Women’s understanding of breast cancer and prevention in a Greek border community

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Research

HJOG 2026, 25 (1), 10-22| doi: 10.33574/hjog.0611

Giannoula Kyrkou1, Maria Deligianni1, Nikoleta Tsinisizeli1,2, Grigorios Karampas3, Anna Deltsidou1, Athina Diamanti1, Anastasia Bothou1

1 Department of Midwifery, School of Health and Care Sciences, University of West Attica, Athens, Greece
2 General State Hospital of Nikaia “Agios Panteleimon”, Neonatal Intensive Care Unit, Athens, Greece
3 Second Department of Obstetrics and Gynaecology, Aretaieio Hospital, National and Kapodistrian University of Athens, Athens, Greece

Correspondence: Giannoula Kyrkou, Midwifery Department, University of West Attica, Athens, Greece, E-mail: ikirkou@uniwa.gr

Abstract

Background: Breast cancer is a major health problem, as it leads to high mortality and morbidity in women around the world. However, as with many other types of cancer, gynecological cancer is a disease that can be prevented and treated if diagnosed early.
Aim: This study investigates women’s knowledge and attitudes regarding the gynecological prevention of cancer at the border area of Greece, Orestiada, Evros.
Methodology: A survey was conducted on women living in the Municipality of Orestiada to achieve the study’s goal. Convenience sampling was applied as the sampling method of the survey. The questionnaire measured attitudes, perceptions, and determinants of women’s behavior in gynecological cancer screening. The statistical analysis was performed with S.P.S.S.
Results: 63.1% of women of all age groups have had mammography screening. It is noteworthy that in the age group over 40 years, 2% had not had a mammogram. 71.1% report that the fear of the result prevented them from performing a preventive check-up. 75.2% knew that the age group that starts pre-symptomatic screening is 31-40 years. 73.5% knew that breast cancer is largely treatable. Unfortunately, 8.7% of participants correctly answered the steps they can take to prevent breast cancer.
Conclusions: This study concludes that it is important to improve breast cancer prevention by organizing health education programs methodically through information that may concern modern forms. The female population of the municipality of Orestiada has the opportunity to improve knowledge through continuous information as well as strengthen the cultural promotion of screening.

Keywords: Breast cancer, prevention, screening, breast self-examination, clinical breast examination.

Introduction­

Breast cancer is the most common cancer affecting women worldwide, affecting 1 in 10 women. It is the second leading cause of cancer death in women [1], [2]. The World Health Organization (WHO) reports that in 2020, 2.3 million women were diagnosed with breast cancer and 685,000 patients died worldwide. Breast cancer occurs in women of all ages after puberty and rates increase with age [3]. In high-income countries, breast cancer mortality, for at least 5 years after diagnosis, is less than 10%. In contrast, in low-income countries, rates increase, such as 34% in India and 60% in South Africa. Studies have also shown that the risk of breast cancer in Western Europe is higher than in Eastern Europe, according to study data [4]. From 1990 to 2016, breast cancer incidence rates more than doubled in countries such as Argentina, Afghanistan, and Brazil. In countries such as Libya, Saudi Arabia, and Paraguay, mortality rates doubled [5]. Early detection and treatment are successful in high-income countries and should be implemented in resource-limited countries where some of the standard tools are available. Thus, significant global improvements in breast cancer can be achieved by implementing what we already know works [3]. The median age at which breast cancer deaths occur in high-income countries has decreased by 40% between 1980 and 2020. The goal of the WHO Global Breast Cancer Initiative (GBCI) is to achieve a global reduction in breast cancer mortality. The three axes that must be applied to the implementation of these goals are early detection, early diagnosis, and comprehensive management of breast cancer. By creating reliable referral centers from primary care facilities in hospitals in the area to specialized breast cancer prevention centers [3].

Aim

The purpose of this study is to investigate and evaluate the knowledge of women in the municipality of Orestiada regarding breast cancer and its prevention.

By investigating and evaluating the understanding of risk factors, symptoms, and signs of breast cancer as well as the importance of regular preventive screening, we have the possibility of maintaining, improving, or readjusting health strategies as they constitute major issues for healthcare providers.

Sub-objectives are to raise awareness among women on prevention issues as well as the importance of early diagnosis.

Material

For the purposes of this descriptive study, a sample of women from the Municipality of Orestiada, Evros, a border area of Greece, participated. The sampling process, both in terms of size and type, was influenced and limited by the measures observed due to the COVID-19 pandemic.

For the selection of participants, specific inclusion criteria were established. Women over 18 years old were included, provided they were residents of the surrounding area. Furthermore, participants needed to have an independent family and professional status, as well as a certain educational level, and be able to understand and write the Greek language. It is important to note that women with a personal or family history of breast cancer were not excluded from the study.

