Recognition and comprehension of breast awareness among hospital staff: a questionnaire survey using the explanatory leaflet in Japan

Abstract

Background

This study aimed to assess the recognition and understanding of breast awareness (BA) among hospital staff, a group considered influential in disseminating information about health. Compared to the traditional approach of breast self-examination (BSE), BA has gained prominence as a concept focused on early detection. The study also explored the effectiveness of an informational leaflet in conveying BA concepts.

Methods

We conducted an online, voluntary, and anonymous questionnaire survey at St. Luke’s International Hospital in Japan, where approximately 1,000 breast cancer surgeries are performed annually. The survey comprised three sections: pre-leaflet questions, the informational leaflet, and post-leaflet questions.

Results

From a pool of 500 completed questionnaires, 499 were deemed suitable for the analysis. Notably, 78% of respondents were unfamiliar with “BA” before the survey. However, 89.1% expressed interest in adopting daily practices for early breast cancer detection. Following the leaflet exposure, 98.4% of respondents claimed to have understood BA, either completely or partially. The leaflet aided 93.2% of these individuals in differentiating between BA and the traditional BSE method. These outcomes remained consistent across various demographic segments such as occupation, age, and experience with breast cancer care.

Conclusions

The study underscores a concerning lack of awareness regarding BA among hospital staff within the surveyed institution. This highlights the need to engage medical professionals in promoting BA within the community. The informational leaflet proved effective in enhancing comprehension of BA across diverse groups, indicating its potential as a widely applicable educational tool. The leaflet facilitated the comprehension of BA among respondents across all demographic groups, indicating its potential for widespread utility.

Background

Breast cancer is the most prevalent cancer type among women globally [1]. This scenario extends to Japan, where statistics reveal the gravity of the issue, with 103,057 women diagnosed with breast cancer in 2020 and 15,912 succumbing to the disease in 2022 [2, 3].

In Japan, breast cancer screening is conducted through both population-based and opportunistic screening programs. Population-based mammography screening, proven to reduce breast cancer mortality, was initiated in 2000 for women aged 50 years and above, with the age threshold lowered to 40 years and above in 2004. Opportunistic screening, however, mainly uses mammography and breast ultrasound, and is offered by companies or at personal expense. Formerly, breast self-examination (BSE) was a recommended method for early breast cancer detection. However, insights from two randomized trials [4, 5] dismantled the notion that BSE reduces breast cancer mortality, revealing an increase in ancillary imaging and biopsy procedures. Consequently, influential bodies such as Cochrane [6] and the US Preventive Services Task Force [7] withdrew support for BSE. In Japan, BSE has been removed from population-based screening programs and is rarely used in opportunistic screening.

Instead, the concept of breast awareness (BA) has garnered recognition as a pivotal approach to early breast cancer detection. BA entails women becoming intimately familiar with their breast characteristics and the evolutionary changes they undergo [8, 9]. Originating in the UK during the 1990s [10], BA has now earned an endorsement in guidelines across the UK [11], the USA [12], and Australia [13]. The significance of BA has gained traction in Japan, championed by government agencies and breast cancer associations [14]. Research within Japan has framed BA around four pillars: (1) Familiarize yourself with your regular breast condition, (2) Stay attentive to any changes in your breasts, (3) Seek medical consultation upon noticing any changes, and (4) Undergo breast cancer screening every 2 years starting at the age of 40 years. As a result, the Guidelines on Health Education for Cancer Prevention and Implementation of Cancer Screening indicated by the Ministry of Health, Labor, and Welfare changed their description from endorsing BSE to embracing BA as a cornerstone for early breast cancer detection. To further facilitate the understanding of BA, a leaflet was developed within Japanese research on appropriate breast cancer screening information (Fig. 1 [translated from Japanese to English for submission]).

Fig. 1

A leaflet developed by the Research on Providing Appropriate Information on Breast Cancer Screening. a. Front side; b. Back side (translated from Japanese to English for submission)

However, understanding and dissemination of BA remain limited in Japan. Previous surveys involving 1,000 Japanese women demonstrated a mere 5% recognition of BA [15]. Even certified mammography-reading doctors exhibited a mere 12% comprehension of the true meaning of BA in another survey [9]. Amplifying BA among women necessitates a vital role from medical staff who interact with them directly. Hence, medical staff should grasp the precise essence of BA and communicate it effectively. While existing studies have yet to delve into the recognition of BA among hospital staff, concerns loom over its low awareness. Given the pertinence of BA, comprehending the extent of recognition among medical staff proves pivotal. Moreover, an assessment of the efficacy of the leaflet in fostering an understanding of BA and fundamental breast cancer screening knowledge becomes essential.

