MetS. Definitions of MetS were consistent with that was applied in the original studies. Reviews, editorials, preclinical studies, and non-cohort studies were excluded.Literature search, data extraction, and study quality assessment were independently performed by two authors according to the predefined inclusion criteria. If inconsistencies occurred, discussion with the corresponding author was suggested to resolve these issues. The following data were extracted: (1) name of the first author, publication year, study location, and study design; (2) characteristics and numbers of women with breast cancer, ethnic groups, criteria for the diagnosis of MetS, and follow-up period; and (3) number of cases with breast cancer recurrence, breast cancer related deaths, and all-cause deaths during follow-up, and variables adjusted when presenting the RRs. The quality of each study was evaluated using the Newcastle–Ottawa Scale (NOS) . This sc2 statistic was also calculated. A significant heterogeneity was considered if I2 > 50%. A random effect model was used to pool the results since this model has been indicated to incorporate the potential heterogeneity of the included studies and therefore could provide a more generalized result. Sensitivity analysis by omitting one study at a time was performed to evaluate the stability of the results [The association between MetS and breast cancer recurrence or mortality outcome was measured by RRs in this study. To stabilize its variance and normalize the distribution, RR data and its corresponding stand error (SE) from each study was logarithmically transformed . The Coc results . To eval results . Potenti results . The RevThe flowchart of database search was shown in Fig. Overall, this meta-analysis included nine cohort studies –23 with 2 = 36%). Pooled results with a random-effect model showed that MetS at baseline was significantly associated with increased recurrence risk of breast cancer (adjusted RR = 1.52, 95% CI 1.08 to 2.13, p = 0.02; Fig. Ten datasets from seven cohort studies –21, 23 w2 = 63%; Fig. 2 = 0%; Fig. Meta-analysis of two studies , 18 showThe funnel plots for the association between MetS and risks of recurrence and all-cause deaths in women with breast cancer were shown in Fig. In this meta-analysis of longitudinal follow-up studies, we found that MetS in women with breast cancer may predict poor clinical prognosis. Specifically, MetS was associated with an increased risk of breast cancer recurrence, even after controlling of potential confounding factors including age, disease stage at diagnosis, HR status, and treatments. Moreover, we found that the association between MetS and increased recurrence risk of breast cancer was significant in studies including Caucasians, but not in Asians. In addition, although a significant association between MetS and breast cancer related deaths was not retrieved by meta-analysis of only two studies, we found that MetS was significantly associated with increased all-cause deaths in women with breast cancer. These results demonstrated that MetS may be a prognostic factor in women with breast cancer, which may predict higher risk of overall mortality.To the best of our knowledge, our study is the first meta-analysis to evaluate the potential association between MetS and clinical outcomes in women with breast cancer. By combining the results of multivariable-adjusted data, results of our study showed that MetS in women with breast cancer is associated with higher recurrence risk and overall mortality, which is independent of some known prognostic factors, such as age, disease stages, and HR status. These results highly indicated that MetS may be an independent predictor of poor prognosis in women with breast cancer. These findings should be validated in large-scale prospective cohort studies, and clinical studies are needed to determine whether optimized management of MetS in women with breast cancer could improve their clinical outcomes. Another interesting finding of the study is that our subgroup analysis showed that MetS is associated with a higher recurrence risk of breast cancer in Caucasian women, but not in Asian women. Although the mechanisms underlying the potential racial difference between the association of MetS and prognosis in breast cancer remain undetermined, some previous studies did indicate a potential racial difference regarding the influence of comorbidities on the survival in women with breast cancer. A previous retrospective cohort study using the Surveillance, Epidemiology and End Results-Medicare linked data showed that diabetes was associated with increased breast cancer-specific mortality in white women, but not in the other ethnicities . MoreoveThe potential pathophysiological mechanisms underlying the association between MetS and poor prognosis in breast cancer may be multifactorial. Previous clinical studies showed that MetS may be associated with more aggressive tumor biology of breast cancer , 14, altOur study has limitations, which should be considered when interpreting the results. Firstly, as a meta-analysis of observational studies, although we combined RR data after adjustment of potential confounding factors, we could not exclude other residual factors that may confound the association between MetS and recurrence of breast cancer, such as treatment with metformin or making diet and or exercise in breast cancer survivors to modify the components of the MetS, which have all been suggested to confer anticancer efficacy –47. SecoIn conclusion, our meta-analysis showed that MetS may predict higher risk of cancer recurrence and mortality in women with breast cancer, particularly in Caucasians. Future studies are needed to clarify the potential influence of cancer HR status and menopausal status on the association between MetS and prognosis, and to determine whether management of MetS in women with breast cancer could improve their clinical outcomes.Additional file 1: Figure S1. Subgroup analyses for the association between MetS and recurrence of breast cancer according to the diagnostic criteria of MetS.


TP53 contribute to the prediction of breast cancer risk. However, most of them focused on Europeans and Americans; the investigations about Asians, especially Chinese women, are scarce. Thus, the aim of this study was to explore the influence of TP53 codon 72 and intron 3 16-bp duplication polymorphisms on the breast cancer risk in Chinese women, especially those from eastern China.Many studies have demonstrated that the genetic variants of tumor suppressor gene Blood samples collected from 254 breast cancer patients and 252 healthy female individuals were investigated. Genotypes of the two polymorphisms were determined by direct sequencing and conventional PCR, respectively.Padj = 0.10; ORadj = 1.43, 95% CI 0.93–2.18), and no homozygous 16-bp duplication (Ins/Ins) genotype was found in the whole 506 clinical samples. For the distributions of allele and haplotype frequencies, no statistically significant difference was observed between the two groups when multiple  genetic models were utilized in the analysis (Padj > 0.05).Heterozygous Arg/Pro and homozygous Del/Del were the most frequent genotypes of the two polymorphisms, respectively. Heterozygous Arg/Pro had a higher prevalence in breast cancer cases  contains supplementary material, which is available to authorized users. TP53, which is located on 17p13.1 and encodes p53, is one of the most significant breast cancer susceptibility genes, as the p53 protein plays an important role in responding to DNA damage, metabolic stress and oncogene activation [TP53 gene, have been identified and reported to be cancer associated, since they can result in the changes of amino acids in the DNA-binding domain, and consequently impact the normal functions of p53 protein [p53 transcript, which may provide a possible molecular basis for the association with high risk of cancer [TP53 polymorphisms and breast cancer risk in Chinese Han women.Breast cancer is the world’s most common and deadly cancer in women. It has been demonstrated that the occurrence of this global disease is associated with not only environmental conditions but also genetic susceptibility , 2. The tivation . However protein –15, wher protein –23. Anotf cancer . Althougf cancer , 22–26, f cancer –33 or Asf cancer –37 populA total of 506 unrelated clinical peripheral blood samples including 254 women patients with breast cancer from Jiangsu Cancer Hospital and the other 252 healthy female individuals recruited by Zhenjiang Center for Disease Prevention and Control were collected and detected. All the studied breast cancer cases are sporadic cases, as those belonging to familial cases were excluded based on the Breast Cancer Linkage Consortium criteria Stratton 1997). The clinicopathological information of the patients and healthy controls is shown in Table 997. The xl DNA Analyzer instrument (Applied Biosystems) after purification from 1.5% agarose gel. The 16-bp duplication polymorphism was determined by PCR using the forward primer: 5′-CGTTCTGGTAAGGACAAGGGTTGG-3′ and reverse primer: 5′-AAAGAGCAGTCAGAGGACCAGGTC-3′. The reaction conditions were pre-denaturation at 94 °C for 2 min; 30 cycles of denaturation at 98 °C for 10 s, annealing at 59 °C for 30 s and extension at 68 °C for 6 s. Then, PCR products were separated by 4% agarose gel and visualized by Gelred staining. Homozygous wild-type alleles  resulted in a 102 bp fragment, while homozygous variant alleles  resulted in a 118 bp fragment. Both two fragments (102 bp + 118 bp) were obtained when the genotype was heterozygous Del/Ins. All reactions were performed in a total volume of 25 μL mixture containing 20 ng of gDNA and 0.3 µM of each forward and reverse primer.Genomic DNA (gDNA) was extracted from the blood samples using QIAamp DNA Blood Mini Kit . The codon 72 polymorphism was determined through direct sequencing. Genomic DNA of each sample was amplified using the forward primer: 5′-GACCTGGTCCTCTGACTGCTCT-3′ and reverse primer: 5′-TGACAGGAAGCCAAAGGGTGAAGAG-3′. The PCR thermal cycling conditions were pre-denaturation at 94 °C for 2 min; 30 cycles of denaturation at 98 °C for 10 s, annealing at 59 °C for 30 s and extension at 68 °C for 25 s. The 430 bp PCR products were directly sequenced using the ABI 3730http://ihg.gsf.de/cgi-bin/hw/hwa1.pl). Chi-square (χ2) test was used to compare the categorical variables. Statistical significance level was set at 0.05. The odds ratio (OR) with its 95% confidence interval (CI) was calculated through logistic regression analysis (adjusted for age) to measure the association between genotypes of the two polymorphisms and breast cancer risk. Additionally, Armitage’s trend test was also performed to improve the statistical power of this study.Statistical analysis was performed using SPSS version 19.0  and the online Hardy–Weinberg equilibrium (HWE) calculator (p = 0.942 and p = 0.407) were within Hardy–Weinberg equilibrium. For the codon 72 polymorphism, the heterozygous Arg/Pro was the most frequent genotype in both groups, and had a higher prevalence in breast cancer cases . The distributions of Arg and Pro allele frequencies were almost equal in both groups . Regarding the 16-bp duplication polymorphism, the homozygous Del/Del was the most frequent genotype in both groups and its distribution frequency was significantly higher (approximately eightfold) than that of the heterozygous Del/Ins; no homozygous 16-bp duplication (Ins/Ins) carrier was found in the whole 506 samples. Briefly, no statistically significant difference was obtained when analyzing using multiple genetic models  (Padj > 0.05) and Armitage’s trend test (Ptrend = 0.58 and 0.86) (Table p > 0.05)   Table .Table 3ATP53 polymorphisms codon 72 and intron 3 16-bp duplication as well as their haplotypes, and breast cancer risk in Chinese Han women. For the codon 72 polymorphism, a lot of studies have reported its contribution to the breast cancer susceptibility in women from different geographic areas and ethnic groups [p = 0.85)  or control group  of their studies.Here, we investigated the relationship between two controversial c groups , 11, 13.c groups , 22, 23.Regarding the 16-bp duplication polymorphism, most of the previous studies accepted that the Ins allele, especially homozygous Ins/Ins, contributed to the increase of breast cancer risk , 24–26. On the other hand, the haplotypes of the two polymorphisms may be another important factor affecting breast cancer risk, since it was reported that they were in strong linkage disequilibrium . Some stTP53 codon 72 as well as intron 3 16-bp duplication polymorphisms and breast cancer risk in Chinese Han women when multiple genetic models along with Armitage’s trend test were utilized in the analysis, but the heterozygous Arg/Pro may exist as the possible risk genotype of the codon 72 polymorphism, which were a little distinguished from the conclusions of previous studies. Still, more relevant studies designed for Chinese population, especially those with larger sample size, need to be done to further validate these findings.In conclusion, through a population-based case–control study, we found that there was no significant association between Additional file 1: Table S1. Distributions of the genotype frequencies of codon 72 and intron 3 16-bp duplication polymorphisms in breast cancer patients with different clinicopathological features.


