Abstract

Background

Breast cancer affects up to one in twelve women in the UK. Breast awareness, which is advocated in place of routine breast examination, involves women becoming more familiar with their bodies.

Conclusion

Nurses have a vital role to play in encouraging women to become more breast aware. Their health promotion activities in this area can have an important impact on the uptake of breast screening initiatives.

Breast Cancer is a feared disease, not only because it is life-threatening, but because it can affect a women's sense of self - her sexuality and femininity. It is the most comman malignancy in women, and it is currently estimated that more than one in twelve women will develop this disease at some stage during their lives (CRC 1996, Denton 1996, Patnick 1995).

Barnett (1997) states that proportionately more women die of breast cancer in the UK than anywhere else in the world. Since the degree of success in treating this disease is influenced primarily by the stage at which intervention is introduced, secondary prevention (early detection) is the mainstay (Morrison 1996).

Changes in the breasts can be detected either by means of a clinical breast examnination, mammography screening or breast self-examination, which is now known as breast awareness (Han et al 1996, Persson et al 1997, Sortet and Banks 1997).

Breast awareness is more than just examining the breasts. It involves a women knowing how her breasts look and feel normally, so that she will be able to detect any change which might be unusual (BCC 1998).

Stoppard (2000) comments that despite a recent controversial report by Danish researchers which discredits screening, British specialists believe there has been a sharp fall in breast cancer deaths since screening was introduced in the UK. She further states that this report could demonise breast cancer again just when women were starting to feel optimistic.

Nurses are in a prime position to make use of the many opportunities that present themselves in their everyday work to encourage and influence women to be more breast aware. They have the potential to make an impact on women's health by encouraging women to become more involved in their own health and make use of the screening programmes available.

National screening programmes

In the UK, the first national screening programme for breast cancer began in 1988, following publication of the Forrest Report (Patnick 1995, Thornton 1993, White and Mackay 1997). Although mass screening programmes for breast cancer were welcomed for health promotion purposes, they are not always attended by those women most in need (Faithfull 1994). The advantge of breast self-examination is that it is a simple, cost-free, non-invasive technique that has a good chance of discovering changes in breast tissue (Sternberger 1994).

There has been controversy about the value of breast self-examination. In October 1991 some confusion was caused when Sir Donald Acheson (the retiring chief medical officer) implied that breast self-examination was not effective. However, the intended message was that women should be aware of any changes in their breasts as part of increasing their knowledge of their own health (Clayson 1992).

• Know what is normal for you,
• Look and feel,
• Know what changes to look out for,
• Report any changes without delay,
• Attend for breast screening if aged 50 or over (Patnick 1995).

Box 1. Breast awareness: a five-point plan

Instead of ritualistic breast self-examination, breast awareness following a five-point plan (Box 1) was advocated. Foster et al (1994) suggest that breast self-examination is associated with a heightened body awareness, as many breast cancers are frequently detected by women accidentally, rather than during formal breast self-examination sessions.

Marie Curie Cancer Care and the Royal College of Nursing now discourage nurses from carrying out breast palpation (Crawford 1997). They recommend instead that the role of the nurse should be to train women to be breast aware by providing information, advice and support. Awareness of body changes through self-detection has become a prime issue in women's health, and in October 1995 the annual Europe Against Cancer Week produced a ten-point code against cancer, with point ten stating 'Check your breasts regularly. Participate in organised mammography screening programmes if you are over 50' (Box 2).

Since 1990 the American Cancer Society has recommended that for women who are 20 years and older, monthly breast self-examination is a good routine health habit. Breast Cancer Care (1988) states that women should start being breast aware from the age of 18 years and should continue their breast checks regularly throughout their lives. Sternberger (1994) and others (Budden 1995, Patistea et al 1992, Pitts and Phillips 1993) emphasise that by performing regular monthly breast self-examination, a crucial component of breast awareness, women become acquainted with what is normal for them, and any changes noticed serve as an effective warning.

It is important to remember that most lumps are not cancerous and that breast awareness cannot diminish the incidence of cancer. It is useful, however, in detecting cancer at an earlier stage resulting in increased survival and decreased morbidity (Sternburger 1994). Budden (1995) asserts that the regular performance of breast self-examination by young women as part of their general body awareness is a health management behaviour that may help save lives in future years, through early detection and intervention.

• Do not smoke. Smokers, stop as quickly as possible and do not smoke in the presence of others.
• If you drink alcohol, moderate your consumption.
• Increase your daily intake of vegetables and fresh fruit. Eat cereals with a high fibre content frequently.
• Avoid becoming over-weight, increase physical activity and limit intake of fatty foods.
• Avoid excessive exposure to the sun and avoid sunburn, especially in children.
• Apply strictly regulations aimed at preventing any exposure to cancer-causing substances. Follow all health and safety instructions on substances which may cause cancer.
• See a doctor if you notice a lump, a sore which does not heal (including in your mouth), a mole which changes shape, size or colour, or any abnormal bleeding.
• See a doctor if you have a persistent cough, persistent hoarseness, a change in bowel or urinary habits or unexplained weight loss.
• Have a cervical smear regularly. Partcicipate in organised screening programmes for cervical cancer.
• Check your breasts regularly. Participate in organised mammography screening programmes if you are over 50.

Box 2. The European ten-point code against cancer

(Redmond 1997). Coleman (1991) stresses how important it is for women to use all three screening methods to help detect breast cancer, as some cancers can be detected by mammography before they can be detected by hand. Even mammography cannot detect all cancers - Blamey et al (1994) suggest that it detects 95% of all breast cancers - and, of course, the disease could also develop between screening examinations (Persson et al 1997).

