Anda di halaman 1dari 17

Int Public Health J 2015;7(4):411-426 ISSN: 1947-4989

© Nova Science Publishers, Inc.

Encouraging Arab women to beat the cancer epidemic:

An investigation into positive attributes that encourage
Arab women to practice prevention methods for cancer

Sara A Suhaibani, MPH and Cecilia S Abstract

Obeng, PhD
Department of Applied Health Science, School of Public Breast cancer in Arab countries tends to occur at younger
Health, Indiana University, Bloomington, Indiana, USA age, with almost half under the age of 50 years. This study
investigates 25 Arab women living in the United States and
their knowledge about breast cancer prevention methods.
Findings indicate that participants reported lack of
knowledge on how to practice breast self-exam. Majority of
participants indicated they never attended any community
program on breast cancer prevention or go for mammogram
examinations. Participants noted that knowing how to do
breast exam and being reminded at the clinics would help
them practice breast self-exam. Given that research
indicates that breast self-exam and mammograms help save
lives, it is recommended that health professionals and
family members remind women, especially Arab women,
about breast cancer prevention methods.

Keywords: Breast cancer, Arab women, mammogram,

breast self-exam

Worldwide, cancer is a leading cause of death among
men and women. In the year 2004, approximately 7.4
million deaths were from cancer alone. Amongst
women, breast cancer is one of the main types of
cancer leading to “overall cancer mortality” (1, 2). In
the United States, among women, breast cancer is the
foremost diagnosis of new cancers and the second
leading cause of death after lung cancer (3). An
epidemiological surveillance indicates that during the
year 2005, the age-adjusted mortality rates of breast
cancer was 24.8 per 100,000 among U.S. female
population (4). According to the World Health

Organization, cancer is the fourth ranked cause of
Correspondence: Cecilia S Obeng, PhD, Associate Professor,
Indiana University, School of Public Health, 1025 E 7th
death in the Arab world after cardiovascular diseases,
Street, SPH 116, Bloomington, IN 47405, United States. infectious/parasitic diseases, and injuries (5). In the
412 Sara A Suhaibani and Cecilia S Obeng

next two decades, cancer is predicted to increase 100- population alone (3). Breast cancer is the most
180% in the Eastern Mediterranean Region (5). In the common cancer among women in the United States,
Arab world, including the Kingdom of Saudi Arabia, other than skin cancer. It is the second leading cause
breast cancer is increasingly occurring among young of cancer death in women, after lung cancer (3). In the
pre-menopausal women as opposed to what happens American population, breast cancer death rates have
in western countries, where breast cancer is common been going down as a result of increased awareness
among women at menopausal age. More disturbingly, about breast cancer prevention and early detection, as
most cases of breast cancer in the Arab world are well as the improvement of treatment techniques.
detected at advanced stages (1, 6, 7). Today, with primary and secondary prevention and
The published facts and statistics about breast the advancement in treatments methods, there are
cancer are indicators of a serious problem that needs more than 2.5 million breast cancer survivors in the
to be addressed. The lack of knowledge and United States (3).
awareness about breast cancer, primary and secondary
prevention, and how to detect breast cancer in its
early stages are causing preventable fatalities among On defining breast cancer
women in this part of the world.
To help the reader understand the issue at hand, a
short background on what constitutes breast cancer is
Why this topic? presented. “Breast cancer is cancer that forms in the
cells of the breasts” (10). The American Cancer
The topic of breast cancer is chosen due to the Society defines breast cancer as a “malignant tumor
situation in the Arab world in general. Breast cancer that starts from cells of the breast.” A malignant
is increasing tremendously in the Middle Eastern tumor is a “group of cancer cells that may grow into
countries. Many young females are losing their lives or invade surrounding tissues or spread to distant
due to being diagnosed with breast cancer in areas of the body” (3). According to the Mayo Clinic,
advanced stages (5). In the Kingdom of Saudi Arabia breast cancer occurs among men and women, but
(KSA), women are diagnosed with breast cancer mostly in women (10). Early menarche: women who
between the ages 20-50 years, reflecting a diagnostic started their period before age 12 years, late parity:
that starts at younger age for that specific type of women who had their first child after the age of 30
cancer. These facts are raising concerns about the lack years, women with nulliparity
of knowledge about breast cancer and attitudes
regarding primary and secondary prevention,
especially about breast self-exam and other early Types of breast cancer
detections methods.
According to the National Breast Cancer Foundation,
“Breast cancer is categorized by whether it begins in
Overview of breast cancer the ducts or lobules, which are the organs responsible
for breast milk production” (11). Types of breast
The American Cancer Society's most recent estimates cancer include:
for breast cancer in the United States indicate that the
chance of a woman having invasive breast cancer
some time during her life is a little less than 1 in 8. Ductal carcinoma in-situ (DCIS)
The chance of dying from breast cancer is about 1 in
35. In addition, during the year 2010, it was estimated This type of breast cancer is one of the earliest stages
that there was approximately 207,090 new cases of where the tumor is still in place and has not yet spread
invasive breast cancer in women, about 54,010 new out. The tumor is found inside the ductal system (11).
cases of non-invasive carcinoma, and around 39,840
deaths from breast cancer in the U.S. female
Cancer and prevention 413

