Among the world’s most dreaded diseases is cancer. Although claims have been made by several persons to have gotten remedy or cure for cancer. Medically there is no known cure for cancer at full blown stage. Cancer is a health menace to the society and a thorn in the flesh of global medicine. Cancer is prevalent in every part of the world with an estimate of 19.3 million new cases worldwide and 10 million [1]. Following this statistic, it can be assumed that the global cancer burden will increase more from this 2020 and beyond.

[1] assert that cancer is among the leading cause of death posing a serious barrier to increase in life expectancy in every country in the world. It was reported in 2019 that cancer was among the first two causes of death before age 70 in 112 of 183 countries [2, 1]. A recent study shows that breast cancer resulted in an estimated 189,000 deaths in developed countries and 184,000 deaths in developing countries, accounting for 16 and 12 per cent respectively, of all cancer deaths in women [3,4]. The study further posits that the situation is not different in Nigeria as the prevalence of breast cancer is also reported to be very high and it is known to be one of the leading causes of death among women [4].

There are various types of cancer, the focus of this study is on breast cancer. Breast cancer is a common cancer type suffered by women. Some studies found that breast cancer is the most frequent type suffered by women and most prevalent cause of global cancer morbidity and mortality as well [5-7]. It impacts over 2 million women every year and contributed about 15% of all cancer death in 2018 killing an estimate of 627,000 women [7]. It has been reported to have overtaken cervical cancer as the leading malignancy among women and to be characterized by younger age distribution, more advanced stage of the disease and high mortality in cancer incidence and top ten cancers in eleven local government areas in Ibadan, Nigeria and its environs, between 2004-2008 [8, 9].

[9] highlight that in Nigeria, as in other developing countries, there is so much late presentation of the disease as more than 70% of Nigerian women present advanced stages of breast cancer, which is too late to be treated therapeutically but are only given some palliative care. The delayed presentation is the reason for the low survival rate of less than 10% in five-years in Nigeria as against over 70% in western Europe and north America where more patients are diagnosed at earlier stage [9].

Hence, early detection is crucial in diagnosing and treating breast cancer. Breast self-examination (BSE) is one easy way of detecting it at the early stage. Over the years BSE has been advocated and advanced by health workers and organizations as a means to reduce cancer and its associated problems by detecting it in the formative stage. One reason BSE was quickly welcomed was because the woman performs it on herself and does not require a procedure that interferes with the skin or inserting an instrument into the body. It also allows patients have their privacy to comfortably look, touch and feel their breasts.

The claim is that BSE will help women to effortlessly perceive any abnormal growth in the breast that may lead to cancer development, which in turn will promote early diagnosis and treatment. However, there are reports that this is not the case. BSE has not proven to be effective in early detection and treatment of breast cancer hence it is no longer recommended as an option for early detection of breast cancer [10, 11] states that it must be included in any evaluation of BSE that its efficacy has no support by current literature furthermore, most medical societies as well as academics discourage its general implementation.

More so, a low prevalence of BSE is widely reported in the literature [12].  These leave a number of questions in the minds of researchers as to the effectiveness of BSE in preventing, detecting, diagnosing and treating cancer of the breast. First is the question of cancer awareness. What is the level of awareness of cancer generally and then the types? Without being aware of the problem how can one begin to pay attention to the problem to know what and how to go about that problem? Without being aware of cancer of the breasts, it becomes difficult to talk about BSE for cancer detection. Such a cancer ignorant person will not see any need to do BSE.

Secondly, the question of awareness of BSE, how it is done and when is another issue. While BSE as widely projected may be helpful in curbing cancer of the breast, are people aware of it? Do people know what exactly it is or what it entails, what to do, how and when to do it?

 Thirdly, since the campaign of BSE, what is the prevalence of practice of BSE among women? Do they take time to practice it for those who do it and how well or often do they do it? And in the event of noticing anything, how willing are they to open- up and seek medical advice?

Lastly, can a person unaware or uninformed of breast care, be knowledgeable to examine herself? let alone understand or notice any deviation from normalcy before giving much time and thought to it or even consult a medical-personnel for proper examination and advice?

Perhaps, being breast aware (BBA), which encompasses a person’s attitude towards her breasts has not been given much attention in the discourse of breast cancer. The foregoing leads to the main issue advanced in this paper, which seeks to answer the question of which is better or should be emphasized by health care workers, health educators, counsellors and advocates on prevention, early detection, diagnosis and treatment of breast cancer. Is it breast self-examination or to be breast aware?