Correspondingly, strict exclusion criteria were applied. Women not residing in the surrounding area were excluded from the study, as were those unable to understand or communicate in the language of the study. Additionally, women with cognitive impairment that could affect their ability to understand and complete the study were excluded, along with those with other health conditions that could affect their participation. Finally, all women who declined to participate in the study were excluded.

Measurement Tool

The measurement tool used was a structured self-administered questionnaire after permission from the author, Tsikaris Aikaterini [6]. In the questionnaire, face validity was carried out by the author herself. For content validity, the researcher resorted to a pilot test on a population of 20 women. The reliability of the navigation scale was investigated with the internal consistency which yielded a Cronbach’s a coefficient equal to 0.72.

Method

The descriptive study method was followed, with a cross-sectional design. The distribution, completion, and collection of questionnaires took place during the period from October 2021 to December 2021. The purpose of the research was explained to the participants and their consent, anonymity, and voluntary participation were ensured. The study population consisted of a random sample of women of any age over 18 years old, regardless of educational, social, economic level, and employment status, but with the common characteristic that they all reside in the Orestiada area.

Statistical analysis

To present the quantitative variables we use the mean and standard deviation, while to present the categorical variables we use the absolute and relative frequencies. The Kolmogorov-Smirnov test and normality diagrams were used to check the normal distribution of the quantitative variables.

To investigate the existence of a relationship between a quantitative variable and a dichotomous variable, the t-test (student’s t-test) was used. To investigate the existence of a relationship between a quantitative variable that follows a normal distribution and an ordinal variable, Spearman’s correlation coefficient was used.

In the case where the dependent variable was quantitative and >2 independent variables were statistically significant at the 0.2 level (p<0.2), multiple linear regression was applied, in which case the multiple linear regression method with backward deletion of the variables was applied. Regarding the multiple linear regression, the b coefficients (beta), the corresponding 95% confidence intervals, and the p values are presented.

The two-sided statistical significance level was set equal to 0.05. Data analysis was performed with IBM SPSS 21.0 (Statistical Package for Social Sciences).

Results 

The study population included 149 women. The demographic characteristics indicated that the majority of the participating women were over 40 years of age 87 (58.3%), lived in an urban area 90 (60.4%), were married or cohabiting 95 (63.8%). More than half of them had children, 84 (56.4%), and were employed, 97 (65.1%). Regarding their financial situation, 68 (45.6%) described it as average, 59 (39.6%) as good, 17 (11.4%) as excellent, while a smaller percentage, 5 (3.4%), assessed it as poor (Figure 1).

Figure 1. Demographic characteristics of women

Of the participants, 94 (63.1%) had undergone a mammogram, with varied experiences reported (41 (43.6%) indifferent, 33 (35.1%) unpleasant, 20 (21.3%) pleasant). Notably, 7 (8%) of women over 40 had never had a mammogram. Most women 99 (66.4%) reported annual doctor visits, while 10 (6.7%) never visited. Nearly half 70 (47.9%) believed they practiced proper breast cancer prevention.

Regarding preventive examinations, among those who had at least one, mammography was most common 80 (92%), followed by breast examination 56 (64.4%) and ultrasound 46 (52.9%). Examinations were frequently performed by 74 49.7% of women, rarely by 57 (38.3%), very often by 8 (5.4%), and never by 10 (6.7%). The primary reasons for avoiding breast examinations included fear of results 43 (71.1%), negligence/procrastination 95 (63.8%), absence of symptoms 36 (24.3%), young age 30 (20.1%), shame 24 (16.1%), and lack of time 15 (10.1%) (Table 1).

44 (30.6%) stated that there is a family history of breast cancer, with the disease occurring more frequently in mothers and grandmothers (Figure 2).

Figure 2. Family history of breast cancer in women

96 (64.4%) of women stated that they self-examine their breasts and 73.9% said that a doctor examines their breasts frequently. 55 (36.9%) stated that they perform self-examination every month, 22 (14.8%) stated that a doctor examines their breasts every two years and 8 (5.4%) said that a doctor examines their breasts for more than two years (Figure 3).

Figure 3. Frequency of self-examination and clinical examination of women

Regarding women’s knowledge of breast cancer screening and mammography indications, the majority 112 (75.2%) correctly answered that clinical breast examination should begin between 31-40 years of age. An even larger percentage 126 (84.6%) knew that a baseline mammogram should be performed at 35 or 40 years, while 107 (71.8%) correctly answered about starting annual mammograms in the same age group. Understanding of breast cancer heredity was also high, with 99 (66.9%) knowing the correct conditions (history in mother, mother/sister, or grandmother without other family presence).