Infiltrating ductal carcinoma (IDC) called "inflammatory" because the breast is inflamed.
The breast appears swollen and red because the
IDC makes up 78% of breast cancer diagnoses in the cancer cells block the lymph vessels in the breast skin
United States, which makes it the most common type which lead to very aggressive consequences (11).
among other types of breast cancer (11). On the
mammogram, IDC shows in one of two shapes: either
star-like shape or rounded shape; the star-like shape is Breast cancer stages
more aggressive (11).
According to the National Cancer Institute, “staging is
the process of determining whether a cancer has
Medullary carcinoma (MC) spread within the breast or to other parts of the body”
(12). According to the Mayo Clinic, “Breast cancer
MC represents 15% of all types of breast cancers and stages range from 0 to IV, with 0 indicating cancer
has a good prognosis. It is called medullary, because that is very small and noninvasive. Stage IV breast
it looks like the gray matter of the brain, which is cancer, also called metastatic breast cancer, indicates
called the medulla (11) cancer that has spread to other areas of the body”
(10). Each of the stages is briefly explicated below:

Infiltrating lobular carcinoma (ILC)

Stage 0
Representing 5% of all diagnosis, ILC forms in the
upper outer quadrant of the breast. ILC tumors give This is the first stage of cancer where the tumor is still
positive results when conducting estrogen and in situ and non-invasive; for example, Ductal
progesterone receptors tests and response well to carcinoma in situ is a stage 0 type of cancer. The
hormone therapy (11). tumor is local (10).

Tubular carcinoma (TC) Stage I

TC appears like a tubular shape under the microscope. This is the first stage of an invasive breast cancer. In
This type of breast cancer is common among women this early stage the tumor has certain characteristics in
aged 50 and over. TC represents 2% of the diagnosis measures and location. The size of the tumor is 2
and has a good prognosis (11). centimeters (3/4 inch) or less and the cancer has not
spread to the lymph nodes or to other organs (10).

Mucinous carcinoma (colloid)

Stage II
This type of breast cancer makes up 1-2% of all breast
cancers. Mucinous carcinoma is different from other This stage describes invasive breast cancer in which
types of breast cancer, because it sets off mucus one of the following is true: the tumor measures less
production inside the breast (11). than 2 cm (3/4 inch), but has spread to the lymph
nodes under the arm; or no tumor is found in the
breast, but breast cancer cells are found in the lymph
Inflammatory breast cancer (IBC) nodes under the arm, or if the size of tumor is
between 2 and 5 cm (about 3/4 to 2 inches) and may
IBC is rare but invasive, it accounts for 1% to 5% of or may not have spread to the lymph nodes under the
all breast cancer cases in the United States. IBC is arm, finally a stage II may show the T larger than 5
414 Sara A Suhaibani and Cecilia S Obeng

cm (2 inches) but has not spread to any lymph nodes menopause at a late age” (3,13). Modifiable risk
(10). factors, typically related to a person’s lifestyle
including: "Not having children, or having your first
child later in life, and lack of breast feeding.” In
Stage III addition, lack of physical activity, being overweight
“particularly after menopause”, using hormone
Stage III is an advanced stage of breast cancer where replacement therapy for a long time, and using oral
tumors start to invade surrounding tissues. This stage contraceptives can increase risk factors of cause
is subdivided into three categories IIIA, IIIB, and IIIC breast cancer (3, 13).
based on a number of criteria including: (size of the
tumor, location of the tumor in surrounding tissues.
By definition, stage III cancer has extended to the Breast cancer prevention
imediat region but has not spread to distant sites (the
tumor is regional) (10). Avoiding risk factors for breast cancer aids in the
prevention of disease development. The National
Cancer Institute recommends several steps to
Stage IV minimize the chances of developing breast cancer.
Stage IV is an advanced stage cancer and is One of the most important, precautious procedures is
considered to be invasive because the cancer has to become familiar with your breasts through breast
spread to other organs of the body (the tumor is self-exam.
distant) usually the lungs, liver, bone, or brain (10). Cancer prevention strategies include avoiding or
limiting hormone therapy, especially after menopause,
eating a healthy diet that is low in fat and high in
Symptoms fruits and vegetables, maintaining a healthy weight,
and making physical activity part of the daily routine
According to the Centers for Disease Control and (12). In addition, other preventable practices to lower
Prevention (CDC), when breast cancer formulates no the chance of developing breast cancer are: avoiding
visible signs and symptoms appear until the tumor smoking and avoiding exposure to environmental
grows. The symptoms start to be evident due to pollution, limiting alcohol intake, and avoiding the
changes in how the breast looks or feels. These use of oral contraceptive pills. Moreover, becoming
symptoms include: a new lump in the breast; lump pregnant at early age and breast-feeding prevent the
that has changed; change in the size or shape of the onset of breast cancer (12).
breast; pain in the breast or nipple that does not go
away; flaky, red, or swollen skin anywhere on the
breast; and a nipple that is very tender or that Early detection and diagnosis
suddenly turns inward” (13).
Anderson et al (3) define early detection as “the
identification of breast cancer at a point in its natural
Risk factors history when it can be treated with techniques that
have the least physical impact and the greatest chance
Several factors may affect an individual’s risk of of producing a cure” (14).
developing breast cancer. These risk factors include Early detection and screening for breast cancer
unchangeable and modifiable risk factors. help in finding a tumor, if it exists, well before any
Unchangeable risk factors include: “gender, age, symptoms develop and in a stage where the cancer is
genetic risk factors, family history of breast cancer, controllable. Going through early detection tests and
personal history of breast cancer, race and ethnicity, exams lead to early diagnosis, a situation that
dense breast tissue, previous chest radiation, starting potentially increases the likelihood of a successful
first menstrual period at an early age, and beginning treatment and better prognosis. There are many
Cancer and prevention 415