The aim of this study was to find out whether BSE is effective in early detection of breast cancer. Specifically, the study seeks to: determine the effectiveness of BSE in early detection of breast cancer; examine the prevalence of practice of BSE among women, make a case for BBA in place of BSE. The major contribution of his study to research and policy among others is that, it is one of the first in post pandemic world order to make a case for BBA against BSE. It explores the dynamics and relevance of breast awareness both in early detection, prevention and cure of cancer. The remainder of the study is structured as follows; methodology, conceptual clarification, empirical review, discussion of findings, conclusion, recommendations and implications for nursing practice.

Research Design

This study seeks to find answer to the central research question: Is breast self -examination or breast self- awareness suitable for early detection of breast cancer? If it is breast self -examination, what interacting variables suggest such suitability, if it is not, what evidence shows that breast self- awareness is more suitable? To find answer to these research questions, we conducted a deepened review of empirical data from multiple sources; World Health Organization (WHO), World Cancer Report, American Cancer Society and similar literature from journal articles, books and bodies related to cancer research, treatment and awareness.

Our unit of analysis is on recent scholarship on breast awareness. The study assessed the empirical evidence and determinants of breast awareness through a relational content analysis including earlier data drawn from the World Health Organization(2018) and the survey of recent authoritative multiple breast awareness  data from the Global North and South including the   American Cancer Society, the  Center for Diseases Control and Prevention, World Cancer Report, the National Screening Unit,  the New Zealand Breast Cancer Foundation,  United States Preventive Service Task Force, which were further reviewed.

Scholars have demonstrated the methodological relevance of content analysis in qualitative research as it provides detailed review and insights on any existing information, data or document [13, 14] offers a broad definition of content analysis as, "any technique for making inferences by objectively and systematically identifying specified characteristics of messages".

Search Strategy

Sources of Data: Multiple seminal empirical studies were searched and reviewed. Specifically, our data sources were drawn from relevant literature reviewed, which included journal articles, books, online sources, health and medical bulletin and institutional literature from World Health Organization (WHO), World Cancer Report, American Cancer Society and similar literature from bodies related to cancer research, treatment and awareness.

Most recent information has been included to contribute to the ongoing debate on breast self- awareness among women. Data were thematically analyzed in line with the overall research objectives and in particular to answer the central research question using content analysis method.

Data were extensively searched from some renowned databases viz, Springer link, Google scholar, web of science, science direct, and Scopus website using important keywords like “breast cancer”, “breast self- awareness “early detection”, “breast self -examination”, to   secure authentic information. Most recent and closely related data detailing the subject under investigation were selected. The data collection and analysis for this study were done between March 2022 to June,2023.

Breast Self-Awareness (BSA)

Being breast aware means knowing what is normal for an individual so that he or she can spot any unusual changes as soon as possible. Everyone’s breasts look and feel different, some may have lumpy breasts, some may have one breast larger than the other or breasts that are different shapes, others have one or both nipples pulled in and these differences may be from birth or may occur while the breasts are developing [15]. According to [16], emphasis has shifted from the monthly BSE to BSA. It is a method that allows women to have more knowledge about the normal feel of their breast and appearance with them not following a particular schedule or technique of performance. There is no step-by-step way suggested to examine the breast or following a certain method and guideline. Rather it entails knowing what is normal for your breast. The main thing is starting it as young as possible and making it part of a daily routine.   

According to [17], women should look and feel for breast changes as part of routine body awareness while bathing or dressing to enable them know what is normal for them as recommended by a number of international organizations (American Congress of Obstetricians and Gynecologists). They further suggest that such check may contribute to the reduction in the number of deaths due to breast cancer in some countries.

[18] also affirms that it is important for people to be familiar with how their breasts look, feel and what is normal for them and that this can be achieved by looking in the mirror regularly; and feel the breasts from time to time while in the shower or bath, lying in bed, or getting dressed; and using the flat part of your fingers and the finger pads to feel the breast tissues.

