Radiol Oncol 2004; 38(1): 27-34.
Breast cancer and breast health awareness as an evolving health promotion concept
Andrej Plesničar1, Viljem Kovač2, Božo Kralj1
1University of Ljubljana, University College of Health Studies, Ljubljana, Slovenia 2Institute of Oncology, Ljubljana, Slovenia
Background. Breast cancer is the most frequent malignant disease in the majority of developed countries. In the last few years the introduction of mammography screening programmes has resulted in an improved survival of breast cancer patients. However, the incidence of the disease in these countries is still on the in-crease. Present focus on secondary breast cancer prevention activities, consisting of early detection and treatment, cannot ensure a decrease of breast cancer incidence. Improved breast health awareness could therefore represent a part of specific health promotion activities aimed at decreasing the incidence of breast cancer.
Conclusions. In developed countries breast cancer is a significant health care issue. Secondary breast can-cer prevention activities should therefore be complemented by specific health promotion activities in order to reduce its incidence in the future. Primary breast cancer prevention would include health promotion ac-tivities aimed at enhancement of the individual as well as collective breast health awareness. Properly en-lightened members of the influential population groups could attain appropriate changes in the fields of leg-islation, taxation, customs and commercial regulations that would enable women to control their own breast health.
Key words: breast neoplasms - prevention and control; health promotion
Received 15 January 2004 Accepted 2 February 2004
Correspondence to: Andrej Plesničar, MD, MSc, University of Ljubljana, University College of Health Studies, Poljanska cesta 26a, SI 1000 Ljubljana, Slovenia; Phone: +386 1 300 11 67; Fax: +386 1 300 11 19; E-mail: andrej.plesnicar@vsz.uni-lj.si
Introduction
Breast cancer is the most prevalent cancerous disease in women in the majority of devel-oped countries. The incidence of breast can-cer in most of these countries is still on the in-crease. However, the current increase of new-ly discovered cases is partly attributable to the introduction of efficient mammography screening tests. This also brought about an improvement in survival of the patients, measured with the length of survival after the discovery of breast cancer, and with an in-
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crease in the five-year survival rate.1,2 Also in Slovenia breast cancer is major cancerous dis-ease in women. According to the Cancer Registry of Slovenia the incidence of the dis-ease is still on the increase; in the year 2000 there were 932 newly discovered cases in a two million population.3
Present health care activities with mam-mography screening tests are primarily fo-cused on early breast cancer detection and treatment. These tests enable the discovery of the disease in the early stages of its clinical development, hence improving the chances for longer survival of breast cancer patients.4 The truth is that the disease is usually rela-tively advanced when it is detected as a per-ceivable change in a mammography image or as a clinically ascertained, locally advanced or metastatically expanded tumorous forma-tion.2,4 In Slovenia, as in most developed countries, the greatest emphasis is put on the already mentioned secondary breast cancer prevention activities.
The methods of primary prevention are rarely or hardly ever mentioned, especially via health promotion activities. These activi-ties could no doubt include initiatives for en-actment of legislation that would create cir-cumstances where choices for avoiding the risk factors leading to breast cancer were of-fered and made easily available to women. At least at the beginning we would try to get some of the influential population groups in the Republic of Slovenia better acquainted with breast cancer characteristics and with the role that the members of those groups could play in stopping the increase of the dis-ease and later, hopefully, in its decrease.
should be attentive to. Above all, the impor-tance of early detection and treatment of al-ready existent breast cancer has been empha-sised.2,4 In doing this, professionals en-counter women’s fear of breast cancer, vari-ous myths and anxieties. They learn about different levels of their knowledge and un-derstanding of cancerous alterations of the breast, as well as about their different opin-ions of benefits of being included in mam-mography screening test programmes.2,4 In most women of all ages, breast cancer brings about fear, confusion and concern. When they visit a specialist those feelings are inten-sified by possible breast pain, asymmetry of the breasts, discharge, lumps or thickenings in the breasts, as well as positive family his-tory.1,5 Indirectly, breast health concern in women is quite well expressed, however, a deeper knowledge of healthy breast charac-teristics or breast health awareness can most often not be found. As a rule it is limited on-ly to the absence of tumorous changes in the breasts.