instruments and tools used to detect breast cancer Hormone therapy

Mammogram. This X- ray instrument is the most Hormone therapy is usually used to treat breast
common screening method used for detecting breast cancers that are sensitive to hormones. These cancers
cancer. It is recommended for women to do their are referred to as “estrogen and progesterone receptor
mammogram yearly, as long as no breast cancer positive cancers” (10).
symptoms are showing, at age 40 years old (2).
Breast ultrasound. “Breast Ultrasound are waves
to produce images of structure deep within the body.” Targeted drug
This diagnostic method is used to determine if the
breast malformation is a cyst filled with fluid (3). “Targeted drug treatments attack specific
Breast magnetic resonance imaging (MRI). MRI abnormalities within the cancer cell” (10).
is a machine that formulates images of the inner
section of the breast by using magnetic and radio
waves to formulate image of the interior of one’s Chemotherapy
breast. Before implementing this method the patient is
given a dye injection (2).
Chemotherapy is a common treatment for cancer in
Breast biopsy. A breast biopsy is removing a
which drugs are used to destroy cancer cells, but it
sample of breast cells for testing. To determine
usually causes many side effects such as loss of hair,
whether a patient has breast cancer or not, the doctor
weight loss, and nausea (10).
will have a biopsy by removing a sample of any
abnormal breast cells. The sample is sent to a
laboratory for testing. In addition, biopsy sample
helps in determining the type of cells involved in the Clinical trial
breast cancer and the aggressiveness (stage) of the
cancer (3). Clinical trials are unproven treatments that may or
may not be better than the other treatment options, but
a doctor may give the patient this treatment option
depending on the condition of the illness (10).
Treatment options for breast cancer
When diagnosed with breast cancer, a doctor
determines treatment options based on the type of Documentation of breast cancer
breast cancer, it’s stage, whether the cancer cells are in the Arab world
sensitive to hormones, the overall health of the
patient, and an individual’s own preferences for Worldwide, it is estimated that around 11 million
treatment. Most women prefer surgical treatment for people developed cancer in 2002. Of these, 53.7%
breast cancer; however, the surgical treatment usually were in developing countries and 46.5% were in
comes along with additional treatment, such as developed countries. Among women in Saudi Arabia,
chemotherapy, hormone therapy, or radiation. Breast breast cancer is the most common form of cancer
cancer treatments include: followed by colon-rectal cancer (15). Cancer is an
increasing problem in the Arab world. According to
the World Health Organization (5), cancer is a leading
Surgical treatment cause of death in this part of the world and is
estimated to kill 272,000 individuals annually. The
This treatment involves removing only the breast Arab world (also called the Eastern Mediterranean
cancer (lumpectomy) or removing one or several Region or Middle East) refers to the Arabic-speaking
lymph nodes (sentinel node biopsy) or removing the countries extending from Lebanon and Syria in the
entire breast (mastectomy) (10). north, Morocco in the west, Yemen in the south and
416 Sara A Suhaibani and Cecilia S Obeng

Iraq in the east. The population of the Arab countries same as those in developed countries. Further, some
is over 300 million spreading along North Africa and risk factors appear to be more significant in some
Western Asia (5). Arab countries share common Arab countries than others. According to Salim et al
demographic problems and embrace the same culture (7) some risk factors like late age at last full-term
and beliefs but different socio economic status (7). pregnancy and long term use of oral contraceptive
Cancer is considered to be a “taboo” in most of were significant predictors for breast cancer among
the Arab world, and people call it ‘‘that other females in Egypt, while in Jordan, increased numbers
disease’’ and fear to mention it by name due to lack of of pregnancies and obesity among postmenopausal
knowledge and awareness (16). Breast cancer is the women were significant predictors for breast cancer
most frequent type of cancer among females in the (7). In Kuwait, significant risk factors for breast
Arab world. Patients with breast cancer in Arab cancer included “high Body Mass Index, lack of
countries tend to be young and almost half of the physical activity, early age at menarche, late age at
patients are under age 50 years; the median age of 49- first pregnancy hormonal therapy, and frequent
52 years of Arab women with breast cancer is a consumption of carbohydrates, sweets, animal fat, and
decade lower when compared to the age 60 years of vegetable oil (margarine) with low intake of fresh
women developing breast cancer in Western vegetables and olive oil” (7).
developed countries (1, 7, 17). In many Arab On the other hand, significant risk factors for
countries “political instability, military conflicts, and breast cancer among Iraqi females were tied with
poor planning have hindered the development of having a family history of breast cancer and oral
medical advances for breast cancer detection and contraceptives use, whereas high-risk human
treatments (17).” In addition, political and economic papilloma virus infections showed a significant
issues slow down research on cancer-related issues predictor for breast cancer among women in Syria (7).
leaving the responsibilities of investigation and In many Arab countries the age-adjusted incidence
advancement under “individuals’ and institutional rates for breast cancer are increasing tremendously (1,
motivation” (16). Salim et al (7) stated that the risk 7).
factors for breast cancer in the Arab world are the

Source: WHO, 2009.