The [19], outlined a five-point code that encapsulates breast awareness as follows: know what feels normal for you; look and feel; know what changes to look for; report any changes without delay and attend full breast screening if aged 50 or over. Changes that one should look out for according to [15] when checking one’s breasts include lump or swelling, skin change, change in color of breast, change in the nipple, crusting or rash around the nipple, any unusual liquid or discharge, change in size or shape of the breast. [18] noted that the feeling should be done regularly at different times of the month so as to know how the breast feels at different times of the month. This is important because the breast feels differently and may show slight changes in shape and size at different times in a month.

Breast Self-Examination (BSE)

Breast self-examination (BSE) is a recommended screening method for early detection of breast cancer, so it is essential to educate women about BSE as an early detection method for this fatal disease. Breast self-examination is a method of checking for early signs of breast cancer. According to [20, 21], it is a way of screening for early detection of breast cancer, which involves looking and feeling one’s breasts for possible lumps, swelling or any distortions by oneself. BSE is a process whereby women examine their breasts regularly to detect any abnormal swelling or lumps in order to seek prompt medical attention [22]. It is a technique that is systematic, performed regularly and repetitively between the seventh and tenth day of the menstrual cycle once in a month.

Although its effectiveness and its potential use as screening method for detecting early breast cancer is controversial. There is still conflict of opinions about the efficacy and effectiveness of BSE as a screening tool for early detection of breast cancer [23, 23, 9]. Some researchers have also shown in their studies that women who correctly practice BSE are more likely to detect breast cancer at early stage of its development [25, 26, 9].

BSE helps women to become familiar with their typical breast structures and to detect any unusual changes in their breast tissues. The changes in the breast to look out for during BSE that should warrant seeing the doctor are grouped into three according to the [27] changes in the shape of the breast- a hard lump, dimple, bump, new shape or size and thick area; changes on the skin surface such as- redness or hotness, pitting, skin sores and orange peel skin; and changes in the nipples such as- crust, sunken nipple and discharge.

For easy practice, a number of steps to follow have been outlined for BSE by various bodies, organizations agencies, hospitals and individuals. Some have three steps, others five and some have more steps but they are basically the same thing.

Although breast self-examination procedure does not cost anything and it is quick and easy to perform yet many women either perform it wrongly or do not perform it at all. [16] posit that in recent years, some organizations (American College of Obstetrics and Gynecology (ACOG) and US Preventive Service Task Force (USPSTF) in USA), have recognized BSE as having limited evidence for them to recommend its use or disuse while [28] state that women should be encouraged to be breast aware.

Breast Cancer

In recent times, various studies in the literature have discussed breast cancer [22], including research funding [29].   Breast cancer is a type of cancer that affects the breasts. It is very rare in men but common among women. One in every eight women is at risk of breast cancer development, which is about 12%.   There is no definite cause of breast cancer. It originates from breast tissues, most commonly from the inner lining of milk ducts or the lobules that supply the ducts with milk [30. It is characterized by uncontrolled abnormal cell growth (that is proliferation of cells) in the milk producing glands of the breast or in the ducts that deliver milk to the nipples [22]. Recent literature has offered deepened anatomical and physiological investigation of female breast [31], yet research regarding breast cancer and its resolution remains an evolving scholarly agenda.

Signs and Symptoms

The literature on breast cancer suggests that there is no consensus among scholars on the specific cause(s) of breast cancer. Although a number of signs and symptoms could be observed. For instance, [32] listed the signs and symptoms of breast cancer as follows: new lump in the breast or under arm, thickening or swelling of part of the breast, irritation or dimpling of breast skin and redness or flaky skin in the nipple area or the breast. According [33], breast lump often appears as a firm and painless lump, which may result to cancer later

Prevalence of Breast Cancer

In their report, [22] state that among women, breast cancer is the most prevalent cancer type worldwide. Breast cancer is the second most common cancer in women worldwide according to [9] who also reported that there was a worldwide incidence increase of breast cancer from 720,000 cases per year in 1985 to 1,000,000 new cases in the year 2000. In 2012, it represented about 12% of all new cancer cases and 25% of all cancers in women. It constitutes 23% of all cancers, second only to lung cancer when both sexes are considered collectively. It is the principal cause of cancer related deaths in women comprising 14% of female cancer deaths [34, 12].