The National Breast Screening Programme currently provides routine mammograms every three years for women between 50 and 64 years. For women who are too young or too old to be included in the current screening programme, breast awareness is of great importance to help in the discovery of any early changes in breast tissue.

Foster and Constanza (1984) and Ludwick (1992) suggest that women who examine their breasts regularly and develop breast cancer generally have a five-year survival rate of approximately 75%. Thus, early diagnosis and intervention are the cornerstones of treatment for this disease, and are correlated with a better survival rate (Ludwick 1992).

Patistea et al (1992) suggest that encouraging this self-care practice is essential for increasing individual's responsibility for their own health. Breast self-examniation, as part of being breast aware, is an action with a specific purpose that follows a set pattern and sequence. Persson et al (1997) comments '..........breast self-examination does not rely on any specialised personnel or equipment, it is a painless and inexpensive self-care action that can be done at home in about ten minutes'.

They also point out, however, that for this self-examination to reach its potential as a screening method, it must be performed both thoroughly and regularly on a monthly basis. Champion (1995) on the other hand, proposes that data indicating the optimal frequency for breast self-examination do not exist, and examining one's breasts every other month, as part of one's general body awareness, may be adequate to detect changes. She does agree though, that promoting monthly breast self-examination links this health behaviour to the menstrual cycle and can encourage habit formation.

Baker (1992) asserts that it is important to convince women to perform breast self-examination without scaring them: '.........we want them to feel empowered not frightened'. She further comments that the key is patient involvement, and that questions about breast self-examination and being breast aware should be standard during everyday contact with a patient. Although health professionals can provide persuasive and relevant information to individuals, the responsibility for changing attitudes and behaviour remains with the individual (Naidoo and Wills 1994).

Studies cited by McMillan (1990) and others (Budden 1995, Slaazar 1994, Sterburger 1994, Wardle et al 1995) reveal that the overall percentage of women who practice breast self-examination is between 29 and 44 per cent. The most popular reason given for not performing breast self-examination regularly was forgetfulness (Budden 1995). Other reasons reported were lack of confidence, fear and a lack of time. In Salazar's (1994) study, non-performers seemed to think that a sensation of some type would be the first symptom and that a healthy lifestyle somehow protected them from this disease.

The nurse's role in breast cancer prevention

Research suggests that women who are advised about breast self-examination and breast awareness by a healthcare professional demonstrate greater knowledge and confidence, and are more likely to practise this procedure routinely, than those who became aware from other sources (Bhakta 1995, Patistea et al 1992, Morrison 1996). Verbal and written explanations of what changes to look out for should be given, and perhaps equally important, support should be given to encourage reporting any such changes (RCN 1995).

Patistea et al (1992) suggest that for a relatively large number of women, the primary source of information about breast issues is the healthcare professional. Nurses are in an excellent position to encourage and teach such secondary preventive health behaviours, as they comprise the largest single group of healthcare professionals that is chiefly composed of women and interact with both doctors and patients in a variety of healthcare settings (Lillington et al 1993). Crawford (1997) also stresses that nurses should be facilitators and educators, encouraging women to be breast aware.

Lillington et al (1993) suggest that as nurses already obtain health histories, identify individuals at risk, and provide education and information to meet individual patient needs, they are in a unique position to have a favourable impact on breast cancer screening and early detection.

Krutli (1991) describes the introduction of a programme on a gynaecological ward where nursing staff were teaching all women who agreed to do breast self-examination. She discovered that women viewed this as part of the nurse's role, and as a result, teaching breast self-examination became one of the nurses' everyday routines.

Breast cancer receives a considerable amount of media coverage resulting in more women being in tune with their bodies and actively seeking to make decisions regarding healthcare options (McCabe et al 1995). Baird et al (1991) point out that this involvement can have a positive influence on satisfaction, coping and outcome. The diagnosis of breast cancer and the ensuing treatments can be highly threatening experiences. Therefore accurate, realistic information is required, especially when nurses are encouraging women to be breast aware.

Most nurses have had some experience of this disease and Patnick (1995) suggest that all can expect to be asked about it by their non-nursing friends and relatives. She suggests that every nurse has the opportunity to explain the facts about breast screening and to encourage women to attend for mammography screening when invited. Clayson (1992) states that all female patients admitted to hospital should be given the opportunity to learn about breast self-examination, as part of being breast aware - Han et al (1996) see this as part of nurses' committment to health promotion and illness prevention. Breast awareness is an important self-care behaviour and one which nurses should teach all female patients, regardless of the setting (Sternburger 1994). As Morrison (1996) states: '........the informed woman, using her hands and eyes, possesses the best tools available for the early detection and ultimate cure of this disease'.

Conclusion

Many exciting advances are being made in the field of breast cancer research, but in the meantime, early detection is our best defence. One way of detecting any abnormality early is through breast awareness. All women should be encouraged to take responsibility for their own health and well-being by performing this simple self-care behaviour on a regular basis, and to attend for mammography screening if they are eligible. Nurse have many opportunities to advocate this behaviour, and by doing so can increase their committment to health promotion, wherever they may work, and even outside work. Hopefully, by tackling this sensitive and emotive subject in a general way, more women will take on board this very important self-care behaviour. This will, in turn, lead to the earlier detection, intervention and consequently more succesful treatment of this cancer.

(c) Karen Bailey (EN(G), RGN, BSc(hons)) (2000) Nursing Standard 14, 30, 34-36.

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