Figure 1. Increases in death from cancer (%).

Cancer and prevention 417

Source: WHO, 2009.

Figure 2. Top 5 cancer causes of death in Eastern Mediterranean Region.

For example, in Lebanon, the breast cancer finding tumors at an early stage which subsequently
incidence rate grew from 20 per 100,000 women in increases the survival rate to as high as 93% if found
1996 to 46.7 per 100.000 in 1998. In Jordan the in the first stage (stage 0) and if the appropriate
incidence rate for breast cancer increased from 7.6 per treatment is implemented (3).Therefore, following
100,000 women in 1982 to 32.8 per 100,000 in 1997 early detection practices can reduce the impact of
(16). Although the incidence of cancer is lower than breast cancer and allow for a greater range of
developed countries, it is expected to reach the treatment options.
highest increased incidence among all World Health Unfortunately, there is a rapid increase in obesity
Organization’s regions in the coming years in Arab countries due to embracing an unhealthy
(5).Unfortunately, although the increase in breast lifestyle of unhealthy food consumption and lack of
cancer incidence is noted worldwide, there is still a physical activity, primarily among children,
lack of national and regional cancer registries in some adolescents, and young adults (3, 18, 19). Adopting
Arab countries. Also, there is inadequate mortality Western cuisine and increasing the production of
and disease specific mortality rates recorded in almost processed food and fast food restaurants have affected
all Arab countries (16). health in the Eastern Mediterranean Region, and has
contributed to the rising numbers of cancer cases (5,
20). Low intake of fruits and vegetables among Arab
Primary and secondary prevention countries has increased the prevalence of breast
cancers. At the same time, changes in lifestyle and
awareness of breast cancer
rapid urbanization have led to less physical activity
(20, 21). In addition to the important role of dietary
According to the American Cancer Society (3), the
factors at play in the etiology of cancer, it is
risk of developing breast cancer can be reduced by
documented that obesity, consumption of a specific
primary and secondary prevention. The best
food like high consumptions of food that are high in
prevention practice is to avoid risk factors that
fat or processed ingredients, and tobacco use are all
increase the likelihood of developing breast cancer
linked to the development of breast cancer (19). Note,
and adopt a healthy lifestyle including eating healthy,
however, that the tobacco epidemic is less advanced
maintaining physical activity, and taking the breast
in developing countries. Tobacco use is responsible
cancer screening when one reaches the appropriate
for about 30% of the cancer burden in some
age or as a doctor recommends (18). In addition, early
industrialized countries, but much lower in
detection for breast cancer plays a significant role in
418 Sara A Suhaibani and Cecilia S Obeng

developing countries since the tobacco epidemic is in health education and advanced treatment options for
its early stage (3, 18). Moreover, environmental breast cancer. The public knows very little about
factors are associated with cancer, yet studies have breast cancer risk factors and prevention methods and
shown that pollution contributes to less than 2% of when an individual develops a cancer he/she cannot
cancer risk factors in developed countries and is not find many treatment options (1). Even knowledge
expected to be higher in developing countries (3, 18). about secondary prevention methods such as breast
Conversely, attitudes and beliefs regarding health self-exam and early detection are limited. In addition,
in Arab countries differ from those in Western most Arab countries lack national programs for
countries. Many Arabs would only go to the doctor screening unless a motivated institution or private
when they noticed severe symptoms. They do not corporation sponsors the screening program (23).
believe in taking precautions or going to the doctor However, few motivated women would undergo the
for screening or early detections (22). Most cancers screening due to poor knowledge about the
present at an advanced stage in Arab countries when a importance of screening and because it is too
cure is improbable, even with the best treatments. In a expensive for the majority of people since
study conducted by El Saghir et al. (16) large governmental and private insurers do not usually
numbers of women in Arab countries presented with cover the expenses of screening. Further, when a
locally advanced and metastatic breast cancer because female is diagnosed with breast cancer, treatment
of poor health education, fear of finding out they have options are limited in most Arab countries. Medical
cancer, shyness, and difficult access to healthcare development in the Arab world is far behind the
facilities. The primary reason behind improved developed countries. For example, if an individual has
survival rates for breast cancer in the U.S. and Europe radiotherapy services as a treatment for breast cancer,
has been shown to be finding the tumor in earlier one would find it far below international standards in
stages of disease. Cautious attitudes regarding breast Arab countries. When comparing Arab countries and
cancer and implementing early detection among the U.S., in terms of available radiation therapy
women in Western countries were achieved through centers, all Arab countries combined have 84
public education and increasing awareness of breast radiation therapy centers, while the U.S. has 1,875.
cancer prevention. It is important to note that data Furthermore, whereas all the Arab countries have 256
have shown that knowledge and attitudes regarding radiation oncologists, the U.S. alone has 3,068, which
breast cancer prevention and early detection are reveal an enormous resource shortage of facilities and
absent in Arab countries. There is an urgent need for a health personnel in the Arab world (16).
public health plan to increase the knowledge and
attitudes regarding breast cancer prevention.
Increasing knowledge about breast cancer is the most Breast cancer in the Saudi female
effective approach of reducing cancer mortality in the
Eastern Mediterranean Region (3).
The Kingdom of Saudi Arabia KSA(KSA) has
witnessed an enormous increase in breast cancer in
Breast cancer management and the last several years (1, 6, 7, 17, 24). The latest
professional implications in the released data from KSA National Cancer Registry
Arab world shows breast cancer as the leading cancer among
women in KSAin 2005, accounting for 22.4% of all
It is estimated that more than 50% of the cancers in newly diagnosed female cancers with the median age
the world are attributable to three factors: tobacco, of 46 years at diagnosis (15, 25). The data revealed an
infection, and unhealthy lifestyle (diet, obesity, and increase in the incidence rate of breast cancer within a
lack of physical activity). Early detection and year from 2004 to 2005 (see figures 4 and 5). The
appropriate treatment for breast cancer increase the data confirm a growth in the age-standardized
ability to control the disease and lead to a better incidence rate from 15.4 per 100,000 in 2004 to 24.4
survival rate. However, Arab countries lack proper in 2005 (24). The five regions with the highest breast
Cancer and prevention 419