Breast cancer is the most frequently diagnosed cancer among women in 140 of 184 countries worldwide, in 2012 there were about 1.7 million new breast cancer cases diagnosed [21]. It has also been found that prevalence rate is more common in young and premenopausal women [5, 21]. Worldwide about one million women are diagnosed with breast cancer every year [35, 12]. In a related study, [21] found that one in eight U. S women will develop invasive breast cancer over the course of her life time. According to [1], the incidence of cancer is 55.9 per 100,000 women for transitioned countries and 29.7 per 100,000 women in transitioning countries. There are according to [1] 19.3 million cases of cancer in 2020 globally, of which 49.3% are in Asia, 22.8% in Europe, 20.9% in America, 5.7% in Africa and Oceania 1.3% and 10.1 million cases are male and 9.2million female. On mortality of cancer, [1] reports that in 2020, there are 9.9million cases of which 58.35 occurred in Asia, 19% in Europe, 14.2 % in America, 7.2% in Africa and 0.7% in the Oceania and there are 5.5 million male and 4.4 million female deaths.

Female breast cancer is most commonly diagnosed type of cancer and constitutes about 11.7% of 19.3 million total cancer incidence leading to 6.9% out of 9.9 million cancer deaths [1]. It is the fifth leading cause of cancer mortality in the world with 685000 deaths and as well accounts for one in every four cases of cancer and one in every six cancer deaths. The mortality rate for breast cancer is about 15 and 12.8 per 100,0000 cases respectively for women [1].

In Ethiopia, breast cancer is the first leading cancer among females with 24.4% prevalence rate. [27] highlight that there are 12,956 diagnosed cases of breast cancer and 26,200 breast cancer related deaths among women in Ethiopia. [36] note that there is an increase in the incidence of breast cancer in Cameroon and   now accounts for a leading cause of mortality. There has been substantial increase in incidence of breast cancer in Nigeria in recent times [9]. Recent reports show an increase in the incidence of breast cancer from 33.6 per 100,000 in 1992 to 52.0 and 64.6 per 100,000 in 2012 in Ibadan and Abuja cities of Nigeria respectively [37].

Diagnosis and Treatment

Breast cancer can be diagnosed and treated if found early. Extant literature shows that breast cancer can be diagnosed early and where this is so, effective treatment is available [38, 39]. Breast self-examination (BSE) is the easiest according to [21]. Breast cancer is the most frequently diagnosed cancer among women in 140 of 184 countries worldwide and about 15% of women who get breast cancer have a family member diagnosed with it. It is a progressive disease with poor prognosis if detected late [22, 40] states that since breast cancer is a progressive disease, early diagnosis increases the chance of better prognosis and survival rate.

Mammography, clinical breast examination (CBE) and breast self-examination (BSE) are screening methods used for early detection [9, 41, 21]. Among these, annual mammography is considered to be the most helpful method for the diagnosis of breast cancer in its initial stage, when it is still a localized growth and therefore amenable to the treatment. With the use of mammograms very early signs of breast cancer can usually be observed before lumps can be felt [4] but they are not totally foolproof as they are not very effective for use on younger women in whom x-rays can be obstructed by their dense breasts’ tissues [42, 9].

Despite the advent of these modern screening methods, cases of cancer of the breast can be detected by women themselves through breast examination. It is for this singular reason that experts are advocating breast self-examination (BSE), as a preventive measure for early detection of breast cancer.

Survival Rate

The rate of survival of the disease is dependent to a very great extent on the stage or phase in which it was detected, diagnosed and the time of commencement of treatment. If these are done early in its developmental phase, the patient has higher chances of survival than late when it must have metastasized. In 2011, there were more than 2.6 million breast cancer survivors in the US [21]. According to [43], 85% to 95% of patients affected by breast cancer survive it when detected in its early stage but a late diagnosis reduces the survival rate to 56%.

Protective Factors

The development of breast cancer can be reduced due to certain factors such as physical activity, breast feeding and management of stress [44]. Thirty minutes to one hour exercise every day is considered adequate. Breastfeeding is associated with menstruation commencement after delivery. Since there is no menstruation during breast feeding, there is also minimal exposure to estrogen. 

What is the Prevalence of the Practice of BSE?

Research in England found that most women were aware of dangers akin to breast cancer but just a few of them carry out BSE regularly [19]. Similar trends are reported from other developing countries such as Nigeria where a study on female university students observed that 87.7% of them knew about BSE but only 19% practiced it [45, 46].