Breast cancer accounted for 1.03% of all deaths in 2014 in Eritrea. Yet the knowledge, attitude, and practice (KAP) of the population in general or the health personnel in the country in relation to the disease, remains unknown. Hence, this study was designed to assess the KAP regarding breast cancer among female nurses working in ten hospital wards in Asmara, Eritrea.This was a cross-sectional study conducted among 414 nurses. Descriptive statistics, t-test, and ANOVA were used to evaluate the KAP of the nurses.Nurses’ knowledge about the possible risk factors of breast cancer was low but the nurses knew the signs and symptoms of breast cancer since each sign or symptom was mentioned by > 50% of them. The practice of breast cancer screening, however, was low . Respondents’ family history of breast cancer, having breast problems, their professional level and unit where they worked were associated with the KAP of nurses about breast cancer.Training programs could help to increase the nurses’ knowledge about the risk factors of breast cancer and practice of breast cancer screening. This could also help to increase the knowledge of the public about breast cancer. Breast cancer is a major, life-threatening, public health concern. Long-term increase in the incidence of the disease has been observed in both developed and developing countries . It is tIn Eritrea, 370 women died from breast cancer in 2014 accounting for 1.03% of total deaths in that year giving an age-adjusted death rate of 21.40 per 100,000 of population [Breast cancer risk factors include increased age, genetic mutation, early menstrual period, late or no pregnancy, starting menopause after age 55, not being physically active, being overweight or obese after menopause, having dense breast, using combination hormone therapy, taking oral contraceptives, personal history of breast cancer, personal history of certain non-cancerous breast diseases, a family history of breast cancer, previous treatment using radiation therapy and drinking alcohol [Information is needed to identify the underlying factors that might influence nurses’ own practice of early detection methods of breast cancer. Empowering nurses with information about early detection methods and their related benefits could help in advancing their skills in performing breast self-examination and expanding their role as client educators . EducatiSeveral cross-sectional studies on Knowledge Attitude and Practice (KAP) of breast cancer have been done among nurses in Nigeria –13 EthioPreviously, studies on the clinical aspects of breast cancer have been conducted in Eritrea –24. Yet,This was a cross-sectional study designed to assess the KAP of nurses on breast cancer. It was conducted among nurses whose qualifications included certificate, diploma, and degree and who were working in ten hospital wards in Asmara, the capital of Eritrea. All the nurses in the selected health facilities and wards were invited to participate in the study. Majority of the nurses working in the surveyed hospital wards were females.Knowledge of breast cancer among the participants was assessed based on knowledge on risk factors of breast cancer, signs and symptoms of breast cancer and knowledge on BSE, CBE, and mammography. The assessment was done by scoring breast cancer knowledge computed by giving “1” to the correct answer, and “0” for the wrong and ‘do not know’ answers. Furthermore, a percent knowledge index (PKI) was calculated for each nurse by summing the number of correct answers for all the variables and calculating the percentage of the correct answers. Furthermore, attitude was assessed by asking respondent about their opinions in regards to whether breast cancer is curable, how they would feel if they develop breast cancer and what they would do if they develop BC. Practice was assessed on what respondents do to detect early symptoms and signs of BC.P < 0.05 was considered statistically significant.Data was collected by a pretested, questionnaire. List of study subjects was obtained initially from the Human Resource Management (HRM) office of the studied hospital wards, and after verbal consent was obtained, an interviewer guided self-administered questionnaire was used to collect the data. Collected data were checked for errors and data entry was completed using census survey processing (CSPro) software. Data were analyzed using the statistical package for social sciences (SPSS version 20) software. Descriptive statistics were used for data presentations. Association between categorical variables were explored using Chi-square. Quantitative analysis was performed using t-test for binary variables and ANOVA for more than two variables. The study was approved by the Research and Ethics Committee of Asmara College of Health Sciences and Eritrean National Commission for Higher Education. An official letter was sent to concerned hospital directors and oral informed consent was obtained from the study subjects prior to questionnaire administration.A total of 427 nurses were approached to participate in this study. The complete response rate was 97% and so a total of 414 nurses’ responses were included in the data analysis. The mean age of participants was 33.85 ± 11.60 (min 19 and max 69 years). Nearly half (48.6%) of the participants were associate nurses. Similarly, half of the respondents (51%) were unmarried. More than nine-tenths of study participants had no family history of breast cancer or no personal history of breast problems (Table Table (82.2%) of the participants were willing to be examined by a male doctor for their breast (data not shown). Similarly, 348 (83.7%) were willing to be examined by a doctor within one week suspecting of developing breast lump.The attitude of the participants on breast lump was satisfactory, 342 Regarding the first time diagnosis of breast cancer, the response of the participants was scared (61.8%), 95.7% consult a doctor, 10.1% use traditional medicine and 80.8% agree on Mastectomy (If necessary).When the nurses were asked about their own overall risk of developing breast cancer, 22% thought that they were not at risk, 21.2% thought that they were at low risk, 11.1% at medium risk and 24% at high risk. The remaining 21.6% stated they don’t know.Nurses were also asked if they had any of the risk factors for developing breast cancer, 51.0% answered they had none of the risk factors, 18.8% mentioned having one risk factor, 8.2% having two risk factors and 4.8% having three or more risk factors. On the potential risk factors of breast cancer,51.0% of the respondents answered none, while 18.8% mentioned are having one risk factor, 8.2% two risk factors and 4.8% three and more than three.More than half (53.6%) of the participants believed that that breast cancer occurs more commonly in old women. In addition, 235 (56.5%) of the participants have thoughts that breast cancer is a curable disease. The overall understanding of the survival period (more than five years) after clinical diagnosed of having breast cancer was 59.4%.Table In addition, 56.5% of the participants thought that breast cancer is a curable disease. The overall understanding on the survival period (more than five years) after clinical diagnosis of having breast cancer was 59.4%.The knowledge of nurses on the correct age for initiation of breast self-examination was 75.8% and more than three quarters (80%) of them reported that they knew how to perform BSE and less than half of them (42%) knew the recommended frequency of conducting BSE.Three-quarters (75.5%) of the nurses said they practiced BSE. Of these, 60.6% practiced once a month, 7.2% once every three months, 14.5% said they did BSE once a year, and 17.8% did not answer. The reasons given for not practicing BSE were; ‘carelessness’ (17.1%), ‘don’t have breast problem’ (14.2%), ‘unsure about its benefit’ (8.2), ‘don’t know how to do it’ (5.3), ‘too frequent to practice’ (2.9%), ‘don’t feel comfortable doing it’ (1.2%) and ‘don’t think I need to do it regularly’ (1%).Thirty percent of the nurses practiced CBE. Of these, 14.9% were examined only once and 13.3% three times and above. The majority (55.3%) of those who did not practice CBE stated that they were reluctant because they had no signs and symptoms of breast cancer. Forty-seven nurses (11.3%) (37% of those aged > 40 years) had undertaken mammography examination in their life and only 8.7% of the overall study participants knew that 40 was the correct age for starting mammography as a screening method.In this study, age and religious affiliation of respondents were associated with knowledge on signs and symptoms of breast cancer. Marital status was not associated with the KAP of nurses. Having breast problems was associated with the KAP of nurses whereas having a family history of breast cancer was only associated with the knowledge of risk factors. Nurses with bachelor’s degree had the highest knowledge compared to registered and associated nurses. The place of work was also significantly associated with the knowledge about breast cancer risk factors and its symptoms; nurses who worked at the Orotta Maternity Hospital had the highest knowledge Table .Table 4Bp < 0.001) in which registered nurses had the highest practice (82.40%), followed by associated nurses (74.4%) and bachelor science in Nursing (BSN) (55.80%) (data not shown).Moreover, there was a significant association between the professional level of nurses and BSE practice (There are four important findings in this study. Firstly, nurses’ knowledge about the possible risk factors of breast cancer is a concern since many established risk factors of breast cancer were mentioned by less than 50% of them. Secondly, nurses had a good knowledge of the signs and symptoms of breast cancer in which each sign or symptom was mentioned by more than half of them. Thirdly, the practice of breast cancer screening was low and lastly, a family history of breast cancer, having breast problems, the professional level of nurses and the unit where they work predicts the KAP of nurses about breast cancer.In some studies elsewhere, nurses’ knowledge about the risk factors of breast cancer has been found to be low , 16, 20 In line with other studies , 15, 20 Knowledge and attitude should be accompanied by practice. A gap in practice was identified in this study in which nurses were found to practice breast cancer screening infrequently. Nurses in this study reported practicing CBE and mammography less often. Only 30% of the nurses practiced clinical breast examination. This was similar to the findings from one study in Nigeria  and loweThere were some limitations in this study. Firstly, the practice of breast cancer screening was reported, but nurses may not adequately remember whether they have done breast cancer screening or not. Secondly, since our subjects were those nurses working in hospitals only, this result may not reflect the knowledge of nurses who work in health centers and small clinics. Despite these limitations, we discovered important gaps in KAP of hospital nurses about breast cancer.This was the first study to assess the KAP of nurses’ about breast cancer. Nurses were found to have good knowledge of the signs and symptoms of breast cancer but little knowledge about the risk factors of the disease. The practice of breast cancer screening among the nurses was low. Therefore, training programs to update nurses’ knowledge about the risk factors of breast cancer and practice of breast cancer screening could potentially help in the practice of healthy habits among the nurses. This, indirectly, could also help to increase the knowledge and practice of the public about breast cancer.