cancer incidence were in the Eastern region at 30.0 patterns from the different regions of KSA shows that
per 100,000 the Makkah region at 20.9 per 100,000, while there is an increase in numbers of cancer cases
the Riyadh region at 18.6 per100,000, the Jouf region in all regions of KSA, it is most striking in the
at 16.9 per 100,000 and the Tabuk region at 12.5 per Eastern, Southern and Northern regions. The age
100,000 (24). The majority of cases are identified in distribution and menopausal status are similar in the
advanced stages; for example, 44% of breast cancer different regions (8, 26). In a study conducted on the
cases are found in advanced stages (regional) (see stages of breast cancer among female patients who
figure 6). Further, a higher frequency of breast cancer came to King Faisal Hospital and Research Centre, it
patients are among younger pre-menopausal women was found that 36% of the cases were early stage
who do not seek help until the cancer reaches an breast cancer (stages I, II), while 64% of the cases
advanced stage (26). A comparison of the referral were at advanced stages (stages III, IV) (24).

Source: Saudi Cancer Registry, 2004.

Figure 3. Incidence rate for female breast cancer in the year 2004, Saudi Arabia.

Source: Saudi Cancer Registry, 2005.

Figure 4. Incidence rate for female breast cancer in the year 2005, Saudi Arabia.
420 Sara A Suhaibani and Cecilia S Obeng

In another study conducted by Ezzat et al (24) most Risk factors for breast cancer among Saudi
women who came at King Faisal Specialist Hospital females are similar to the risk factors in the U.S., yet
seeking breast cancer treatment were premenopausal some of the emphasized risk factors include “estrogen
women at median age of 46 years and the cancer was use, hormone replacement, oral contraceptive pills,
found in stage III (24). However, there is a lack of early menarche: women who started their period
accuracy regarding the number of cases of breast before age 12 years, late parity: women who had their
cancer in these two studies. The number of breast first child after the age of 30 years, women with
cancer cases is estimated to be more than what was nulliparity, women who did not have any children or
mentioned but they were not recorded due to who did not report any pregnancies” are at high risk
malfunctioning of the hospital staff (28). of breast cancer (27,. (see figure,3, 4, and 5)

Source: Saudi Cancer Registry, 2005.

Figure 5. Distribution of female breast cancer in Saudi Arabia.

Knowledge and prevention of breast information to avoid risk factors of breast cancer (6,
27). In a study by Amin et al (27) trying to assess the
cancer among Saudi females
“level of knowledge about risk factors and utilization
of screening methods used for breast cancer among
Promoting health education and breast cancer
Saudi women, the results show that knowledge about
preventable behavior is essential to decrease the odds
breast cancer risk factors and early detection methods
of developing breast cancer and to improve the
were low and dependent upon educational and
quality of life for the population (20, 27). In Saudi
occupational status”. In addition, early screening is
Arabia, breast cancer is increasing among younger
underutilized among participants due to several
females in all different regions (8, 15, 26). The
perceived barriers. Moreover, the study showed early
increased prevalence of breast cancer among Saudi
detection methods were employed by less than 5%
women at a younger age is tied with a lack of
and mammography by only 3% of cases (27).
awareness about primary and secondary prevention
Dandash and Al-Mohaimeed (6) discovered that
implications (6, 17, 29). Many women have no access
most of the 90% of respondents (women) in the Al-
to mammograms due to “racial, environmental,
Qaseem region who participated in their study showed
financial/insurance barriers; lack of education; and,
lack in basic knowledge regarding breast cancer
most importantly, lack of encouragement by a
prevention. The study also revealed that persons with
physician” (9). Social and demographic factors play
higher socioeconomic lifestyle had higher knowledge
an important role regarding the level of knowledge of
about breast cancer prevention, but even then people
breast cancer leading to an unfavorable outcome of
did not practice early detection (6). Also Milaat (29)
breast cancer in KSA (27). However, even individuals
assessed the level of awareness regarding breast
who are knowledgeable about breast cancer
cancer prevention and breast self-examination among
prevention methods will not necessarily use the
students in Jeddah city, and discovered a very low
Cancer and prevention 421