In parts of Asia a number of studies in the literature have discussed prevalence of cancer. For instance, in their study on breast Self-examination knowledge and Practice among Female Dental Students in Hyderabab City of India, [47] found minimal knowledge and practice despite some evidence of self-examination. In a related study, [48] examined the dynamics of practices and barriers toward breast self-examination among Palestine women in Gaza City. Their key finding suggests low level breast awareness despite some level of self-examination.

In Africa, same studies have examined issues of awareness of breast cancer as well as breast self-examination, for example, [49] conducted a survey among female undergraduate students in a higher teacher training college in Cameroon and found that there are serious issues with breast cancer awareness as most of the students are not breast aware. In Ethiopia, [50]. conducted an assessment of breast self- examination practice and associated factors among female workers in Debre Tabor Town public health facilities, in North West Ethiopia, The cross-sectional survey. showed that both examination practice and breast awareness have been in the margins among female workers [51]. reported same finding in their study on knowledge, attitudes, and practices related to breast cancer screening among female health care professionals.

In a similar study using nurses, [52] examined awareness of breast self-examination and risk factors of breast cancer among Jordanian nurses. He found that almost half (46%) of the nurses have never performed BSE, while, 55.4% of them agreed to have practiced. Amazingly, 80% of those who agreed to have performed BSE said they did so irregularly, only 19.4% were regular with BSE. Over 30% of them stated that they had performed BSE less than four times in the past 1 year.  Of these, 9.7% perform BSE immediately before menstruation and an equal percent perform BSE at a time in month. Again, this study asserts existing gaps between nurses' knowledge and their practices of BSE.

In a descriptive study carried out in a Specialist Hospital at Ikere-Ekiti in 2015 using 238 women attending the antenatal and immunization clinics by [9], the aim was to determine the knowledge of breast cancer, prevalence of BSE practice and its correctness. It was found that 84% of the respondents were aware of breast cancer but 87% of them had poor knowledge of its symptoms. 56.7% of the respondents were aware of the disease through health workers (44.4%) and information media (30.4%). Again, just a little more than half (55.6%) of them practiced BSE of which only 24% were adjudged to have good practice. The study further showed that the performance of BSE was significantly related to respondents’ level of education (p=0.001) and marital status (p=0.032). The conclusion was that the quality of BSE practice and knowledge of breast cancer symptoms among women was poor despite good awareness.

In Edo state, Nigeria, [4] investigated the practice of BSE among six hundred and seventy-four (674) female students in tertiary institutions and found high level of BSE practice. The study further revealed that most of the respondents did not practice BSE correctly as they are not able to detect lumps, not able to use the pad of the three middle fingers in doing the examination and not able to palpate the entire breasts alternately with both hands. Continual enlightenment campaigns on BSE and more research directed at ascertaining under what circumstances knowledge of BSE does not translate into its practice were recommended.

In contrast to the findings of [4, 34] on the assessment of knowledge and practice of BSE among university students aimed to assess the students’ knowledge and practice of BSE found that majority of their research participants practiced BSE. Two hundred (200) female nursing students of tertiary institutions in Benin city Edo State were selected as the study sample by convenient sampling for the descriptive cross-sectional survey study. It was found that majority (84.5%) of the respondents were knowledgeable about BSE and practiced it.

[53] researched on health beliefs of midwifery students about breast cancer and BSE acknowledgement at Istanbul University using a descriptive cross-sectional survey study. They examined the attitude and beliefs of the students towards breast cancer and the practice of BSE. 160 midwifery students participated in the study. The data analysis showed that 90% of the students have knowledge of breast cancer and BSE but only 14.4% percent of them practiced BSE.

Research by [21] on awareness and practice of BSE found low practice of BSE women who took part in the study even though they were aware of BSE. Only few knew how to perform it in step wise and majority of women neglect to practice BSE on a periodic basis. They neglect to practice it because of lack of details of BSE.

[21] in their study, concluded that women have good awareness on BSE but only a few know how to perform it in following the correct steps and that majority of women neglect to practice BSE on regular bases. Based on the findings, it is concluded that respondents were aware on breast self-examination but confused on time and BSE performing in circular movement. Women are ignorant on performing BSE due to lack of detailed knowledge on disease and lack of awareness.