Potentially modifiable risk factors account for approximately 23% of breast cancers, with obesity and alcohol being the two greatest. Breast screening and symptomatic clinical attendances provide opportunities (‘teachable moments’) to link health promotion and breast cancer-prevention advice within established clinical pathways. This study explored knowledge and attitudes towards alcohol as a risk factor for breast cancer, and potential challenges inherent in incorporating advice about alcohol health risks into breast clinics and screening appointments.A mixed-method study including a survey on risk factors for breast cancer and understanding of alcohol content. Survey results were explored in a series of five focus groups with women and eight semi-structured interviews with health professionals.Women attending NHS Breast Screening Programme (NHSBSP) mammograms, symptomatic breast clinics and healthcare professionals in those settings.205 women were recruited (102 NHSBSP attenders and 103 symptomatic breast clinic attenders) and 33 NHS Staff.Alcohol was identified as a breast cancer risk factor by 40/205 (19.5%) of attenders and 16/33 (48.5%) of staff. Overall 66.5% of attenders drank alcohol, and 56.6% could not estimate correctly the alcohol content of any of four commonly consumed alcoholic drinks. All women agreed that including a prevention-focussed intervention would not reduce the likelihood of their attendance at screening mammograms or breast clinics. Qualitative data highlighted concerns in both women and staff of how to talk about alcohol and risk factors for breast cancer in a non-stigmatising way, as well as ambivalence from specialist staff as to their role in health promotion.Levels of alcohol health literacy and numeracy were low. Adding prevention interventions to screening and/or symptomatic clinics appears acceptable to attendees, highlighting the potential for using these opportunities as ‘teachable moments’. However, there are substantial cultural and systemic challenges to overcome if this is to be implemented successfully. A mixed methodological approach enabled a broader exploration of knowledge and attitudes to alcohol as a risk factor for breast cancer than achievable using a single research method.Participants were women attending the NHS Breast Screening Programme (NHSBSP) mammograms, symptomatic breast clinics and healthcare professionals based in a single hospital, to understand how attitudes and information needs in this area may differ across these groups.Cross-sectional survey results were explored in a series of five focus groups with women and eight semi-structured interviews with health professionals, to enable triangulation of data.Research in this area is at an early stage, such that there are no standardised tools to measure the constructs explored.The study was conducted in a single UK centre, limiting the potential generalisability of the results.Breast cancer is the most common cancer in the UK with >54 000 new cases diagnosed annually and the incidence is continuing to rise.Alcohol use is now estimated to be responsible for between 5% to 11% of breast cancer cases and current evidence suggests that it is a risk factor for all age groups.Two important components for motivating and sustaining behaviour change are the awareness of the health risks (or benefits) of a behaviour, and one’s own risk level.Evidence for lifestyle advice interventions in breast cancer prevention is limited,The NHS Breast Screening Programme (NHSBSP) provides free breast mammographic screening every 3 years for all women aged 50 and over. In total, 1.94 million women aged 45 and over were screened within the programme in England in 2011 to 2012 with a 73.1% uptake of routine invitations.Despite the positive potential of implementing interventions in this setting, it is important to first understand how features of the breast health appointment context may influence the applicability - and acceptability to patients and staff - of any intervention.This mixed-method study used quantitative data as the primary frame, with a secondary qualitative frame to build on the quantitative data. Outcomes of the analysis of cross-sectional survey data were used as prompts for focus group and telephone discussions.Recruitment based on securing a minimum sample size of 100 for each clinical group and 20 staff members was determined to be plausible based on known attendance and staff numbers at Southampton breast services, and to be sufficient to generate data of risk factor and alcohol knowledge to be explored in depth within qualitative interviews.Staff interview questions about risk factors mirrored the survey questions and additionally explored meaning and emotional appraisal. Three focus groups consisting of a maximum of eight women each were planned, as eight is considered the optimum focus group number when the topic is of importance to participants.The study received approval from the NRES Committee South Central - Hampshire A Research Ethics Committee (reference no.14/SC/1399), and all participants gave informed consent.The design for this study was developed at an innovation workshop funded jointly by Cancer Research UK (CRUK) and BUPA Foundation  which included patient and public involvement (PPI) representation. Following up the initial survey results with participants in a series of focus groups and telephone interviews ensured participants were actively involved in the conduct of the study. The data and preliminary findings were presented at a CRUK showcase event including a wide range of PPI stakeholders.Participants were recruited from three different populations: (1) Women attending NHSBSP mammograms (SG), (2) women attending symptomatic breast clinics (CG) and (3) NHS health professionals associated with these services (HP). All participants meeting the eligibility criteria for inclusion (over the age of 18) on the 12 days the researcher (ES) was in the specified breast health services were approached, and those with sufficient English to give informed consent were recruited. Uptake rate was 82% in SG, 88% in CG and 71% in HP groups, suggesting limited bias in sampling. In the event five focus groups were conducted with a total of 29 women. The smallest group size consisted of three women and the largest 11. All data were collected between January - July 2015. All patients provided written informed consent before completing the survey.question ‘write down anything you think might increase the risk of breast cancer’, was coded by ES, and 10% of the responses were double-coded by JS to check consistency.As there are currently no psychometrically validated tools to measure knowledge of breast cancer risk factors or estimation of alcohol content in UK drinks, we developed our own questionnaire specifically for this study . Participants were given four multiple choice questions to identify the units of alcohol in four drink types  as the two greatest potentially modifiable risk factors for breast cancer. Participants in each of the three groups completed the same survey to allow for comparison across groupsto discuss their opinion about some of the methods available to try and reduce the number of women who develop breast cancer’. The topic guides are available in online Women attending either a clinic or a mammography screening appointment who had taken part in the survey were invited  to a focus group ‘10.1136/bmjopen-2018-027371.supp3Supplementary pdfe 3Health professionals, working in breast clinics or screening services, were also invited to take part in a semi-structured telephone interview to discuss some of the findings of the survey further. Interviews were by telephone to reduce participant burden and maximise the degree of anonymity for participants to encourage frank and open responses.Clinic/mammogram attenders (CG and SG groups) reported their views of what may be acceptable and appropriate in terms of information about alcohol as a risk factor for breast cancer, delivered as an intervention embedded within NHS breast clinics (both symptomatic and preventative screening appointments).After the clinic/mammogram attenders (CG and SG groups) and staff (HP group) data sets were analysed separately, they were compared with each other to determine where the staff and attendee views met and diverged, giving two sides of the same story.Chi square tests assessed differences between the recruited groups in terms of demographical and health characteristics, risk factor identification and ability to identify alcohol units. Likelihood ratio tests comparing logistic regression models with and without interaction terms were used to assess if the association between risk factor identification and individual characteristics varied between groups. Analysis were conducted using Stata V.14.2.Qualitative data from the focus groups and telephone interviews were transcribed verbatim, and then analysed using the principles of thematic analysisIn total 238 people completed the survey; 102 NHSBSP attenders (SG), 103 symptomatic breast clinic attenders (CG) and 33 breast unit staff (HP). Other than the differences that would be anticipated between the groups due to the populations they were recruited from  smoking was significantly less frequent in the staff compared with the attender group . An overview of the characteristics of the participants in the three samples is shown in There were significantly more women under 50 and over 70 years in the symptomatic clinic group than attended screening. In terms of knowledge of risk factors, there was little difference between the two groups see . Each gr2 12.7, p=0.0004). See Personal alcohol consumption was reported by 60% of participants in the screening group and 73% in the clinic group. In those who did not drink alcohol, there was no difference between screening and clinic groups in identifying alcohol as a risk factor for breast cancer (15% vs 16%). However, among those who drank alcohol, identifying this as a risk factor for breast cancer was significantly more likely in the symptomatic group (35%) than those attending screening (4%) (XOnly 88/152 (57.9%) participants who drank alcohol stated that they knew how to estimate the alcohol content in drinks, and of these 72%, 55%, 24% and 24% correctly identified the number of units in a standard glass of wine, pint of beer, litre of cider and bottle of spirits respectively, out of a choice of four options for each one. Overall in both SG and CG there was a significant association between identifying alcohol as a risk factor for breast cancer and personal alcohol consumption , as well as a positive association with being able to correctly identify the alcohol content of drinks. Of those who got none of the four drink units correct, 86.2% also did not identify alcohol as a risk factor compared with 13.8% who did identify alcohol as a risk factor (p=0.01), suggesting that increased awareness about alcohol is associated with the knowledge necessary (if not sufficient) to facilitate behaviour change see .In terms of BMI, based on