Hence, this study aimed to assess the current level of BA recognition among hospital staff and evaluate their comprehension of the accompanying informational leaflet.

Methods

Participants

The questionnaire survey was conducted at St. Luke’s International Hospital in Tokyo from March to May 2022. All hospital staff were notified of the survey through internal emails. As of April 1, 2022, the hospital employed 2,713 individuals, including full-time and part-time staff. To increase the number of respondents, we sent three announcement e-mails over the 2 months.

Questionnaire and leaflet

The questionnaire, originally developed for this study using an online survey platform (Google Form) based on a previous study [15], received approval from the Ethics Committee of St. Luke’s International Hospital on January 28, 2022. Divided into three sections, the questionnaire captured information before reading the leaflet (Table 1), included the leaflet itself (Fig. 1), and collected responses after reading the leaflet (Table 2). The first section collected participants’ basic information and assessed their familiarity with BA and breast cancer screening. In the second section, a PDF version of the leaflet was provided to introduce the concept of BA. Following the leaflet, the third section of the questionnaire included questions assessing the respondents’ level of comprehension regarding BA.

Table 1 Questions in the online questionnaire before reading the leaflet

Table 2 Questions in online questionnaire after reading the leaflet

At the outset of the questionnaire, consent for participation was obtained owing to the anonymous nature of the survey. Respondents who did not provide consent were excluded from the analysis. The leaflet utilized in the survey had been developed by the Research on Providing Appropriate Information on Breast Cancer Screening, supported by the Ministry of Health, Labour and Welfare. As mentioned in the background, to further promote BA in Japan, experts such as breast surgeons, radiologists, and screening physicians engaged in extensive discussions to create the leaflet.

Statistical analysis

Responses to the survey were aggregated, processed, and analyzed using online survey statistical tools. Free-text responses were organized into themes and categories using Microsoft Excel (Excel for Mac, V.16.71). For the analysis, recognition of BA was defined as “recognized BA” if respondents indicated they “Have heard the word” or “Know the meaning of the word,” while understanding of the information in the leaflet was defined as “understood” if respondents indicated they “Understood well” or “Understood somewhat.” Chi-square test was conducted for each factor, including “engagement in breast cancer care,” “occupation,” and “Have a family member or a close acquaintance with breast cancer,” to compare respondents who recognized BA to those who did not. The Cochran–Armitage test was used to evaluate a trend in recognition of BA according to age. Moreover, odds ratios with 95% confidence intervals were estimated to assess the background factors related to the recognition of BA, as well as understand it after reading a leaflet, using a logistic regression model. All statistical tests were two-sided, and p values < 0.05 were considered statistically significant. All analyses were conducted using RStudio (2023.12.0 + 369).

Results

A total of 500 respondents completed the online questionnaire, resulting in a response rate of approximately 18.4% (21.3% in women, 8.7% in men) based on the total number of employees at the institution on April 1, 2022. Of the 500 respondents, 499 (99.8%) provided consent and were included in the survey analysis. Table 3 shows the result of questionnaire before reading the leaflet, and the detailed results are shown in Supplementary Tables 1–4. Regarding sex distribution, 88.6% (442 respondents) were women, while 11.2% (56 respondents) were men. Most respondents (30.1%) fell within the age range of 30–39 years old. In terms of occupation, 40.3% (201 respondents) were nurses, followed by 25.5% (127 respondents) clerical staff, and 12.0% (60 respondents) doctors. The majority of respondents (71.1%, 355 respondents) were not directly involved in breast cancer care; meanwhile, approximately half of the doctors (25 out of 60, 41.7%) were engaged in breast cancer care (Supplementary Table 1). Furthermore, 60.9% of respondents shared that none of their family members or close friends had a history of breast cancer. Conversely, 89.1% expressed their desire to “learn and implement” or were “already practicing” daily actions beyond breast cancer screening aimed at the early detection of breast cancer. Among women, 61.9% reported engaging in “self-examination.”

Table 3 Results of the questionnaire before reading the leaflet

Regarding participants’ knowledge of basic breast cancer screening, queries were posed about dense breast, screening methods, and the recommended age to commence breast cancer screening. Concerning dense breast, 120 respondents (24.0%) were familiar with its implications, while 136 (27.3%) recognized the term without comprehending its meaning. Concerning evidence-based screening, 22.8% (114 respondents) exclusively selected “mammography.” For the optimal age to initiate breast cancer screening, 34.5% (172 respondents) favored starting at the age of 40 years, whereas 24.8% (124 respondents) opted for the age of 20, and 36.3% (181 respondents) chose the age of 30.