knowledge level among the students. Specifically, for breast cancer prevention that use multiple
over 80% of the participants showed lack of channels of communication can be used to effectively
knowledge about breast cancer (29). Additionally, disseminate relevant information regarding breast
students who demonstrated better knowledge of breast health risks to vulnerable populations and encourage
cancer were among older students, married, or having adoption of health-promoting behaviors (31, 32).
a child, and students who experienced breast Such recommendations can be broadened to be used
problems personally or in the family (29). in the Arab world in general or in one specific country
The presented data point to the urgent need for like Saudi Arabia
educational programs and national campaigns to The focus of our strategic plan is promoting
promote awareness about breast cancer, since it has primary and secondary awareness regarding breast
been estimated that there will be a 350% increase of cancer. A proposed approach once implemented
breast cancer in KSA by the year 2025. The only way effectively would serve the purpose of breast cancer
to stop these appalling predictors is to spread prevention through promoting awareness regarding
knowledge in the community and to educate risk factors about breast cancer and the importance of
individuals to avoid risk factors of breast cancer and early detection. This approach is a culturally sensitive
implement early detection methods (20, 30). Breast health communication program, in which cultural
cancer programs should be structured and traditions, norms, and settings are taken into
implemented on a wide scale and tailored to fit consideration while conducting the program in order
individual communities (6). These statistical to meet the health consumer preferences and draw a
disparities in the Arab world in general and KSA in large population to the program (33). An example of
particular, imply the importance to establish such an approach is the Cancer Care Mission Program
community based promotion programs to enhance the in Pune, India. In this program health professionals
knowledge about breast cancer, expand access to addressed the targeted population by categorizing
breast cancer screening, diagnostic services, and them according to their religion, language, literacy
treatment. This approach can be achieved by focused and education, financial status, villagers and city
efforts and collaboration between governments and residents (33). In addition, the team in this program
healthcare system. made additional efforts to address the multiple
languages, cultures, and religions through appropriate
research and knowledge of the different cultures. In
Strategic plan to promote breast communicating the targeted knowledge about breast
cancer, the project members addressed each
cancer prevention and early detection
individual according to their level of education and
literacy, so for highly educated people the team
It is estimated that 40% of cancers can be prevented
presented statistics and scientific information, and for
by risk factors modifications. Therefore, prevention
the illiterate, basic knowledge and visuals like posters
offers the greatest public health potential and the most
and powerpoint presentations in their local languages,
cost effective long-term approach for cancer control
needs, and beliefs were utilized. Also, cultural
(3). Since breast cancer is commonly diagnosed at late
sensitivity is crucial for such programs to succeed.
stages in Arab countries, efforts should be directed to
Health professionals in this project integrated images
increasing knowledge about prevention and
and pictures from the local heritage in presenting
promoting awareness regarding early detection of
sensitive images like breasts and other women body
breast cancer. Such a focused plan can lead to
parts. Overall the issue of cultural and religious
diagnosis at earlier stages, potentially improving the
sensitivity and how they are being treated in any
odds of survival and successful treatment of breast
initiative, whether a health promotion program or an
cancer, and enabling simpler and more cost effective
awareness campaign, is of a high priority in Arab
treatments. Reducing the impact of breast cancer in
countries and specifically in KSA where such aspects
the Arab world will require modifications and
of life are considered more important that any given
improvements to the healthcare system and public
health issue (see figures 6 and 7).
education. Strategic health communication campaigns
422 Sara A Suhaibani and Cecilia S Obeng

Source: Yip et al. 2008.

Figure 6. Barriers to awareness, education, and outreach programs and activities for early detection programs for
breast cancer.

Source: Anderson et al., 2007.

Cancer and prevention 423

Figure 7. Breast care programs: human resource allocation table.

Future trends planning and resourcing, hopefully the health status

will improve among all Arab communities and cancer
The trend has been attributed to several factors will no longer be an epidemic concern.
including emphasis on early detection and education In view of the above literature in the Arab world,
of professionals and public yet these trends are going this study examines Arab immigrant women in the
slowly and need to be emphasized. In addition, in the United States and their perspectives on breast cancer.
Arab world in general and in KSA specifically, there The purpose of this study was to investigate the
is a need to improve the healthcare system as a whole reasons behind an increasing number of breast cancer
in order to promote the health outcomes among the cases in their advanced stage among Arab women in
population. Many taboos need to be overcome and general and among women in Saudi Arabia, and find
replaced with knowledge and valid facts. Breast the solutions to promote prevention against breast
cancer is one side of the story and for just that issue cancer.
one will find that there is a lot to do to reduce breast
cancer morbidity and mortality. To fix the problem
we need to start from zero and renovate the health Methods
system. Primary healthcare workers are rarely
provided with sufficient education about the early Twenty-five Arab females aged 18 to 54 years were
signs of cancer or where to refer suspected cases. This recruited for this research. Purposeful sampling (34)
could be remedied by short training courses like was used to recruit the participants. Participants came
continuing education programs, brochures or posters, from different backgrounds, specifically KSA, Egypt,
and by establishing links between those who deliver Syria, Sudan, Jordan. However, More than half of
primary healthcare and referral centers (5). participants came from KSA. During this study, all
Authorities in the Arab countries and KSA should participants resided in the United States for academic
embrace the concept of training sufficient numbers of purposes. Majority of participants were married 60%
nurse practitioners and physician assistants to with a bachelor degree or beyond.
promote health knowledge about breast cancer (17). The authors used a phenomenological approach
Also, access to multi-disciplinary tumor boards and for data analysis (35). The questionnaire was
clinics will improve breast cancer care. Development distributed to participants by hand as well as via
of centralized, specialized cancer centers may be a email. The data collection instrument contained a list
cost effective way to deliver breast cancer care to of eight questions. The questionnaires were composed
some women. Panelists of the Global Summit of open-ended and closed-ended questions.
Consensus Conference noted that measures to educate After approval by Indiana University’s
the public and healthcare providers about breast Institutional Review Board, potential participants for
health and breast cancer detection, diagnosis, and the study were contacted through email, phone calls,
treatment are considered more important than and, where possible, in person by one of the authors.
screening in countries with limited resources to Potential participants were notified that taking part in
deliver such care to women nationwide (16). Also, this study was voluntary. It took 25 minutes for each
awareness campaigns and screening should be applied participant to complete the questionnaire. Completed
according to resources. Awareness campaigns should questionnaires were hand delivered where possible, or
also be directed to the whole family and to husbands sent by email.
instead to encourage their daughters and wives to Data from open-ended questions were used for
enroll in early detection programs. Radiation therapy this research. Because this study used a
facilities and manpower remain very limited and phenomenological approach, it allowed the
deserve better planning and investment, and to be researchers to code according to similarity in the
more widely available and distributed in major cities identified answers. Commonalities in participants’
and distant regions (16, 31). Health promotion is a personal experiences were also grouped together and
new concept in the Arab world but with strategic sorted into categories by theme (34-37).
424 Sara A Suhaibani and Cecilia S Obeng