The result of a cross sectional survey by [43] on tackling breast cancer in developing countries involving four hundred and thirty two (432) female senior secondary school students in Otuocha Educational Zone of Anambra State, Nigeria showed that 84.6% and 55.2% had respectively heard about breast cancer and BSE, and the general knowledge of breast cancer was high (75.2%), despite that knowledge on correct BSE techniques was 52.9%, but few know when to commence (43.1%), the right frequency (31.5%), or the right timing (24.6%). A large majority (73.6%) had positive attitudes, but only 6.1% practice it monthly, while 55.3% had never done it at all. No significant predictors of knowledge and practice of BSE was identified.

Despite the uncertainty of effectiveness of BSE in detecting breast cancer or reducing breast cancer related morbidity, some researchers and health organizations recommend that BSE can still be practiced in developing countries where there are not enough resources for or availability of mammography screenings with no resources of mammography screening [43].

Breast Cancer Risk Factors and Prevention

The main factors that enhance risk of breast cancer in women comprise some inherited genetic mutations, a personal or family history of breast cancer, and hyperplasia. Other risk factors are: late menopause, obesity and hormonal therapy after menopause, use of oral contraceptives, nulliparity or having the first child after age of 30, exposure to radiation, or taking one or more alcoholic drinks per day [12]. Others are gender, increasing age, race/ethnicity, early menarche [36]. Also, genetic mutation (e.g., BRCA gene) is known to increase the risk of breast cancer [54].

A study reconfirmed that the risk factors for the occurrence of   breast cancer in women of Kelantan were similar to those of the Western populations; nulliparity, overweight/obesity, family history of breast cancer and oral contraceptive usage [38, 39]. The knowledge of some of these risk factors and avoiding those that are behavior related are very important in the prevention of the disease. While breastfeeding, physical exercise, and maintaining a healthy body weight decrease the risk to some extent [12].

Early detection of breast cancer plays a pivotal role in reducing related mortalities. Until circumstances are favorable for routine mammographic screening in resource-limited settings, emphasis should be oriented towards encouraging women to regularly practice BSE. [4] opines that BSE is advocated as a preventive measure for breast cancer because cases of breast cancer can be detected by women themselves by examining their breast [24]. also support this view. According to the [52], regular cancer screening is very important because breast cancer is sometimes found after symptoms appear but many women are asymptomatic until late.

Breast Self-Examination or to be Breast Aware?

Our multiple empirical data provide a varied response to the study of both BSE and BSA. With abundant literature on breast cancer, there is still lack of clear research evidence on the effectiveness of BSE as a tool for early detection of breast cancer. Also, low prevalence in the practice of BSE among women could be implicated following the increase in mortality rate among breast cancer patients as our reviewed empirical studies suggest.

Both [55] opine that although, the efficacy of routine BSE in early detection of breast cancer is debatable, it is still recommended as a screening method for increasing breast health awareness because it is inexpensive, non-invasive, involve little time, physical energy and does not require complex technical training[38].  argue that BSE costs nothing and it is a practice that is very useful in raising awareness among women on changes in their breast and body. It is home based, simple, easy, harmless, requires no equipment, self-practiced and protect women’s privacy [53].

According to [56] breast self-examination benefits women in two ways. Women become familiar with both the appearance and the feel of their breasts, and detect any changes as early as possible. [57, 58] as cited by [4] posit that 90% - 95% of the times, breast cancer is first noticed by the woman herself during the performance of BSE. According to John Hopkins Medical Centre it is important to establish a regular breasts self-exam as 40% of diagnosed breast cancers are detected by women who feel a lump [21]. But is it established that the lumps were dictated because the women were regular, conscious and very knowledgeable in their practice of BSE or it was discovered by chance?

Our findings from the various studies reviewed, show that what is clear is that the prevalence of BSE practice among women is low. Only a few of the previous studies reviewed reported large practice of BSE. The rest found low prevalence of BSE. The low prevalence is even recorded among people who have attained good educational status, medical and nursing students and among health workers. These are those who are supposed to be championing the course of BSE. Thus, it is glaring that BSE is not achieving its aim as projected since its inception as a tool for early detection of breast cancer.

It was further established by literature search that there is minimal research evidence on the effectiveness of BSE in early detection of breast cancer and that the three is low prevalence on the practice of BSE among women in various parts of the world.

Breast Awareness as Alternative

Thus, despite the call for the continuing practice of BSE in countries with low resources where there is lack of access to modern equipment used for screening of breast cancer, it will almost be a waste of energy to keep promoting BSE given that most women do not give time to it for various reasons.