In some countries certain measures have been adopted more than ten years ago in order to reduce the number of deaths caused by breast cancer. With methods of early detec-tion the breast cancer mortality rate was sup-posed to drop to less than 25% by the year 2000. Therefore, numerous activities were aimed at increasing the number of women in-cluded in the mammography screening test programmes. In certain age groups with high risk for developing breast cancer the inclu-sion rate was expected to increase at least to 70%. In some places and regions of certain countries this inclusion rate was actually achieved, above all by dissemination of spe-cific information about mammography screening tests.2, 5-8
In this context information about the ben-efits of being included in mammography screening tests was an integral part of specif-ic health promotion activities. Traditional information methods aimed at an increase of
Present focus on secondary breast cancer prevention activities
For the last few years experts from different fields have been quite active in spreading information on breast  changes  that women
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29
the inclusion rates comprised of information brochures and posters, newspaper, radio and sometimes television advertising, meetings with experts in local communities and peri-odical visits to the local centres for early breast cancer detection with the introduction of a mammography apparatus. Also, specific information and education programmes on this subject have been introduced for primary health care professionals. Women with firsthand breast cancer experience very often par-ticipated in those activities by writing news-paper articles and giving interviews in the media, and sometimes even their partners joined in with their support.1,5,8 However, these activities are chiefly aimed at the in-crease of inclusion rates to mammography screening test programmes and as such their main aspect is emphasis on the secondary prevention that is focused on detecting and treating the already existing disease. Mostly they anticipate a change of attitude of a cer-tain part of the health care system and also changes of women’s attitude.1,2,5-8 Despite an increase of the inclusion rate in mammogra-phy screening test programmes, the role of women in this process remains limited and passive.
New initiatives and activities would not be limited only to women in certain age groups, but would include women of all ages as well as everybody else. They would be aimed at overreaching the existing cultural and social differences among women.5 Such initiatives and activities would encompass a wider, more holistic and, maybe some time in the fu-ture, more successful approach to the breast cancer problem. Apart from disseminating and adapting information on breast cancer in healthy women, we would like to put special emphasis on breast health awareness.2,5,9-12 Lower average clinical stages in patients with subsequently citologically confirmed breast cancer and longer survival can be achieved with high inclusion rates into the mammog-raphy   programmes.1,2   However,   the   inci-
dence of breast cancer itself can not be re-duced solely in this way.
Health promotion, individual and collective
breast health awareness and breast cancer
incidence reduction
Long-term changes in the community in re-sponse to the decreased incidence of breast cancer (as well as some other cancers) could possibly be achieved by applying intersec-tional and multidisciplinary approaches.4,5,13 Primary prevention activities, first of all health promotion activities with quite specif-ic aims (e.g. the already mentioned breast cancer incidence reduction) would have to be implemented on the individual as well as on the community or collective level with the participation of the interested public and the adequately educated experts. The sole in-volvement of doctors and other health care professionals would most probably not suf-fice.4,5 On the individual level, breast health awareness means accepting health responsi-bilities to greater extent by being able to rec-ognize normal appearance and structure of breasts during different cycle periods and with regard to age, and by being able to rec-ognize undue changes and inform the physi-cian immediately.14 It could therefore proba-bly also be enhanced by learning how to choose healthy nutrition, a healthy lifestyle and by realisation of biological potentials, as well as by getting to know the structure and composition of healthy breasts with regular self-examination. On the community level (local, regional and state institutions), breast health awareness could also be explained as arising from the underlying collective breast health awareness; initiatives would have to be instigated that would stimulate groups of influential individuals to actively participate in the implementation of adequate changes of legislation, taxation, customs and commercial regulations, enabling every woman to have at
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least partial control over her own health.13 Breast health awareness would therefore not be limited only to individual women but would become a collective and community prospect, thus gaining a wider social dimension.
Planning of the integral initiatives in the field of health promotion, including the achievement of greater collective breast health awareness, can be taken up only on the basis of reliable data. Although data on women’s views and perceptions of breast health are not available in Slovenia, regular yearly reports of the Cancer Registry of Slovenia render possible a notion the influence of life-style changes have on the incidence of breast cancer and other cancers in the second half of the 20th century in Slovenia.3-5 The overall strategy for achieving the goal (breast cancer incidence reduction) could therefore include smaller, and temporarily, only hypothetical projects with a common basic outline (Figure 1). In the case of breast cancer, a decreased exposure to
1. Project design
2. Project development and goal specification
3. Acquiring funds and active project participants
ˇ
4. Identification of individual and group goals
(e.g. within the National Assembly)
ˇ
5. Evaluation
ˇ
6. Data presentation (symposium, workshop,...)
ˇ
7. Evaluation
8. Project evaluation
ˇ
9. Presentation of project results
Figure 1. Outline of a hypothetical health promotion project (possible reduction of exposure to breast cancer risk factors).