self-reported height and weight, see  a minori5 min cancer prevention information session’ to either the SG or CG was similar in both groups 60/197 (30.5%) said it would make them more likely to attend and 137/197 (69.5%) said it would make no difference to their attendance. No one marked the option that it would make them less likely to attend. Potential disadvantages of adding a cancer prevention session were identified by 28% of the SG and 40% of CG, with time, additional use of resources and potential cause for anxiety cited as the main concerns. In terms of preference for how this might be delivered, 31% stated they would prefer this to be by an electronic device, 26% by post, 40% by a trained nurse and 18% by a trained volunteer.The response to adding a ‘Thirty-three health professionals (HPs) participated and key findings are summarised in In accordance with the open ended focus group questions .I mean a glass of wine’s… it’s a bit like a cup of tea… a glass of wine used to be like that, Both women and staff recognised a need to understand more about lower risk alcohol consumption specifically relative to volumes of drinks consumed. Women’s motivations, understanding and rationalisation for their own alcohol consumption were varied and complex and perhaps reflect the varied cultural values, symbolic value and messages about alcohol represented in today’s social environment.Women’s expectations of the role of health professionals in providing health education were also apparent here; they said they were happy for staff to advise them in breast screening clinics, hinting at a certain passivity in their own role in seeking/receiving alcohol information of this kind.I think having any kind of information about it. I mean I haven’t heard anything about breast cancer at all. Not from my GP – no one’s mentioned it once. So I think it’s just having any kind of information at all would be a good place to start .Both women and staff wanted consistent, evidence-based facts about alcohol consumption, and specific risks related to breast, rather than other forms of cancer …People aren’t aware exactly how much they drink and also are surprised when they find out that alcohol is a risk factor for breast cancer .Participants felt there were many mixed messages about the risks of alcohol consumption, and wanted clear information from a trusted sourceit’s been marketed in such a way that, particularly with wine, that it’s good for you, in a way .Both staff and women saw concrete, evidence-based information as a necessity in a field where there is an overwhelming amount of uncertain information, which can cause anxiety.However, despite appearing to value and engage with information gained from peers in focus groups, women talked of finding it hard to know how to view conflicting information from media, hearsay and their own experiences. Women who talked of knowledge gained from lived experiencesI had it (breast cancer) 10 years ago. I don’t drink, I don’t smoke, and I still got it had views that were seemingly less flexible and demonstrated a lack of trust in ‘evidence based’ preventative information.Staff echoed this uncertainty, highlighting their own and women’s confusion; they reported needing evidence about alcohol consumption and its specific links to breast cancer to feel more confident advising patients. Staff also displayed their own relatively low levels of literacy around alcohol in relation to breast cancer when talking about what they felt the content of preventative information should be.…the whole idea of trying to prevent cancer through lifestyle seems like it’s quite in its early stages…it’s not just the public that we need to spread the word to but it’s the healthcare professionals too because people are not really aware of it .Health professionals were fearful of offering false advice, again underlining their mixed views about the legitimacy of including preventative information in their role as health professionals and a strong concernyou just have to be careful you don’t put women off coming to screening… ,yet women did not mention this as an issue, confirming the survey results presented above; rather that they wanted more opportunities to access information.Staff also underlined their own need for training about levels of alcohol consumption and its bearing on breast cancer to improve their confidence delivering advice to patients.Lack of time to engage with information was also a factor for women - they highlighted the need for succinct, universally appealing information that would engage across different groups in society. In a similar vein to the pink ribbon used for fundraising by breast cancer charities, staff suggested the idea of a symbol to use to catch women’s attention for prevention information.Both staff and women recognised a need for a wider cultural change before fully accepting the need to accept, act on and acknowledge alcohol as a modifiable risk for breast cancer.I think as a nation we are not very honest about the harms of alcohol, and that goes across the board in terms of doctors and nurses as well .There appeared to be an unacknowledged ‘collusion of denial’ where staff and women avoided being proactive in discussing alcohol as part of the dialogue around preventing breast cancerI mean when is the best time for health promotion, I don’t know .This suggests a challenge of dealing with alcohol as a risk for breast cancer on both sides, where women seemed to assume staff would tell them about risks that are important and where staff would not ask women about their alcohol intake as they did not see it as part of their role.Staff agreed that breast screening appointments could be ideal opportunities for preventative informationbecause you’ve already got yourself a self-selecting audience, people who feel it’s important enough to turn up,though did not see it as part of their role to deliver this information.A key motivator for women appears to be whether a risk factor applies to them specificallyIf you don’t own it, you’re not going to act on it are you? .In order to make informed choices about how to prevent breast cancer they reported wanting personalised information in order to address the risks they knew about, and if it was meaningful to them, they seemed more motivated to make the changes. Confusion between relative risks of individual risk factors, population based risk factors and definite ‘causes’ were common.Any rationale given for changes specifically to prevent breast cancer was primarily from women with lived experience of breast cancer (themselves or a close family member). They had either been advised by health professionals to make changes, or made aware by their affected family member:I’ve got it on both sides of my family, …I…check what I eat….and I don’t drink a lot anyway (FG2);they seldom talked of changes to alcohol consumption.Overall, women with a family history of breast cancer reported being less inclined to make lifestyle changes, especially if relatives had adopted healthy lifestyles and had still got breast cancer, re-enforcing a more fatalistic viewmy GP’s told me of various risk factors but then it happened to my mum anyway. So I shrug my shoulders  and there’s certain lifestyle things I can do but then I have, like, this little thing on my shoulder going ‘well it didn’t make any difference for my mum .Women suggested the use of humour as a way of making breast cancer prevention information more engaging and accessible…There should be more discussion between mothers and daughters … like fathers and sons. . ‘have you checked your balls son?’ [laughter] There should be a light-heartedness about it rather than it being you know when you see these adverts and it’s all tears … ,although this was in the context of self-examination rather than addressing alcohol consumption.In sharp contrast to the discussions of women in the focus groups, a common theme that ran through the interviews with staff was an ambivalence about discussing alcohol use with women who came to screening or symptomatic breast appointments. This ambivalence appeared to reflect a number of underlying processes. These are described here in preliminary form, but will require much greater exploration in future research See .Staff recognised that prevention and health promotion was important, but did not see it as their role. Alcohol use was described asthe last thing (staff) would discuss with patients (iv1).There was a certain sensitivity and worry about raising the topic.People don’t like to think they’re being lectured to, patronised… it’s quite a careful balance…, between imparting useful information in a way that people are going to be receptive to or people feeling that you’re sort of ‘nanny stating’ them .There were also concerns about giving advice based on population risk and the inherent uncertainties between cause and effect that this containsthey might do (what is suggested)… they think they’ve done everything right and then they still get breast cancer .Staff agreed with the idea of health promotion, in principle…it is important but maybe not essential",but often felt the responsibility did not lie with them . This seemed connected with seeing themselves responsible for diagnosis and treatment rather than prevention. There was ambivalence as to whether it was their role to encourage patients to take a preventative approach, by advising about lifestyle risk factorsI don’t really think it’s our role to do that.This tension between reactive and preventative health roles may be a barrier to integrating health prevention within already established screening and treatment services as part of a cancer prevention culture.We’re very good at just focusing on the disease and not telling the patient what they can do to help .There was also a suggestion that different competencies may be required to fulfil the role:for those of us that are trained in symptom control or diagnostic activities, to be a health promoter is a very, very different kettle of fish and a very different training I would imagine .Women however did not appear to make this differentiation within the health professional role, and saw them all as a trusted sources of advice.I definitely think the preventative line you’re going down is far better than the reactive system we have at the moment .A cultural mind-set underlying alcohol was considered to be a key barrier to acceptance of it as a modifiable risk factor for breast cancerI can’t quite see…, a bottle of Lanson Champagne, saying on the bottle, you know this is a killer, don’t - don’t drink [laughter] .With one exception, there was difficulty in talking about alcohol use except as a significant problem for a minority of peopleit would be important to reinforce the idea that a lot of people drink too much that aren’t alcoholics and highlight the fact that it’s very normal ,The need for a cultural shift in attitudes to alcohol-related behaviour as well as towards making preventative lifestyle choices was acknowledged in order to make conversations around alcohol and health less problematic.I