Therefore, the need for something simpler and easier is imperative. Something that can serve the same purpose as BSE and even go a longer way in encouraging women to know what is normal about their breasts and take appropriate measures in the event of detecting any abnormal or strange feeling by way of reporting to the clinic or for further screening if breast cancer is suspected. This is what being breast aware (BBA) offers.

Making a case for breast awareness, [59]. in their study on breast cancer awareness, attitude and screening practices among university students, recommended urgent need for intervention on breast awareness. Similarly, [49] discusses the importance of awareness of breast cancer especially among midle aged and young females.

Our reviewed literature further suggests that although, some health professionals and agencies are still campaigning for and carrying out interventions on BSE, however, given the available literature, evidence supporting the view that BSE is not effective in early detection of breast cancer abound. This is compounded by increasing emphasis on evidence-based practice as the new norm in health management. The argument on whether BSE is still relevant in the discourse of breast cancer or should it be replaced with BBA has become paramount. In the late 2008 three reputable organizations- the Cancer Society, the National Screening Unit and the New Zealand Breast Cancer Foundation released a joint position on breast cancer stating that BSE is no longer recommended as a cancer screening option, instead women should be breast aware [16].

[10] asserts that most medical organizations no longer recommend routine self-breast examination as a part of breast cancer screening because it has not proven to be effective in detecting cancer or improving survival from breast cancer and that doctors believe that it is more valuable for women to be familiar with their breast (breast aware). [11] highlights that several organizations have proposed replacement of BSE with BBA, which can help women become cognizant of their breast and can potentially screen breast cancer without going through the rigor and ritual of regular BSE.

However, [11] notes that there is no validated evidence on the effectiveness of breast awareness as strategy for improving breast cancer outcomes. While BSE is useful in raising awareness of body and breast changes, its effectiveness and potential for using it as screening method for detecting early breast cancer is however debatable [36, 60].

Some assertions made against BSE based on some study findings include that BSE has no beneficial effect on improving the mortality of breast cancer [36], that any significant changes detected during BSE was by chance [61], and that no difference existed between those who practice BSE and those who did not practice BSE in terms of seeing their doctors [61]. However, BSE (in a study of trials of BSE training) was associated with increased number of women seeking medical advice and having biopsy [16].

The legitimation of BSE as a screening tool is invalidated by absence of its observed benefit in cancer mortality, and the occurrence of negative outcomes of regular performance of it [11]. Further, [11] observes that such negative outcomes include false positive findings that may result in increased benign lesion identification, unnecessary imaging and biopsies, undue anxiety from fear possible cancer diagnosis. BSE could give a woman who did not feel a lump in her breast an erroneous reassurance that there was no need for further screening.

Certain bodies have gone ahead to recommend against BSE. An example is the United States Preventive Service Task Force in its 2009 published guideline, which outlined the associated harms of BSE [11].  The [54] did not recommend clinical breast exams or breast self-exams as part of a routine cancer screening schedule stating that there is not enough evidence that they are helpful in early detection of breast cancer and research has not shown clear benefit of regular BSE and CBE. They recommended regular cancer screening test as the most reliable way to early detection of breast cancer.

This study looked at the current trends in the practice of breast screening for early detection of breast cancer. While there are other various methods for proper screening for breast cancer, this study considered the relevance of breast awareness beyond mere breast self-examination method. It specifically answered the question of the effectiveness of breast awareness as a tool for early screening of breast cancer and the prevalence among women thus making a case for being breast aware (BBA).

Breast cancer, which can be effectively managed if detected early enough seem to be ravaging many nations as there is evidence of increase in rate of its incidence, with low awareness. It is only through awareness that regular examination and screening can be effective for detection of cancer as BSE, which was projected as a way of examining a person’s breast for detection of breast cancer is no longer supported for lack of clear evidence in the detection of breast cancer. Apparently, BSE from the discussion has not met the target of detecting breast cancer early. This is because there is low practice of BSE amongst women across the world. More so, among the few women who carryout BSE, they do not carry it out regularly at the right time. Some of the challenges in the practice of BSE include; poor knowledge of the skill, belief, and the fear of discovering a lump in the breast. Therefore, BBA, which is a lot easier and without rigor should be encouraged among women. To be breast aware will make women to become very conscious of their breast thereby quickly noticing any change in their breast and take necessary actions towards ensuring having a healthy breast.