good start in addressing the problem. However, as

time problems were also reported, such educational
Results efforts should reinvent themselves in manners that
accommodate the public needs and correct any false
Research findings indicated that participants lack ideas. Collaborative efforts from public service
knowledge regarding how to practice breast self- offices, health officials, and interested groups might
exam. Participants cited several reasons, such as not consider creating educational materials that take into
knowing how to do the breast self-exam. A participant the consideration people’s culture and the sensitivity
stated: “I do not know how.” There was also lack of of the subject and reach out to the public in a variety
time to do the exam as expressed by a participant: “I of ways.
don’t have an opportunity to do it.” Some participants The taboo nature of the issue could also be
noted that influences from family members and providing misinformed grounds for the disease to
medical practitioners also impacted their choice of not flourish. As women rarely talk about it or only talk to
going to a clinic. A participants noted: “because no very close family members and relatives (16),
one in my family has, the doctor said I do not need misinformation could be the only source for deciding
it”. on what to be done about preventing the disease. This
Additionally, the majority of participants (64%) conundrum amplifies the role of physicians and their
indicated they never attended any program in their responsibility in informing their patients and
community to gain knowledge regarding breast cancer explaining measures available to them.
prevention. However, we also noticed that the group Given that research indicates that primary and
of participants who positively reported doing the secondary prevention, especially breast self-exam and
exam also reported attending an educational program mammogram help save lives, it is highly
on breast cancer and prevention. recommended that health educators, nurses,
Furthermore, the majority of participants (80%) physicians, and family members routinely remind
reported not ever getting a mammogram. We had female members about breast cancer prevention
hoped to explore such practices within the specific methods.
age (40 years and above), however we could not do so Proper knowledge about the issue should
due to lack of participants in this age range. Some facilitate the development of better informed citizens
participants attested that if healthcare professionals who are able to navigate through misinformed
would help them learn about breast cancer prevention arguments. The lack of time obstacle was particularly
methods and remind them at the clinics, it would go a interesting as breast self-examination takes little time
long way to help them practice breast self-exam. and could be done while in the shower.
From this study we conclude how crucial it is to
make available proper awareness and practices about
breast cancer as our observations showed a positive
correlation between attending an educational program
about breast cancer prevention and taking proper
Findings from the study confirm the existing literature
measures in preventing breast cancer.
emphasis on the lack of knowledge and awareness
among Arab women about breast cancer awareness
and prevention measures (6, 27, 29). Knowledge
among individuals in the Arab community concerning References
breast cancer and its prevention including breast self-
examination and having a mammogram is [1] Najjar H, Easson A. Age at diagnosis of breast cancer in
Arab nations. Int J Surg. 2010;8(6):448-52.
insufficient. Inadequate personal knowledge on the [2] World Health Organization. The World Health
issue of breast cancer seems to be a big factor in Organization’s cancer fact sheet 297, 2009. URL:
allowing this life threatening disease to continue in
the Arab world. As participants reported, educating nt.html
the public about prevention measures would be a
Cancer and prevention 425