think undoubtedly people will bring their own prejudices to wherever they are, and clearly, people don’t like to feel hypocritical either do they, so I think the best bet is to try and be honest to people.Avoidance of risks was one way women reported gaining control over getting cancer, but this also related to feelings of guilt if they saw it as their fault for not avoiding somethingYou think what might I have done that’s caused this? .If a risk of cancer was seen as genetic then women tended to feel they were immune from responsibility or blame for not making healthy lifestyle choices. One woman alluded to the judgement that might be made about someone with breast cancerI just think [of them as] someone who’s got it wrong somewhere along the line. But then you’ve got – you know – genes that - that get passed on from your family, so then I’d be wrong in that instance .This provokes questions around women’s feelings of guilt and blame for making the ‘right’ and ‘wrong’ lifestyle choices and also show how stigma can exist even in groups of women who have experienced cancer themselves.This study demonstrates the potential acceptability and need for the development of a contextualised ABI as part of encouraging a cancer prevention culture in breast health settings. The qualitative findings illuminate where women’s and staff views meet and diverge. This will inform the development of an appropriate intervention that engages women with alcohol information, giving them feedback about their alcohol consumption in a breast health context. This can be used as an opportunity to improve awareness of alcohol as a risk factor for breast cancer, and improve skills in monitoring alcohol consumption.Although the exact mechanism by which alcohol acts to promote carcinogenesis is unclear, epidemiological evidence that alcohol is a significant and modifiable dose dependent risk factor for breast cancer is now widely accepted by the scientific community. However, our data indicate that this information is not known by the majority of women attending breast screening and symptomatic clinics. These results are similar to others which have examined awareness of alcohol as a risk factor for breast cancer,This is particularly important as recent changes to UK Chief Medical Officers’ low risk drinking guidelinesThe Health Survey for England (2014) indicates that almost 80% of women had drunk alcohol at some point during the previous year; the percentage of women drinking over 14 (UK) units per week was highest in the 45 to 54 year (20%) and 55 to 64 year (22%) age groups and the proportion of people drinking at increased-risk-levels was greatest in the highest income groups.Both staff and clinic attendees showed ambivalence about discussing alcohol, concerned about it being taken as stigmatising or blaming women, demonstrating a wider social ambivalence about our relationship with alcohol. However, this study and the predicting risk of cancer at screening (PROCAS) clinical trial, which is exploring the potential to produce personalised breast cancer risk assessments, have both confirmed that it is feasible for women to interact with a brief and unsupervised health survey while attending routine screening appointments, despite the short appointment times provided in this setting.The effectiveness of ABIs to reduce alcohol intake in people drinking at non-dependent levels has been investigated extensively, with good evidence for effectiveness.et al published guidelines encouraging physicians to use ‘teachable moments’ to provide patients with lifestyle advice aimed at cancer prevention, regardless of the patient’s motivation to receive the message.In 2008, Demark-Wahnefried The study is limited in that it was carried out in a single centre and was cross-sectional in nature. Given the lack of research in this area, a survey utilising a range of response modes, including free text responses, was used to explore knowledge of alcohol as a risk factor for breast cancer in the absence of a validated tool. However, a significant strength of this study is the use of mixed methods to explore in greater depth the findings from the survey, to better understand the ambivalence that attendees and staff have to discuss alcohol use as part of cancer prevention.This study confirms that knowledge of alcohol as a modifiable risk factor for breast cancer is low among women attending symptomatic breast clinics or routine NHSBSP mammograms. A lack of literacy regarding the alcohol content of commonly consumed drinks indicates that many women are not well equipped to assess their own alcohol intake. However, many women participating in this study reacted positively to the suggestion of adding information on cancer prevention, in general, to NHS breast screening or clinic attendances, although there was ambivalence by staff to delivering it. Full utilisation of these ‘ teachable   moments ’  will require education of healthcare professionals, as well as a wider cultural change around alcohol use. Further research is also required to understand how best to embed a prevention culture, which includes giving clear non-judgemental information about the relative risks of alcohol consumption, within current health systems.


Breast cancer prevalence continues to increase globally, and a significant proportion of the disease has been linked to genetic susceptibility. As we enter the era of precision medicine, genetics knowledge and skills are increasingly essential for achieving optimal cancer prevention and care. However, in Nigeria, patients with breast cancer and their relatives are less knowledgeable about genetic susceptibility to chronic diseases. This pilot study collected qualitative data during in-depth interviews with 21 participants. Of these, 19 participants were patients with breast cancer and two were relatives of patients with breast cancer. Participants were asked questions regarding their knowledge of breast cancer, views on heredity and breast cancer, and views on genetic counseling. Participants’ family histories were used as a basis with which to assess their hereditary risk of breast cancer. Participant responses were audio recorded and transcribed manually. The study evaluated patients’ and relatives’ knowledge of genetic counseling and the use of family history for the assessment of familial risk of breast cancer. This will serve as a guide to the processes of establishing a cancer risk assessment clinic. Nigerian patients with breast cancer and their relatives may also not understand the function of breast cancer–associated genes, as they may not be familiar with the genetic implications or outcomes of their disease.15 As the dissemination of genetic findings and the clinical implementation of new genetic knowledge is key for translational research to achieve its full potential, it is crucial to be cognizant of patients’ current knowledge and understanding of cancer genetics and risk before creating widespread genetic counseling programs with which to address cancer risk and prevention.It has become evident that breast cancer and its underlying genetic mechanisms vary by population.16 Counseling sessions focus on providing patients with vital, unbiased information and nondirective assistance during the patient’s decision-making process17; however, there is little information on how many and which women would want to address the possible genetic component of their breast cancer and take preventive measures at a time when their primary concern is survival.18 To this effect, it is crucial to gauge the knowledge of Nigerian patients with breast cancer and their relatives of genetic susceptibility and genetic counseling to better tailor genetic counseling programs and educational materials to their individual needs.The main purpose of genetic counseling is to help patients and their family members understand genetic diseases and risk, discuss disease and risk management options, and explain the risks and benefits of genetic testing.The current study sought to elicit patient and family members’ knowledge and attitudes about genetic counseling and the use of family history in assessing familial risk of breast cancer. In the process of assessing participants’ knowledge of breast cancer and heredity via the creation and use of family pedigrees, this study also sought to elicit participants’ concerns about genetic counseling.This study relied on qualitative data from 21 in-depth interviews that were conducted at University College Hospital  from February 2015 to May 2015. Qualitative data were collected using in-depth interviews from 19 female adults with breast cancer who reported positive family history and two of their first-degree relatives (FDRs) from four oncology units of UCH Ibadan. A convenience sampling technique was used to select patients with breast cancer from four clinics or departments at UCH—the Surgical Outpatient Clinic, Radiation Oncology Clinic, Radiology Department, and Surgical Oncology Ward. Patients with a confirmed diagnosis of breast cancer history as well as their FDRs were approached by nurses trained in genetic counseling. Those who confirmed a positive family history of any cancer and gave informed consent were selected for a precounseling in-depth interview. In total, 19 adults with a self-reported family history of cancer were selected from a list of 102 patients, and two consenting FDRs of those patients also participated. Some demographic characteristics were obtained from participants.Participants were asked questions about their knowledge of breast cancer, views about its hereditary causation, and views on genetic counseling and the use of family history to assess the hereditary risk of breast cancer. All questions were open ended and asked in a way that allowed patients and relatives to elaborate on topics that were seen as most important to them. Responses were recorded verbatim and transcribed manually.This study was part of a larger study, titled “Effects of Genetic Nursing Education on Nurses’ Competencies in Counselling Cancer Patients and their Relatives in Selected Teaching Hospitals in Southwest Nigeria.” Ethical review committees of selected teaching hospitals approved the larger study.Twenty-one participants—19 patients with breast cancer and two FDRs—were interviewed. Transcripts and notes were manually analyzed to raise themes and identify emergent issues related to knowledge about cancer and breast cancer, pedigree, knowledge about genetic counseling, and concerns about genetics, and the process of genetic counseling.Demographic characteristics demonstrated that more than one half (58%) of participants were within the age range of 40 to 59 years, and all participants were females. They were largely of Yoruba ethnicity .The majority of participants (90.0%) claimed to have heard about breast cancer but did not have an idea of what it is exactly and what causes it . Some ofI never heard about breast cancer until lately. I have no knowledge, though, I have seen some posters but I don’t understand them. I have no idea of its cause or causes.I heard that breast cancer kills although nobody ever told me how it happens or what causes it. [This is the most prominent response from almost all respondents.]I felt a small lump in my breast and went to a medicine store who directed me to general hospital where I had biopsy and they said it is cancer.