This study is in support of BSA because it does not recommend any guideline on how to perform the technique, which requires proper education of the women. With women facing so many challenges, much stress and being too busy these days, they may not even remember the process or the timing. But with BSA, while bathing or dressing, a woman can take a quick look at her breast and observe any changes instead of waiting for menstruation. Since we, the health professionals are the point of contact for women who seek breast health care, we urge practitioners to use every opportunity that present itself adequately and properly to educate and motivate women on practice of breast self-awareness, which in turn will impact on the health of the society.

To be breast aware and to know what a breast symptom is and to seek advice timely will improve outcome for women who are symptomatic and reduce unnecessary invasion in the name of intervention. If an individual is familiar with her breast, she might be more likely to notice any unusual changes that could be a sign of breast cancer [15]. Being aware of the changes and learning how an individual’s breasts feel at different times will help understand what is normal for the individual. To be breast aware includes getting to know one’s breasts and what is normal by looking at them and feeling them; seeing a doctor or health worker if any unusual changes are noticed and to get mammogram every two years if an individual is 50-74 years old [15]. Most breast changes are not because of breast cancer. However, the sooner breast cancer is diagnosed, the more successful treatment is likely to be [15].

The following recommendations are made:

The study elaborates on some strands of breast awareness such as self -enlightenment, consultation, counselling, creating women friendly centers, regular clinical examination and check etc.;

• Self -enlightenment: Health education and in particular the enlightenment of women on the dangers of not detecting breast cancer and on the benefits of BBA to promote practice and help women become more conscious of their breasts and look out for possible changes in them should be intensified.
• Consultation: Health professionals should take it as a point of duty to educate female patients that come to the hospital even for other reasons.
• Women friendly centers should be established in health centers. This will encourage women to freely report any changes found in their breast
• Women should be encouraged to go for proper and regular clinical examination and screening to check their status as this is a surer way of early detection of breast cancer.
• Guidance and Counselling: There is need for periodic guidance and counselling both in the developed and low -income countries. Thus, care givers, nurses, counsellors and psychologists must be engaged to guide and counsel patients and the wider public.

Implications for Nursing Practice

As shown, in this study issues of early detection of breast cancer and the question of breast Self -examination or Breast Self- Awareness have several implications for health care practitioners particularly nurses. Nursing as a professional practice places a significant premium on care giving and counselling. This makes the need   for new nursing education as a source of awareness on cancer necessary. The need is for cancer awareness to spread to all levels of the society both in rural and urban areas, thus education for nurses is crucial for them to understand the need for breast awareness and disseminate same to the wider public. Such enlightenment will prevent the spread of the disease. Thus, both BSE and BSA should be properly taught and demonstrated in smaller groups to ensure interactive sessions and a deeper understanding of the concepts and their relevance. Given the nature of nursing practice, breast awareness puts more responsibility to nurses and the practice of the profession. While there is nothing necessarily contradictory about BSE, its poor practice and non-awareness has made it less effective in transforming incidence and/or prevention of cancer. Nurses should therefore engage in more practical translation of the knowledge of breast self-awareness to women to promote regular practice. This will improve women’s ability to identify early breast changes and in turn seek medical care early.

The arguments on breast self-examination and breast self -awareness have serious implications for nursing research, thus nurses and similar care givers are required to dig deeper and reflect more objectively through research. The essence is to make new scientific discoveries and provide cure for cancer. Thus, while the literature has uncovered the wide spread and prevalence of cancer among women, those who practice BSE do not do it correctly and at regular interval. Many lack the right skills to practice it as it should be, hence researchers can carry out intervention studies.

Above all, premised on the primacy of policy response and strict compliance to cancer awareness, the varied and important roles that breast awareness plays calls for new nursing policy is essential for sustainable health Like all other medical professions, breast awareness has a number of policy implications for nursing profession and in particular early detection of cancer, such policies could regulate or guide regular check, routine activities etc. Further, such policy will chart new cause for the transformation of cancer, building on new awareness strategies and promoting the collective efforts of relevant stakeholders to strengthen early detection. Thus, the practical and policy upshot of our analysis is essential for nursing profession in many ways, while acknowledging the many relevance of early detection, our study nonetheless suggests that there is need for more awareness, particularly with regards to the prevalence and spread of cancer disease.

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