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some of the risk factors connected to the development of this cancerous disease, would be attained with time (Table 1).1,2 Some of these factors could be influenced only indi-rectly with the hope that after a longer period of time breast cancer incidence would finally decrease. A more direct influence could be exerted by banning cancerous agents in food, at the work place and in the living environment. The specific importance of adequate health education could also be defined.
In the beginning, planning of integral initiatives aimed at achieving greater collective breast health awareness would be focused on different influential and other population groups: perhaps even the members of the National Assembly of the Republic of Slovenia. Specific health promotion activities would include projects that would introduce breast cancer risk factors, breast cancer epi-demiology in Slovenia and basic information on carcinogenesis at least to some members of these groups. The beginning of any such hypothetical projects for improvement of col-lective breast health awareness with the help of influential population groups would defi-nitely be marked by endeavours to identify the interested individuals in those groups. Later they could be joined by the other mem-bers of these groups. However, in the begin-ning, they could represent important parts of alliances or coalitions for achieving the strate-gic goals. Different professionals from differ-ent educational areas, members of government, as well as non-government organisa-tions and volunteers could work together.5
Execution of a hypothetical project
for improvement of collective breast health
awareness within an influential group
The elected members of the legislative bodies are definitely one of the most powerful groups in society. They should serve as an ex-ample for illustrating the form and anticipat-
Plesničar A et al. / Breast cancer and breast health awareness
31
ed development of health promotion projects, with a long-term goal of reducing the inci-dence of breast cancer. In the Republic of Slovenia there are 90 members of the National Assembly; many of them are also members of various committees, councils and other bodies.15 The powers of the National Assembly enable their members to pass laws and executive regulations that could help women to make healthy choices towards an active breast cancer prevention role. Assistance for the realisation of such projects should be sought from women members of the Assembly, deputies that are doctors and other medical professionals, and probably amongst those members of the Assembly with women relatives who have developed breast cancer. These people alone could rep-resent a particularly influential group within the National Assembly and the project could be carried through. In favourable conditions it could be later repeated with the participa-tion of all the members of the National Assembly (or of any other influential group). Interested groups and individuals could prob-ably also be found among volunteers and oth-
er participants of such a pilot project, and participation of women who recovered from breast cancer would also be invaluable.
In the initial part of health promotion strategic activities, focused on decreasing the exposure to breast cancer risk factors, a smaller multiphase project would be used to gather information about the views of specif-ic groups (or all members) of the National Assembly of the Republic of Slovenia (Figure 1). According to the results, we would later try to introduce significant characteristics of this type of cancer and to discuss with Assembly members to what extent they would be willing to participate in specific health promotion activities with the final goal of decreasing the breast cancer incidence.
Already in the conceptional phase of the project pertinent references to the subject of »breast cancer and health promotion« would be found in professional publications. Alliance and/or coalition of the interested participants would be identified (Table 2), and at the end of this phase, the leadership of the project would be determined. During the designing phase of the project, attainable and
Table 1. Breast cancer risk factors
Early menarche, late menopause
Nulliparity, age at first birth, number of born children
Excessive body weight
Treatment with estrogens
Excessive alcohol consumption and high energy nutrients intake
Benign epithelial proliferative lesions
Family history of breast cancer
Genetic mutations (BRCA1, BRCA2, TP53)
Table 2. The expected participants of a hypothetical health promotion project for the reduction of exposure to breast cancer risk factors
Interested members of influential groups (e.g. members of the National Assembly, ...)
Ministries
Epidemiology, carcinogenesis and breast cancer experts
Clinical specialists (doctors, nurses, ...)
Non-government organisations (Cancer Society of Slovenia, »Europa Donna« Society, ...)