“I think my own cancer is an arrow. I went to a specialist private hospital and I was asked to come back for the test. My mother was sick with something like what I have now… ‘Won ta won lofa ni’” [she had a spiritual arrow sent to her]. Another female respondent stated that she went to various hospitals but they did not find anything, “I thought mine is spiritual too.”Approximately one fifth (19.0%) of participants perceived breast cancer to be a spiritual attack and called it an arrow . According to one middle-aged female respondent, The remaining 10% of participants stated that they had never heard about breast cancer before. Some of their verbatim responses included:What breast cancer is or what causes it, I don’t know.I have never heard anything about breast cancer. Se ko ni ‘affect’ awon omo mi sa o?’ [I hope it will not affect my children in any way.]Similarly, 91% of participants did not know anything about the genetics of breast cancer or genetic counseling; these participants were curious to know what genetics is about . Some reI never heard about genetic counseling.I never knew it is part of cancer care and management.I trained here and I have nursed breast cancer patients, but I never gave them genetic counseling because I didn’t know about it and I will like to know.We have come for treatment, not counseling. I don’t know anything about genetic counseling but it is a welcome idea.I never had any information about cancer or genetic counseling.…I also fear that my children may contract it from me.I never heard any investigation called genetic testing for breast cancer, so I will like to have the counseling.All participants, however, had concerns about genetic counseling. These concerns included participants’ inability to provide complete family history or being able to inform other family members about the possibility of having the disease . Some ofTo trace past generation is difficult, since they [our parents] did not tell us. How then are we supposed to know and provide accurate information here?Thank you for informing me about genetic information and counseling, but can one remember everything about one’s family?Besides, to my mind, this is late, why didn’t you give us this information before we develop cancer? I never heard about breast cancer until about 3 years ago on radio during what they called ‘pink month’ celebration in University of Ibadan, then I said ‘God forbid.’ I don’t know how I can ever tell my sisters that I have cancer talk less of informing them about any test to find out the possibility of their own susceptibility, God forbid bad thing and come to think of it, why should I be the one to spread this type of bad news. This is tough.My mummy’s pastor once told me that ‘it is not in your family, it will not start from you and she asked me to reject it.’ I am really afraid, I don’t want me or my children to have breast cancer.20 In Nigeria, patients present in clinical settings late, likely as a result of their lack of knowledge about the disease.21 The findings of the current study also reveal that the majority of participants and their relatives who have heard about breast cancer said they were told “it is an arrow.” This belief has been variously reported among Nigerian women and it has been a factor in why Nigerian women present with advanced breast cancer. This notion deserves more pragmatic intervention to address it.25All participants in this study were females, which was not surprising considering it is the gender that breast cancer affects most. A majority of study participants reported that they had never heard about breast cancer or its causes, which is consistent with findings in the literature.26 These factors, combined with the influence of lay beliefs and advice from the community, led to a delay in seeking help at the hospital.27 A recent review of the literature of factors that contribute to the late presentation of patients with breast cancer in hospital also confirmed this result.27 The knowledge and beliefs of patients and their FDRs is important in their understanding of cancer genetics and potential genetic counseling. This has implications for improved health-seeking behavior and consequent increases in the uptake of screening services and early treatment. Addressing the lack of community knowledge and awareness immediately will likely go a long way in improving cancer care outcomes.In a study carried out in Botswana, patients with breast cancer were found to not have knowledge about the disease before diagnosis, which led to fear of the diagnosis, of death, and of misinterpretation of its signs and symptoms.28 In another randomized controlled study of genetic testing for breast and ovarian cancer susceptibility in diverse groups of women in western Washington in the United States, it was found that a majority of women from each group had read or heard nothing or relatively little about genetic testing for breast cancer risk.16 Of particular note, African American women were least likely to have heard about such genetic testing during the study. In addition, despite this self-reported lack of knowledge of genetic testing for breast cancer risk, a large proportion of women from all study groups responded that they would be appropriate candidates for this genetic testing given their family history.16 In a similar study of female patients who awaited appointments at a large primary care clinic of the Group Health Cooperative , 47% of women had read or heard almost nothing about genetic susceptibility testing, and most did not know the answers to questions that assessed knowledge of breast cancer genetics.29 We found similarities to these studies in the Nigerian setting in which a larger proportion of patients did not know anything about genetic susceptibility to breast cancer or what genetic susceptibility might imply for them. This may be connected with the negative belief systems surrounding not inheriting what are thought to be bad genes from parents.Almost all participants in the current study were curious to know about genetic counseling. They claimed to have never heard about it and were never before counseled in this regard. There is a dearth of literature on the knowledge of patients with breast cancer about genetic susceptibility and genetic counseling in Nigeria; however, in an American study of patients with breast cancer and FDRs of affected individuals, the population was moderately knowledgeable about breast cancer genetics, with an average score of 5.35 of 10.30 and the situation has been worse for genetics and genetic counseling in Nigeria than in other countries as there had not been any resources for communicating the role genetics plays in cancer causation. Recent training conducted for nurses in teaching hospitals in southwestern Nigeria concluded that cancer genetics and genetic counseling is presently missing in the curricula of nursing programs and from comprehensive cancer care in Nigeria.31 The establishment of a cancer risk assessment program therefore becomes important for bridging the knowledge gap about cancer genetics between health professionals and patients.17In Nigeria, information about genetics from health professionals was lacking until 1986, when genetic counseling in sickle-cell disease began in Lagos,32Some participants had concerns about the possibility of breast cancer affecting their children. Health education should address the misconception about cancer being contagious. Such misconceptions could create fear in family members and affect the necessary level of support needed by patients from their family members. Other concerns that have been raised by participants include how they can give a correct history if their parents did not provide them any information, as well as how they can inform their family members of their disease and their relatives’ susceptibility. The extent of secrecy in disclosing cancer diagnoses to others as well as social factors that influence the perception of familial cancers in Nigeria is reflected in these concerns and in the fact that people living with breast cancer are often stigmatized.In general, knowledge of genetics and genetic counseling was not adequate for patients with breast cancer and FDRs to understand the possible reason for their disease and its influence on prevention for others in their families. Despite the increasing body of evidence for the contribution of genetics to health or illness and genetic counseling, patients with cancer and their relatives in the current study do not know that this information is available; however, the participants welcome the innovation of genetic counseling and yearn to know more. It is clear that there is fertile ground for the application of genetics to the prevention and care of breast cancer in Nigeria. There is a pressing need to pilot comprehensive cancer care centers in Nigeria, which includes creating a cancer risk and prevention clinic for specific genetic services. Nonetheless, it is important that genetic counselors do not underestimate the existing knowledge that patients with breast cancer have concerning genetics and its importance in assessing genetic factors, because this knowledge influences the kind of genetic information given during counseling and the way it is received by patients and relatives.There are various strengths and limitations in this study. This study was limited to a small number of female participants at one specific teaching hospital in Ibadan, Nigeria, which may limit the generalizability of its findings to other locations in Nigeria and to the knowledge and views of males with regard to cancer genetics, heredity, and genetic counseling. Moreover, only two of those participants were FDRs of the patients. Many patients and their relatives were anxious about the cancer diagnosis and apprehensive about treatments, so they felt that being interviewed was a waste of time; however, by conducting in-depth interviews, we were able to solicit more complete information and views from participants.Despite an increasing body of evidence for the contribution of genetics to health and illness, the availability of information about cancer generally and about genetic counseling is still unknown to an overwhelming majority of patients with cancer and their FDRs in Nigeria; however, patients and their relatives expressed a willingness to receive information on cancer genetics as well as genetics counseling services if and when they were to become available. Having explored patients’ knowledge of and interests in cancer genetics and genetics counseling as a potential risk-prevention strategy in Nigeria, the findings of the current study indicate that the creation of a cancer risk and prevention clinic is a welcome idea in Nigeria.


