So far, mammographic screening is the only mode of detection that has been shown to reduce breast cancer mortality (Montazeri et al). Thus unless women are educated about mammography and mammographic screening, the goal of reducing breast cancer fatalities will remain out of reach. The aim of this study is to assess mammographic screening awareness of traders in Enugu metropolis, Enugu state using Ogbete market as a case study. A well structured questionnaire was used for this study. It was administered to 350 registered female traders in Ogbete market. Data analysis was performed using tables and charts (descriptive analysis). The data collected was analyzed using tabulated frequencies and percentages. They were categorized in line with the objectives of the study; tables, pie charts and a bar chart were the statistical tools used. The mean age of the respondents was 44.6 (range was 18-80years). 139 (41.2%) were aged between 41 and 50years, and are the most represented. Out of the whole number of respondents, 238(80.9%) had formal education and 67(9.1%) had no formal education. Only 87(24.9%) of the traders have heard of mammographic screening, and 32 out of them have undergone mammographic screening. When asked the reason for not have undergone mammographic screening, 50.6 %( 161) responded lack of awareness or insufficient information, 2.2 %( 7) responded lack of advice, 8.8 %( 28) responded fear of cancer detection, 20.8 %( 66) responded lack of physician referral, 0.9 %( 3) responded cost of screening and 16.7 %( 53) responded belief. The result of this study showed that the level of awareness and practice of mammographic screening among female traders in Nigeria is unacceptably low.

Table 1: Educational background of respondents

Table 2: Age distribution and knowledge of breast cancer of respondents

Table 3: knowledge of mammographic screening and level of education of the respondents

Table 4: knowledge of mammographic screening

Table 5: how long does it take you to get to the breast cancer screening centre?

Table 6: how many times do you undergo mammographic screening in a year?

Table 7: why have you never undergone mammographic screening? 

Table 8: what do you feel about mammographic screening?

Figure i: distribution of age of the respondents

Figure ii: what type of breast screening examination have you undergone? 

Figure iii: why have you never undergone mammographic screening?

Title page i

Approval ii

Dedication iii

Certification iv

Acknowledgment v

Tables and figures vi

Abstract vii

Table of contents viii

CHAPTER ONE     

1.2 Purpose of study 9

1.2.1 Specific objectives of the study 9

1.3 Significance of study 10

1.4 Scope of the study 11

1.5 Definitions of terms 11

CHAPTER TWO LITERATURE REVIEW

2.2.3 Why the test is performed 17

2.2.5 Limitations of mammography 20

2.3 Awareness and knowledge of mammographic screening 20

2.4 Need for the society to be aware of mammographic screening procedures 23

2.5 Need for mammographic screening awareness for future challenges 27

2.6 Factors affecting mammographic screening practice and awareness 29

2.7 Calls for mammographic screening awareness among traders and other workers 33

2.8 Steps involved in breast self examination 34

CHAPTER THREE

3.1 Research design 37

3.2 Target population 37

3.3 Sample size and sampling technique 37

3.4 Tools for Data Collection 38

3.5 Method of data collection 39

CHAPTER FOUR

4.1 Data presentation and analysis 40

CHAPTER FIVE 

5.1 Discussion 50

5.2 Summary of findings 54

5.3 Recommendations 55

5.4 Limitations of study 57

5.5 Conclusion 57

 References

Appendix

Mammographic screening refers to the medical screening of asymptomatic, apparently healthy women for breast cancer in an attempt to achieve an earlier diagnosis [1] .The assumption is that early detection will improve outcomes. A number of screening test have been employed including: clinical breast examination (CBE), self breast examination (SBE), and mammography [1].

Breast cancer is a malignant tumour that occurs in the tissues of breast. A malignant tumour is formed from an increased number of cancer cells that develop in certain tissues and when left untreated can spread to areas of the body (metastasis). Breast cancer can occur in both female and males but cases of breast cancer in males are rare, this is because male breast is rudimentary and relatively insensitive to endocrine influence [2]. Breast cancer can develop in the ductal cells (cells of the duct), in the lobular cells or in the lymphatic nodes that are located in the breast. There are three types of lymphatic nodes in the breast.

a) Axillary lymphnodes found in the under arm area

b) Internal mammary nodes, located inside the chest

c) Supra or infraclavicular nodes, located above or below the clavicle respectively.