Volunteers
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realistic goals would be set and suitable sponsors found. The contents, the structure and the methodology of the project would be dis-cussed with the project participants, and, if possible, the interested individuals and specifically interested groups among the National Assembly members would be iden-tified. Qualitative and quantitative data on how well the National Assembly members are acquainted with this particular health promotion project and how willing they are to participate in it would be gathered via spe-cially prepared questionnaires. The relevant information about this topic would be pre-sented in a form of a symposium, a workshop (brainstorming) or in another manner of con-veying information, and it would be followed by handing out evaluation questionnaires. Processing of the gathered information and the following discussion would reveal whether the continuation of the project is vi-able. This discussion would also cover the participants’ perception of breast health and an exchange of possible experiences with breast cancer within their families. Experts would help clarify any dilemmas that might occur, and concrete health promotion activi-ties with the goal of reducing the incidence of breast cancer in the future would also be dis-cussed. Reports on the evaluation of the proj-ect results would be presented to the partici-pants, sponsors and to the National Assembly members, and in various other forms possibly also to the professional and lay public.
One can only guess at the expected results of the project. Nevertheless, it could be put to good use as a means of spreading information about breast cancer among the members of the group that crucially influences the life of the population. Data on the attitude of this group towards an important health issue and at least some reflections about the chosen method of presenting information on breast cancer would also be gathered.
Discussion
In developed countries worldwide and also in Slovenia, breast cancer represents an impor-tant public health problem together with oth-er cancerous diseases.2,4,5,16-18 In the last decades, introduction of and constant per-fecting of different treatment methods with surgical procedures, radiotherapy, chemo-therapy and supportive treatment have markedly improved survival rate and quality of life of breast cancer patients in these coun-tries.2,19,20 However, in the majority of devel-oped countries, including Slovenia, the inci-dence of breast cancer is still on the in-crease.2,3,13,18,21,22 Improved breast health awareness for the individual and for the col-lective level could therefore represent a part of specific health promotion activities with the goal of decreasing the incidence of this disease.
Health promotion activities aimed at greater individual and collective breast health awareness can only be a supplement and by no means a substitute for the secondary breast cancer prevention activities. Early de-tection and timely treatment have con-tributed to longer survival of breast cancer patients.2,23-32 The use of these secondary pre-vention methods instigated deliberations about breast health and breast health aware-ness.5,10,13 Certain activities, that could be conditionally viewed as health promotion ac-tivities, are aimed at increasing the inclusion of women from specifically defined groups (certain age groups with some specific excep-tions at younger age) into mammography screening test programmes.2,5,23-32 One should bear in mind that the carcinogenesis of breast cancer is a phasic and continuous process at all ages, that it takes several years for breast cancer to develop, and that it takes quite some time for a tumorous formation in-side the breast to become clinically observ-able.2,33,34 New attitude towards breast health that would focus not only on the absence of
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tumorous formations in the breasts could in time probably result in the decreased exposure to breast cancer risk factors that directly or indirectly intensify the processes of car-cinogenesis in the breast tissue. It would be an attempt at introducing subtle and hardly measurable changes in women’s and the general population’s way of daily living that could in longer time frame bring about the de-crease of breast cancer incidence.
Individual and collective breast health awareness levels are co-dependent up to a point, and improvement of one could proba-bly trigger a positive change in the other. Goal oriented activities of influential groups of population could probably represent also an incentive for the improvement of breast health awareness on the collective level. The most influential of all groups in every demo-cratic country is undoubtedly the highest legislative body. In the Republic of Slovenia this is the National Assembly with its 90 mem-bers. On different levels health promotion ac-tivities usually include also politics, therefore the idea of a project that would inform the members of the influential groups (the most influential group being the National Assembly) about the meaning and the burden of breast cancer in Slovenia and also about breast health awareness, should not come as
a surprise.13,35
Since in Slovenia breast cancer is an im-portant public health issue, the inclusion of influential population groups into health promotion activities would be reasonable and ac-ceptable. Just like the whole community and its every individual, the members of these groups should be adequately educated and informed about this problem. Specific health promotion activities in connection with breast cancer within the framework of well considered public health policy would thus come near to the sphere of activities, recom-mended in the Ottawa Charter.4,13,35 The re-duction of breast cancer incidence as a possi-ble outcome of these activities would signifi-
cantly influence the health of a large part of women in the community and consequently the health of the entire community.
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