Breast cancer is the leading cause of cancer mortality worldwide. The incidence of breast has been increasing in most regions of the world. Regular breast self-examination is one of the most cost-effective methods for early detection of breast cancer in asymptomatic women. Despite this fact, breast self-examination practice remains low in Ethiopia. Therefore, the aim of this study is to assess breast self-examination practice and associated factors among women aged 20–70 years attending public health institutions of Adwa town, North Ethiopia.From the total study participants, only 26 (6.5%) of them had ever practice breast self-examination, and only 25 (6.25%) of them practice breast self-examination regularly. Being a government employee , having good perceived confidence to do breast self-examination  and having perceived good susceptibility to develop breast cancer  were the factors significantly associated with breast self-examination. Breast self-examination practice among the study participants was low. Therefore, informing every woman is susceptible to breast cancer, improving the confidence of women is recommended to increase breast self-examination practice. Breast cancer is a type of malignant tumor which starts in the cells of the breast and commonly occurs in women than men . Breast Breast cancer incidence has been increasing in most regions of the world, but there are huge inequalities between rich and poor countries. Incidence rates remain highest in more developed regions, but due to lack of early detection and access to treatment facilities, mortality is much higher in less developed countries . It is tIn Ethiopia, breast cancer is the second common cancer next to cervical cancer. It is estimated that around 10,000 Ethiopian women have breast cancer with thousands of more cases unreported as women living in rural areas often seek treatment from traditional healers before seeking help from health facilities . It becoBreast self-examination practice remains low in many countries. It was only 12% on the study in Kiewit . SimilarDespite a lot of investment of government of Ethiopia in the health sector, communicable and infectious diseases are still the major health issues in the country. Cancer, particularly breast cancer, is on the bottom of the priority lists. That is why there is no much infrastructure and facilities to fight against breast cancer .Although there are some early detection methods in health facilities of developing countries, they remain inaccessible to the women due to limited diagnostic and curative facilities. Mammography cannot be routinely applied in countries with limited health service resources since it is expensive it needs technology and trained professional . ClinicaBreast self-examination is still recommended as a general approach to increase breast health awareness and allows for early detection of any abnormalities. BSE continues to be recommended by healthcare practitioners because it is free, simple, need low technology and teaching is possible .Despite its prevalence, reproductive organ cancers (ROC) are not addressed as major public health problems at any level of the health care system. Nationwide, there is no organized ROC prevention, education, screening or curative care program . MoreoveA facility based cross-sectional study was conducted among women attending health facilities of Adwa town, North Ethiopia, from March 1st to April 15th, 2017. The town has two governmental health institutions; one health center and one general hospital. The health facilities had an average daily flow of 22 women aged 20–70 years. All women aged 20–70 years attending public health institutions of Adwa town were the source population, and systematically selected women were the study populations.A sample size of 404 was calculated using single population proportion formula with assumptions of 39.4% prevalence of BSE practice , 5% margThe dependent variable is breast self-examination practice. Factors included in the model as independent variables are:Socio-demographic and economic factors like age, marital status, educational level, household monthly income, residence, employment and family history of breast cancer or cancer in other body parts.Knowledge, attitude and perception related factors like knowledge on breast self-examination, attitude towards breast self-examination and perception on breast self- examination.Knowledgeable:participants who scored mean and above values from the provided 14 close-ended questions about the knowledge of BSE Good attitude:participants who scored mean and above values for attitude-related questions towards BSE, which was measured by the provided eight questions Perceived susceptibility:participants who scored mean and above values regarding their risk of breast cancer from the provided five close-ended questions were considered as having good perceived susceptibility Perceived benefits:participants who scored mean and above values regarding the benefit of BSE from the provided 6 close-endedquestions were considered as having good perceived benefits Perceived barriers:participants whose answered to barrier relate questions to do BSE measured by 6 questions, and scored mean above values were considered as having a perceived barrier to do BSE Perceived confidence:participants whose answered mean and above values regarding confidence to do BSE practice measured by 6 questions, were considered as having good perceived confidence to do BSE The questionnaire was prepared by reviewing relevant literature. Two days training was given to data collectors and supervisor on the aim of the study, the content of the questionnaire and on how to conduct the interview. A pre-test was done on 5% of the subjects in Aksum health center, found in Aksum town, Ethiopia. Data were collected using APRE-tested and interviewer-administered set of questionnaire. The collected data were cleaned and coded, and then entered into Epi-Info version 7 software and finally exported into SPSS version 21 statistical software for further analysis.Descriptive analysis was conducted and summarized using the mean, standard deviation for continuous variables and proportion for categorical variables. Before inclusion of predictors to multivariable logistic regression analysis, fulfillment of model assumption was checked. The goodness of model fitness was tested using Homers–Lemeshow test. Multi-co linearity was checked using Variance Inflation Factors (VIF).Both bi-variable and multivariable logistic regression models were used to identify factors that affected BSE practice. Variables with a P-value of ≤ 0.2 in the bi-variable logistic regression model were entered into the multivariable logistic regression model. Variables with a P-value of < 0.05 in the final model were considered as independent factors associated with the BSE practice.Out of the expected 404 study participants, 400 of them give a complete response, with the response rate of 99%. About two-third, 266 (66.5%) of the study participants, were between the ages of 20–29 years. More than two-third, 276 (69%) of the study participants, were married. More than one-third, 156 (39%), of the study participants, were completed secondary education. More than one-fourth, 110 (27.5%), of study participants, were unemployed , with 95% CI (50.8–61.0%), of them score mean and above value. An assessment of the participant’s knowledge of screening methods revealed that 246 (61.5%) participants know about breast cancer screening methods; from those 194 (48.5%) know types of the screening methods. One hundred and seventy-eight, 44.5% of the total respondents, had ever heard about BSE. Television was the predominant source of information to 100 (25%) respondents followed by health professionals 42 (10.5%) and radio 22 (5.5%). Less than half, 185 (46.3%) with 95% CI (41.5–51.5%), of the respondents had good attitude towards BSE , of the respondents perceived that they are susceptible to breast cancer. More than half, 212 (53%), of the respondents perceive that performing regular BSE is beneficial to find a lump in the breast, that might become cancerous in the future. One hundred and sixty-eight, 42%, of the respondents had perceived barriers to perform BSE, and 152 (38.0%) of the respondents were not confident enough to do BSE  with 95% CI (4.3–9.0%), of the study participants, had ever practiced BSE, and only 25 (6.25%) with 95% CI (4–8.6%), of the respondents practiced BSE regularly ]. Women who had a good perceived confidence to do breast self-examination were 5.32 times more likely to practice breast self-examination as compared to women who had low perceived confidence to do BSE, . Women who had good perceived susceptibility to develop breast cancer were 3.79 more likely to practice BSE as compared to women who had low perceived susceptibility  (Table According to the result of this study, only 6.5% of the study participants had ever practice breast self-examination. A similar finding was found in studies which were conducted in Kiewit and among female teachers of Kaffa Zone, Southern Ethiopia, both of them were 12% , 16. ButIn this study, only 6.25% of the respondents had regular breast self-examination. This is similar to the study conducted in logs, Nigeria, which was 11% . But ThiSelf-employed women were 88% more likely to practice breast self-examination as compared to government-employed women. This can be due to the fact that self-employed women could have more time to check their breast and to do breast self-examination. Women who perceived as they are susceptible to breast cancer were 3.79 times more likely to practice breast self-examination as compared to their counterparts. A similar result was found in the study done Kaffa Zone, Ethiopia . This coThe odd of BES practice among women who had good perceived confidence were 5.32 times higher as compared to women who had low perceived confidence. A similar result was found in a study done in Iran among school teachers , 21. ThiThe behavioral outcome is based on self-reported information. Therefore, the possibility of under or over-estimation may not be ruled out. Social desirability and recall biases may not be eliminated. It was not also triangulated with a qualitative method.