The study also showed high levels of knowledge regarding the curability 108 (73.5%) and preventability 103 (70.5%) of breast cancer. Furthermore, a very large percentage 135 (90.6%), knew that the combination of self-examination, mammography, and ultrasound increases diagnostic success rates. However, only a small percentage 13 (8.7%) of the sample had complete knowledge of all prevention factors (healthy diet, avoiding smoking, avoiding alcohol, frequent examinations by a specialized doctor, frequent self-examination, frequent exercise).

Finally, concerning preventive interventions for a 40-year-old woman with an average risk of breast cancer, most women correctly answered that breast self-examination should be done monthly 94 (63.1%) and mammography annually 106 (71.1%), while a smaller percentage 13 (8.7%) knew that a clinical examination by a doctor should be done every three years (Table 2).

Table 3 presents the bivariate correlations between demographic characteristics and breast cancer knowledge scores.

After bivariate analysis, a statistical relationship at the 0.20 level (p<0.20) emerged between 4 independent variables and breast cancer knowledge score. For this reason, multivariate linear regression was applied, the results of which are presented in Table 4.

According to the results of the multivariate linear regression, the following emerge:

Women with children had more knowledge about breast cancer.

Working women had more knowledge about breast cancer.

Discussion

The results of the analysis demonstrate that a fairly large percentage of women have a positive attitude and sufficient knowledge about breast cancer and its prevention. The information and mobilization of women in the Municipality of Orestiada confirmed the importance of prevention and early diagnosis of breast cancer. 63.1% of women of all age groups have undergone a mammogram, while only 2% of the age group of 40 years and older have not undergone a mammogram. In a corresponding study of mammogram screening from 17 European countries, the results showed that in Belgium, the Czech Republic, Estonia, France, Germany, Iceland, Italy, and Luxembourg the participation rate was below 70%. The highest rates were recorded in Finland at 80% and the lowest in Slovakia with rates approaching 30% [7].

It is widely known that the combination of preventive examinations increases life expectancy, as early diagnosis has better results in treating pathological findings. However, only 47.9% of participants believe that they are doing the right prevention, as 49.7% often do preventive examinations. Various reasons contribute to preventing breast examination. The most common reason that acts as an inhibitor in performing breast examinations is fear of the result with a high percentage of 71.1%, followed by 63.8% due to negligence and procrastination. In a survey conducted in a specialized private breast radio diagnostic laboratory in central Greece, a sample of 150 women answered a corresponding question that fear of the result was 38%, while negligence and procrastination were 44% [6].

The attitude and perception of Greek women in Orestiada are identical to the general attitude of women regarding the prevention of screening. In a systematic review carried out on 21 articles selected from 2134, the opinion of 1084 women was recorded. The reasons that prevented them from undergoing screening, apart from lack of knowledge and financial and geographical obstacles, were the fear and, at the same time, the belief of women that they would be in pain during the examination (mammography). The above reasons were ranked in the 3rd place of the reasons that prevented them [8]. Also, in a study by Rahman et al. [9], breast cancer is the main cause of mortality among women in the United Arab Emirates (UAE). Many young women in the UAE have poor knowledge about breast cancer screening, including risk factors and warning signs/symptoms. Although most participants were aware of breast cancer, knowledge about risk factors and warning signs/symptoms was relatively poor. This highlights the importance of raising awareness about breast cancer and breast self-examination among young women in the UAE.

Regarding the frequency of mammography observed that a large number of women are examined once a year or/and every two years. These results, which concern all levels of education of the sample, are supported by relevant research, which showed that the high level of knowledge of women regarding preventive examinations directly depends on their level of education [10].

Regarding the reasons why women in the present study abstained from breast screening, the largest percentage of them stated fear of the results (71%), negligence/procrastination (63.8%), and the fact that they had not noticed symptoms (24.3%). The results show that the participants maintain a moderate attitude regarding the severity and mortality of the disease, although they know that it can be prevented (70.5%). The results of the study by Polat et al. showed that the participants noted a statistically significant difference between the groups that underwent screening compared to those that stayed away due to fear, available time, and sufficient information [11].

Regarding the sample’s views on the benefits of screening, the results showed that the majority agree that it contributes to reducing mortality and early detection of the disease. A similar study involving women with a family history of cancer showed that reduced benefits and barriers due to the role of emotions reduce the frequency of screening [12].

The investigation and evaluation of the identification of factors affecting the frequency of self-examination showed that women who believed that they were vulnerable to a possible breast cancer disease often performed breast self-examination compared to women who had a reduced sense of vulnerability. Specifically, 63.1% of women had had a mammogram. Among them, 43.6% stated that mammography is indifferent, 35.1% that it is unpleasant, and 21.3% that it is pleasant. It is noted that among the 87 women who were over 40 years old, 7, or 8%, had not had a mammogram. Most women stated that they visit a doctor once a year (66.4%), while 6.7% stated that they never visit. 47.9% of women considered that they are doing proper prevention for breast cancer.