In terms of recognizing BA, 77.8% of participants were unfamiliar with the term “BA” before the survey, and a mere 7.0% accurately comprehended its significance (Table 3). Particularly noteworthy was the limited prior awareness of BA among participants who were not directly involved in breast cancer care (3.4%), while those engaged in breast cancer care were more likely to be aware of BA (Fig. 2a, p = 6.2 × 10^–11). However, even among those engaged in breast cancer care, only a minority precisely understood the meaning of BA (17.3%), and more than half were unfamiliar with the term (57.1%) (Supplementary Table 1). Among occupation groups, 85.0% (108 out of 127) of clerical workers responded that they had “never known” or “never heard of” BA. In contrast, 75.0 to 78.6% of hospital staff (nurses, technicians, and other co-medicals) and 61.7% of doctors provided similar responses (Fig. 2b). Notably, focusing on non-clerical staff (doctors, nurses, technicians, and other co-medicals) who are also engaged in BC, 53.4% (63 out of 118) had never heard of or known BA (data not shown) Based on whether participants had a family member or a close acquaintance with breast cancer, BA was well-recognized among those who had a family member or a close acquaintance with breast cancer (Fig. 2c, p = 2.7 × 10^− 6).The likelihood of familiarity with BA increased with age (Fig. 2d, p = 1.2 × 10^− 4): 14.1% for respondents in their 20s, 17.4% for those in their 30s, 27.4% for those in their 40s, 26.3% for those in their 50s, and 46.1% for those in their 60s. In multivariable analysis, age ≥ 40 years, engagement in breast cancer care, and having family members or friends with breast cancer were significantly associated with recognition of BA. Occupation as clerical staff was not found to be significant, unlike the result of univariable analysis (Table 4).

Fig. 2

Recognition of BA by subgroups. a. Engagement in breast cancer (BC) care; b. occupation; (c) have a family member or close acquaintance with BC; (d) age. Fisher exact tests are used in (a)–(c), and the Cochran–Armitage test is used in (d) as described in the methods. Since no answers are obtained from 11 of 499 (2.2%) in (a), 5 of 499 (1.0%) in (b), 3 of 499 (0.6%) in (c), and 2 of 499 (0.4%) in (d), these are excluded as missing data

Table 4 Univariate and multivariate analyses of recognition of BA and understanding BA after reading the leaflet

Subsequently, in the post-leaflet questionnaire, 98.4% of respondents reported a good or partial understanding of BA after reading the leaflet. Notably, over 90% of those respondents acknowledged that the leaflet facilitated their differentiation between BA and BSE (Table 5). However, among them, 40.3% indicated that they only “somewhat understood” the difference between the two. Additionally, 69.5% of participants expressed confidence that they, their family members, or partners could integrate and maintain BA in their lives in the future. Furthermore, 72.7% indicated their willingness to educate their family and friends about BA. These outcomes exhibited consistency across various demographics, including age, occupation, experience in breast cancer care, and the presence of family members or close friends with breast cancer. Additionally, the multivariate analysis did not identify any independent variables among these factors (Table 4, Supplementary Tables 5–8).

Table 5 Results of the questionnaire after reading the leaflet

Discussion

This study represents the first questionnaire survey to assess the recognition of BA and efficacy of an explanatory leaflet about BA among hospital staff in Japan.

As mentioned in the introduction, a prior study indicated low BA recognition among 1,000 Japanese women [15], and our survey similarly discovered this awareness to be limited among hospital staff. Uematsu et al. in 2018 [9] reported that only 11 to 13% of women undergoing population-based screening in Fukui Prefecture, Japan, were familiar with the term “BA” or its meaning. In our study involving hospital staff, the recognition of BA stood at 22%. Considering the earlier study’s focus on a general population of women 4 years prior, this figure appears disconcertingly low. Particularly noteworthy is that our institution, performing approximately 900 breast cancer surgeries annually, serves as a high-volume breast cancer center. One could speculate that this setting might stimulate greater interest in breast cancer and its prevention; however, the results show that BA awareness remains quite limited among our staff. This suggests that BA recognition among hospital staff at other institutions in Japan could be even lower.

Occupation-wise, a larger proportion of clerical workers (85.0%) were unfamiliar with BA compared to medical professionals (61.7–78.6%). This divergence might be influenced by variables such as age, engagement in breast cancer care, and the presence of family members or friends who have experienced breast cancer, as indicated by the results of multivariate analysis, as well as differing levels of medical expertise. On the other hand, even among non-clerical staff engaged in breast cancer care, more than half of the respondents did not know about BA. At the same time, this result suggests that raising recognition of BA among hospital staff is important irrespective of their occupation. Historically, the Pink Ribbon movement in Japan has significantly encouraged breast cancer screenings, largely due to support from a diverse range of individuals, not just doctors [16]. The same could likely apply to BA. If all hospital staff who interact with patients, not just doctors, are knowledgeable about BA and can provide accurate information, it could greatly enhance the recognition and understanding of BA.