Evidence from India, a country with unique and distinct food intake patterns often characterized by lifelong adherence, may offer important insight into the role of diet in breast cancer etiology. We evaluated the association between Indian dietary patterns and breast cancer risk in a multi-centre case-control study conducted in the North Indian states of Punjab and Haryana. Eligible cases were women 30–69 years of age, with newly diagnosed, biopsy-confirmed breast cancer recruited from hospitals or population-based cancer registries. Controls  were frequency matched to the cases on age and region (Punjab or Haryana). Information about diet, lifestyle, reproductive and socio-demographic factors was collected using a structured interviewer-administered questionnaire. All participants were characterized as non-vegetarians, lacto-vegetarians  or lacto-ovo-vegetarians . The study population included 400 breast cancer cases and 354 controls. Most (62%) were lacto-ovo-vegetarians. Breast cancer risk was lower in lacto-ovo-vegetarians compared to both non-vegetarians and lacto-vegetarians with odds ratios  of 0.6 (0.3–0.9) and 0.4 (0.3–0.7), respectively. The unexpected difference between lacto-ovo-vegetarian and lacto-vegetarian dietary patterns could be due to egg-consumption patterns which requires confirmation and further investigation. Breast cancer is the leading malignancy in terms of both site-specific incidence  and mortality  among women worldwide .In India, breast cancer is the leading cancer site in most states. Although the average national incidence rate is lower than that in the West , ,8. The dThis is a multi-centre case-control study conducted in 2013–2015 in the neighboring states of Punjab and Haryana in North India. The eligibility criteria for all female participants included age 30–69 years (at diagnosis for cases and the same date for matched controls) and residence in the study area for at least 10 years. Women with any prior treatment for breast cancer or history of another primary cancer were excluded from the study.The study recruitment protocol included a hospital-based and population-based component. Cases were newly diagnosed, biopsy-confirmed breast cancer  patients with a date of diagnosis from January 2013 through January 2015. Hospital-based cases were recruited from two large hospitals located in the study area  that serve the majority of cancer patients in the region. Population-based cases were recruited from the cancer registries. Cases had a date of diagnosis less than 6 months from the date of registration with any stage of disease, and could not have started treatment before recruitment into the study. Two population-based cases could not participate due to severe illness.All controls were frequency matched to cases in 5-year age groups  and state/territory of residence (Punjab or Haryana). Hospital-based controls were recruited among women receiving outpatient Orthopaedic care and residing within 25 km of the district headquarters of the cases and also matched to cases on date of diagnosis (within 6 weeks). Population-based controls were selected from a list of residents of the study areas supplied by population survey registers available at the village level, where for every recruited case, ten eligible controls were randomly sampled for participation in the study. These were women living in the same state and residing within 25 km of their district headquarters of the cases and also matched to cases by the type of location . Among population-based controls, 19 were unavailable at their home when visited, and 2 refused to participate.N = 765; 404 cases and 361 controls) across the participating institutes and general population, of whom 11 had incomplete questionnaires (7 controls and 4 cases declined to respond in full due to time constraints) yielding a final sample size of 754 (400 cases and 354 controls). We enrolled 308 hospital-based cases and 256 hospital-based controls and 92 population-based cases and 98 population-based controls. The response rate exceeded 99% for both cases and controls with respect to population and hospital settings.We recruited eligible participants  and its duration in years were self-reported by the participants. Lacto-vegetarians were those who ate no eggs, meat of any type (including poultry) and fish; lacto-ovo-vegetarians were those who included eggs in their diet but no meat of any type and fish and non-vegetarians were those who ate eggs, meat of any type and/or fish. More than half (54%) of participants reported lifelong adherence to their dietary pattern; adherence for over 10 years and up to 10 years was reported in 24% and 10.5% of interviews, respectively; and the information on duration of adherence was missing for 11.5%.N = 298; 170 cases and 128 controls) was asked to respond to a semi-quantitative, validated, 184-item food frequency questionnaire (FFQ) adapted from the Indian Migration Study ) or medians (interquartile ranges [IQR]) for continuous variables or as numbers (%) for categorical variables. Bivariate comparisons of cases and controls with respect to socio-demographic, lifestyle-related (including dietary), reproductive and anthropometric factors were carried out using appropriate tests for statistical significance depending on the type and distribution of variables under investigation.2), waist circumference (cm), duration of estrogen exposure (years), age at first pregnancy (years), breastfeeding per child (months) and history of diabetes (yes/no) and hypertension (yes/no). Total estrogen exposure in years was calculated as the difference between ages at menopause and menarche for post-menopausal women or the difference between age at recruitment and age at menarche for pre- or peri-menopausal women. Effect modification by menopausal status was tested by likelihood ratio tests for interaction of dietary patterns with menopausal status.We used multivariable unconditional logistic regression analysis adjusted for a priori selected confounders and matching variables. The covariates in fully adjusted models included age (years), region of residence (Punjab or Haryana), mode of recruitment , education , religion  family history of cancer (yes/no), physical activity (minutes/week), BMI  and were accompanied by a Kruskal-Wallis test.All study participants provided informed consent. Information sheets in local language were given to the participants, and their signatures were obtained in the consent forms. Ethics committee approval was obtained from all participating institutions, which included the coordinating centre PHFI India (TRC IEC-170/13), as well as from study hospitals (P-371/PGI/IEC/2013/1690 and ECR/27/SP/2013) and from the population-based cancer registry, and the procedures followed were in accordance with the ethical standards of the committee.The study population consisted of 400 breast cancer cases and 354 controls . The meap < 0.001). Further, a higher proportion of the cases reported having diabetes  and a family history of cancer . Cases also had greater waist circumference (mean: 95.9 (14.8) cm versus 93.0 (13.5) cm; p = 0.0051) compared to controls, but the two groups did not differ with respect to BMI. Reproductive factors such as average age at first pregnancy (22.9 (3.7) years versus 21.9 (2.8); p < 0.0002) and number of years of estrogen exposure (29.4 (6.6) years versus 27.5 (6.7) years; p = 0.0357) were also higher among cases while physical activity  versus 240  min/week; p = 0.0003) was higher among controls.Despite matching, cases were on average 2 years older than controls at recruitment and had higher proportions of individuals with formal education  was the major dietary pattern reported in this population followed by lacto-vegetarianism (20.7%) and non-vegetarianism (17.2%). A majority reported following the dietary pattern either lifelong (53.9%) or over 10 years (24.0%) . Missingp < 0.001) and reported breastfeeding their children for a longer time (17.3 (±10.7) vs. 13.9 (±12.4) months per child; p = 0.0156).Overall, a higher proportion of non-vegetarians had a family history of cancer and reported having diabetes or hypertension; they also had greater waist circumference and BMI, higher age at first pregnancy and lower physical activity compared to lacto-ovo- and lacto-vegetarians . On the p = 0.033) or lacto-vegetarians  and were not modified by menopausal status.Multivariate analyses revealed that lacto-ovo-vegetarians were less likely to have a diagnosis of breast cancer compared to either non-vegetarians , but most corresponding comparisons were no longer statistically significant due to the small sample size (data not shown). When the same nutrient intakes were compared in cases and controls, a significant difference was only observed for cholesterol  with breast cancer risk after adjusting for all important non-modifiable and modifiable risk factors. The inverse association was observed when compared to both non-vegetarian and lacto-vegetarian diet patterns. The associations were consistent in the sub-set of participants with FFQ estimated nutrient data. These associations did not differ by menopausal status both in the full study population and in the subset. The study findings did not support our hypothesis that a lacto-vegetarian diet has potential benefits against breast cancer risk in women, but a lacto-ovo-vegetarian diet was found to be inversely associated with breast cancer risk.Evidence across different populations indicates an inverse association of breast cancer risk with healthy dietary pattern consisting of fruits, vegetables, legumes and whole grains and a positive association with a dietary pattern consisting of red and processed meat, fried foods and sugar . The eviAn important distinguishing feature of traditional vegetarian diets in India is its prevalence (30% of women and 22% of men aged 15–49 years)  and heteN = 2101 cases and 2255 controls) found no association of life-long vegetarianism with breast cancer risk; however only 3% (N = 31) of participants in that study were lacto-ovo-vegetarians, so the study was underpowered to evaluate this effect [In our study population, over 60% were lacto-ovo-vegetarians followed by lacto-vegetarians (20%) and non-vegetarians (17%). A majority of participants (78%) followed their dietary pattern for more than 10 years and more than half reported lifelong adherence. This is aligned with nationwide surveys such as the National Family and Health Survey-5  for the states of Punjab and Haryana, where 75–79% of women do not consume fish or meat (including poultry) in their lifetime . Our stus effect  or weak s effect  with breThe distinguishing factor of lacto-ovo-vegetarians versus lacto-vegetarians in our study could be the intake of eggs and egg-based foods. Previous studies addressing this issue observed non-linear associations, with highest breast cancer risk observed among persons who either consume no eggs at all or report at least daily egg consumption ,32. A meThe major dietary nutrients linking high intake of eggs with increased breast cancer risk include cholesterol, choline and protein intake relative to energy . CholestN = 100/128) were lacto-ovo-vegetarians), a significant difference was only observed for cholesterol, suggesting modest egg consumption in our study population. Although we did not have this information in our study, the median egg consumption in Indian lacto-ovo-vegetarians (N = 205) across four different geographical regions (including participants from 18 states of India) was about 6 gm per day (3.1–13.1 gm) according to Indian Migration Study [In a sub-analysis of FFQ data, intakes of nutrients such as protein were slightly lower in lacto-ovo-vegetarian group compared to lacto-vegetarians, with the highest daily intakes of cholesterol and choline evident among non-vegetarian study participants. On the other hand, intakes of several presumably beneficial antioxidant/anti-inflammatory nutrients were higher in non-vegetarian than in both vegetarian groups. These observations may have several interpretations. First, it is plausible that the FFQ data did not capture important differences in nutrients such as fatty acids, or other more relevant pro- and anti-inflammatory components of the diet. Second, as reviewed elsewhere,  a reducton Study ,15 with The nutrient values in our study are under-estimated compared to routine estimates in Indian populations ,15; howeThese concerns notwithstanding, to the best of our knowledge, this is the first multi-centre case-control study in India that included a subset of population based cases and controls  to investigate the association between traditional dietary patterns and breast cancer risk among North Indian women, with additional nutrient information from a standardized, validated FFQ on a sub-set of participants. Another important feature of this study is the relative stability of dietary patterns, which may partially alleviate concerns about the accuracy of self-reports. Although FFQ data were only available on the subset of the study population, the main associations did not differ in this subset and in the full study population. In addition, detailed information about known modifiable and non-modifiable risk factors for breast cancer enabled adjustments for multiple confounders. Future detailed investigations on egg consumption patterns, and nutrient intake, along with cooking methods in this population are highly recommended.Our results suggest that lacto-ovo-vegetarian, but not lacto-vegetarian dietary patterns may be associated with lower risk of breast cancer among North Indian women. While this could be attributed to egg consumption patterns, the mechanisms of the observed association are not clear. The observed difference between lacto-ovo-vegetarian and lacto-vegetarian dietary patterns requires confirmation, and if confirmed, further investigation.