In addition, women who positively evaluated mammography and self-examination for protecting themselves from breast cancer scored higher than women who stated that screening is not important for protecting their health. Specifically, among women who had had at least one screening, 92% had had a mammogram, 64.4% had had a breast exam, and 52.9% had had an ultrasound. 49.7% of women stated that they often have screenings, 38.3% that they rarely do, 5.4% that they do very often, and 6.7% never do.

Finally, women who rated screening negatively performed breast self-examination less frequently compared to women who rated mammography and self-examination positively. However, the majority of the study did not believe that they were completely vulnerable to the potential risk of breast cancer exposure.

Most participants have a skeptical attitude towards the possibility of breast cancer, as they often do not accept the seriousness of the disease. Furthermore, they seem to be fully aware of the benefits of participating in screening to significantly reduce the chances of developing the disease in the future. It should be noted that the need and value of prevention are articulated in this model, as most of them have mentioned effective and necessary prevention methods for early detection of cancer.

The literature also supports the additional benefits of validated decision aids for breast cancer screening [13]. Regarding the sociodemographic characteristics examined in this study, younger age and marital status were associated with significantly lower interest in screening.

Following the assessment, participants reported a range of mixed emotions, including interest, anxiety, and fear, demonstrating concerns about breast cancer – which may influence the importance given to the information provided and subsequent decision-making. The mood changes highlight the importance for health professionals to provide the context for measuring the appropriateness of genetic counseling services.

In particular, ESMO – European Society of Medical Oncology (2012) [14] highlights the need for early screening among women who are sexually active or over 18 years of age, with a Pap test and pelvic examination annually. In addition, for high-risk women, there are also non-invasive gynecological sampling methods and technologies (genomic, epigenetic, and proteomic approaches) that have been evaluated for the early detection of gynecological cancer [15].

Furthermore, in Wada et al Multicenter Cohort Study [16], it is reported that the diagnosis of cancer can have a significant impact on mental health and well-being. Depression and stress can hinder cancer treatment and recovery, as well as quality of life and survival. In addition, research by Park and Rosenstein [17] reported that younger cancer patients have consistently higher rates of psychological distress and psychiatric syndromes than adults with cancer. Mystakidou et al. [18] found that depression is associated with older age. However, this is the only study to show that depression severity is associated with age among people with cancer pain.

Most participants reported that they did not experience social or financial problems, while a percentage of them reported that financial difficulties excluded them from social activities. This finding was similar to the Liang et al. study [19], which confirmed that financial hardship affects more than half of gynecological cancer patients and is associated with material hardship.

The social consequences of cancer can also be revealed in the areas of social relationships. The disease can cause a disturbance in women’s sexual desire or disrupt their partner-partner relationship [20]. Decreased relationship satisfaction may be accompanied by lower quality of life, as well as higher levels of anxiety and depression in cancer patients [21]. Manne [22] suggests that resilient women may report a higher quality of life upon diagnosis of gynecological cancer because they are more likely to express positive emotions, positively reframe the experience, and cultivate a sense of peace and meaning in their lives.

Our small survey in this border area of Greece on women’s knowledge of breast cancer prevention can provide significant benefits both locally and at a wider level.

Our survey can contribute to raising awareness among women in the area about the importance of breast cancer prevention and the need for regular screening. The results can identify the gaps in women’s knowledge about risk factors, symptoms, and available preventive screenings. Based on the survey results, targeted information and education programs can be designed to meet the specific needs of the community. In addition, conducting the survey can be an opportunity for collaboration with local health bodies, social bodies and local authorities to develop joint actions to promote prevention.

Limitations of the study

This study was conducted under difficult circumstances due to the COVID-19 pandemic. The conditions of the pandemic imposed teleworking and travel restrictions. Specifically, a very small number of participants stated that they have a personal history and family history of breast cancer. This means that it was not possible to make correlations between the groups of women with a personal or family history of breast cancer and women with a free history. The same was true for the marital status of the women. The category of women who were widowed or divorced had a small number of observations compared to the category of women who were married. Possibly, a more balanced sample of observations per category in this question could provide more statistically significant correlations.

Conclusion

The present study concludes that it is important to make improvements in the field of breast cancer prevention, organizing health education programs methodically through information that may concern modern forms. A national strategic prevention program would enable women to understand the seriousness of the disease, would contribute to the proper preparation of younger women and to the mobilization of those who, due to age, are at greater risk of exposure to the disease.

The female population of the municipality of Orestiada has the potential to improve knowledge through continuous information as well as strengthening the cultural promotion of screening. Additional studies in the wider area, with a larger number of participants, would highlight the results of correlations between demographic data with greater clarity.

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

Data Availability Statement

All data generated or analysed during this study are included in this published article.

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