[3] American Cancer Society. Cancer facts and figures [19] Holmes M, Willett W. Does diet affect breast cancer
2010. URL: risk? Breast Cancer Res 2004;6(4):170-8.
@epidemiologysurveilance/documents/document/acspc- [20] Al-Amri A. Prevention of breast cancer. J Fam
026238.pdf. Commun Med 2005;12(2):71-74.
[4] National Cancer Institute. Surveillance Epidemiological [21] Khatib O. Noncommunicable diseases: risk factors and
End Results Program: State cancer profiles: Death rates, regional strategies for prevention and care. East
2009. URL: Mediterranean Health J 2004;10(vi): 778-88.
bin/deathrates/deathrates [22] Lipson J, Meleis A. Issues in health care of Middle
[5] World Health Organization, Regional Office for the Eastern patients. West J Med 1983;139(6): 854-61.
Eastern Mediterranean. Strategy for cancer prevention [23] Hanna T, Kangolle A. Cancer control in developing
and control in the Eastern Mediterranean region. Cairo, countries: using health data and health services research
Egypt: WHO/EM/NCD/060/, 2009. to measure and improve access, quality and efficiency.
[6] Dandash K, Al-Mohaimeed A. Knowledge, attitudes, BMC Int Health Hum Rights 2010;10:24.
and practices surrounding breast cancer and screening in [24] Ezzat A, Ibrahim E, Raja M, Al-Sobhi S, Rostom A,
female teachers of Buraidah, Saudi Arabia. Int J Health Stuart R. Locally advanced breast cancer in Saudi
Sci 2007;1(1):L61-71. Arabia: high frequency of stage III in a young
[7] Salim E, Moore M, Al-Lawati J, Al-Sayyad J, Bazawir population. Med Oncol 1999;16(2):95-103.
A, Bener A, et al. Cancer epidemiology and control in [25] Ministry of Health, Saudi Cancer Registry. Cancer
the Arab world: Past, present and future. Asian Pacif J incidence report 2005. URL: http://www.emro.who
Cancer Prev 2009;10:3-16. .int/ncd/pdf/saa_cancer_registry_2005.
[8] Ezzat A, Raja M, Rostom A, Zwaan F, Akthar M, [26] Khan A R Hussain NK Al-Saigh A Malatani T, Sheikha
Bazarbashi S, et al. An overview of breast cancer. Ann AA. Pattern of cancer at Asir Central Hospital, Abha,
Saudi Med 1997;17(1):10-5. Saudi Arabia." Ann Saudi Med 1991;11(3):285-8.
[9] Abulkhair O, Al Tahan F, Young S, Musaad S, Jazieh [27] Amin T, Al Mulhim A, Al Meqihwi A. Breast cancer
A. The first national public breast cancer screening knowledge, risk factors and screening among adult
program in Saudi Arabia. Annals of Saudi Med Saudi women in a primary health care setting. Asian
2010;30(5):350-357. Pacific J Cancer Prev 2009;10(1):133-8.
[10] Mayo Clinic. Definition. Breast cancer.URL: [28] Al-Zahrani A, Baomer A, Al-Hamdam N, Mohamed G. Completeness and validity of cancer registration in a
cancer/DS00328. major public referral hospital in Saudi Arabia. Ann
[11] National Breast Cancer Foundation. - Breast cancer Saudi Med 2003;23(1-2):6-9.
types. Accessed 2010. URL: http://www.nationalbreast [29] Milaat W. Knowledge of secondary-school female students on breast cancer and breast self-examination in
[12] National Cancer Institute. Breast cancer treatment. Jeddah, Saudi Arabia. East Mediterranean Health J
URL: 2000;6(2/3):338-44.
/treatment/breast/patient/allpages/print [30] Alam A. Knowledge of breast cancer and its risk and
[13] Centers for Disease Control and Prevention. Breast protective factors among women in Riyadh. Ann Saudi
cancer and you: what you need to know. URL: Med 2006;26(4):272-7. [31] Anderson B, Yip C, Smith R, Shyyan R, Sener S, Eniu
_2010.pdf A, et al. Guideline implementation for breast healthcare
[14] Anderson B, Braun S, Lim S, Smith R, Taplin S, in low-income and middle-income countries: overview
Thomas D. Early detection of breast cancer in countries of the Breast Health Global Initiative Global Summit.
with limited resources. Breast J 2003;9(2):51-59. Cancer 2008;113(8):2221-43.
[15] Ministry of Health, Saudi Cancer Registry Cancer [32] Yip C, Smith R, Anderson B, Miller A, Thomas D, Ang
incidence report. URL: E, et al. Guideline implementation for breast healthcare
/SCR2005.pdf in low- and middle-income countries: early detection
[16] El Saghir N, Khalil M, Eid T, El Kinge A, Charafeddine resource allocation. Cancer 2008;113(8):2244-56.
M, Geara F, et al. Trends in epidemiology and [33] Kreps G, Sivaram R. Strategic health communication
management of breast cancer in developing Arab across the continuum of breast cancer care in limited-
countries: a literature and registry analysis. Int J Surgery resource countries. Cancer 2008;113(8):2331-7.
2007;5(4): 225-33. doi:10.1002/cncr.23832.
[17] Ibrahim E, Zeeneldin A, Sadiq B, Ezzat A. The present [34] Patton MQ. Qualitative evaluation and research
and the future of breast cancer burden in the Kingdom methods, 2nd ed. Newbury Park, CA: Sage, 1990.
of Saudi Arabia. Med Oncol 2008;25(4):387-93. [35] Moustakas C. Phenomenological research methods.
[18] Vogel, V. Breast cancer prevention: a review of current Thousand Oaks, CA: Sage, 1994
evidence. CA Cancer J Clin 2000;50(3):156-70.
426 Sara A Suhaibani and Cecilia S Obeng

[36] Smith JA, Osborn M. Interpretative phenomenological

analysis. In: Smith JA, ed. Qualitative psychology: A
practical guide to research methods. Thousand Oaks,
CA: Sage, 2007:53-80.
[37] Van Manen M. Researching lived experience. Ontario,
Canada: Althouse Press, 1990.

Received: September 12, 2014. Revised: October 06,

2014. Accepted: October 15, 2014
Reproduced with permission of the copyright owner. Further reproduction prohibited without