Regarding age groups, recognition of BA increased with age, implying that individuals at a higher risk of breast cancer displayed more interest and improved health literacy. This correlation could be attributed to targeted health promotion efforts, where women aged 40 years and older were encouraged to undergo mammography, supported by local governments. Consequently, they were more likely to encounter news about women of similar age being diagnosed with breast cancer. While these factors may influence BA recognition, even among those aged 40 years and above, BA awareness remained insufficient. Conversely, recognition of BA was lower among those in their 20s and 30s. Given that breast cancer occurrence in this age group is relatively rare, with the number of cases per 100,000 women in the 20s and 30s being 1.7–9.3 and 33.5–78.2, respectively [2], routine screening mammography for this group is not advisable owing to the potential harm of radiation exposure or false-negative results from dense breast tissue. Therefore, an alternative approach is needed to promote early breast cancer detection among younger women. BA emerges as a suitable solution and is recommended for women younger than 40 years old according to the NCCN guidelines [17]. Notably, BA is essential not only for early breast cancer detection in women in their 20s and 30s but also for fostering a habit of breast self-awareness for the future. The possibility of disseminating BA more effectively to the same generation by medical practitioners, for example, through social media platforms, is also being considered.

The efficacy of the leaflet was extended to all participants, including clerical workers with less specialized medical knowledge. This positive outcome indicates the potential utility of the leaflet for the general population. Although the recognition of BA prior to reading the leaflet differed among age groups, the positive result was consistent across all age categories. However, despite participants’ overall understanding of the difference between BA and self-examination, nearly half selected the option “understood the difference somewhat.” The research group responsible for providing appropriate information on breast cancer screening defined BA as being familiar with one’s breasts and recognizing changes from the norm, as opposed to BSE, which is a technical process for detecting breast cancer. Although these distinctions were outlined in the leaflet and understood to some degree by the participants, there is room for improvement in the clarity of these concepts. These findings may influence the research group to create a leaflet that offers a clearer explanation of the differences between BA and BSE in future updates. Additionally, most participants expressed willingness to share BA with their immediate circles. These reactions imply that the leaflet can empower hospital staff to easily convey the importance of BA to others, even without specialized breast cancer expertise.

This questionnaire survey boasts several strengths. Notably, it stands as the first on a significant scale, particularly involving hospital staff. Additionally, the use of evidence-based leaflets developed through comprehensive Japanese group studies adds validity to the findings.

However, certain limitations should be acknowledged. Most importantly, this study was a questionnaire survey conducted at a single institution with a limited sample size of about 500. We initially anticipated that 30% of all employees would participate and sent notifications three times over two months. However, the response rate stagnated, possibly due to the inclusion of part-time employees, who may have had a lower response rate, and the timing of the survey, which coincided with Japan’s hiring and resignation season, potentially reducing the effectiveness of reminders. Another limitation is that the questionnaire was self-reported and did not include specific comprehension measurements. While assessing how accurately respondents understood BA through the leaflet is important, we believe it is equally crucial that respondents feel confident and motivated to share BA with others. Many respondents expressed a desire to do so, suggesting that our goal of empowering hospital staff to disseminate BA could be achieved. Additionally, since no similar studies have been conducted in the past, the data obtained on the recognition of BA among healthcare workers is considered interesting and significant. Furthermore, background bias may exist among respondents. A significant proportion of participants were inherently interested in early breast cancer detection for personal reasons. Despite this potential selection bias, the results further highlight the low BA awareness among hospital staff. Additionally, the proportion of female respondents exceeded that of male. This likely reflects the sex distribution of our hospital staff, which is approximately 75% female. However, there may also have been selection bias due to differing response rates between women and men. The incidence of breast cancer was lower among men, which may have contributed to the difference between the response rate of men and that of women. Simultaneously, this allowed for the collection of data on male awareness and interest in BA, which, despite the small number of male respondents, remains valuable for devising strategies to promote BA. Finally, the survey did not collect data on educational levels; however, they are anticipated to be high, given that over 70% held national licenses for specialized roles such as doctors, nurses, and technologists. Future studies could investigate the usefulness of the leaflet distribution among women with varying educational backgrounds.

Conclusions

Our questionnaire survey revealed the low recognition of BA among hospital staff at our institution, even among those engaged in breast cancer care. To propagate BA in Japan, it is imperative to provide education for hospital staff who serve as key intermediaries for the general population. The leaflet successfully enhanced the understanding of BA among hospital staff across various occupations. This outcome suggests the potential utility of the leaflet on a broader scale.