Breast cancer is the most frequently occurring cancer in women globally; it is the leading female malignancy in the world and now the most common cancer in Nigeria [2]. The peak incidence of breast cancer in Nigerian women is about a decade earlier than in Caucasians and about 57% of breast cancer cases in Nigeria occur in women under 50years of age[1]. It has been reported that in each year, more than 1.15million women worldwide are diagnosed with breast cancer and 502,000 die from the disease, thus, this disease remains an important public health problem [3].

 In order to reduce morbidity and mortality rate and improve the survival rate of breast cancer patients, there is an urgent need to create awareness and encourage mammographic screening among the population. Mammographic screening is relatively new breast imaging modalities in the developing world; however the capacity to perform mammography is gradually becoming widespread in Nigeria [4]

The screening methods being;

 Breast self examination (BSE): Is a method that involves looking at and feeling each breast for possible lumps, distortions and swelling [1].  With the aid of a mirror, you look at both breasts paying close attention to their shape, size, and skin texture. Then using the pads of your fingers to feel for any abnormal texture or lumps including nipples as well as the area beneath each arm. It can be practiced monthly [1] and if you find a lump or any change in your breast, talk to a health care provider as soon as possible. Know that if you find a change in your breast, it does not necessarily mean you have cancer. There are many other less serious problems that can cause breast changes such as cysts, infections or injuries [1]. However, it’s important to report any changes you find to your health care provider.

Clinical breast self examination (CBE) is a physical examination done by a health professional on the breast to detect early changes.

Mammography is used as a screening tool for human breast using low energy x-ray with a high sensitivity in detection of characteristic masses and/or micro calcifications [3]. Each breast is placed in turn on the x-ray machine and gently but firmly compressed with a clear plate. This lasts for a few seconds and it’s harmless. This pressure helps to keep the breast still and get a clear radiograph using lowest amount of radiation. It may be slightly uncomfortable or painful.

The recommendation is that women get a mammogram once a year, beginning at age 40[4]. If you're at high risk for breast cancer, with a strong family history of breast or ovarian cancer, or have had radiation treatment to the chest in the past, it's recommended that you start having annual mammograms at a younger age (often beginning around age 30) [4]

Unlike CBE and mammography which requires hospital visits and specialized equipment and expertise, BSE is inexpensive and can be carried out by women themselves [1]. However, women over 40years of age are recommended to undergo mammography screening which improves breast cancer survival rates due to its early detection in comparison to BSE and CBE [6]. For the average woman, the US preventive services task force recommends mammography every 2 years, in women between the ages of 50 and 74 [7], the European cancer observatory recommends mammography every 2-3 years between 50 and 69 and in Canada, screening is recommended between the ages of 50 and 74 at a frequency of 2 to 3 years [8].

 Other screening tests are been studied in clinical trials such as;

Magnetic resonance imaging: it is a procedure that uses a magnet, radiowaves and a computer to make series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).  MRI does not use any x-rays.  Women with a high inherited risk of breast cancer, screening trials of MRI breast scans have shown that MRI is more sensitive than mammography for finding breast tumours [10].  MRI is better than other methods of assessing the response to neoadjuvant chemotherapy and is helpful in identifying the primary tumour in patients who present with axillary adenopathy [9].

According to National Cancer Institution 2011 [10], MRI can be used to study lumps in the breast that remains after surgery or radiotherapy, study breast lumps or enlarged lymphnodes found during a clinical breast examination / self breast examination that were not seen on mammography or ultrasound and also in plain surgery for patients with known breast cancer [10].

Ultrasonography: it is a diagnostic aid to mammography. It is used for breast of younger women which are still glandular and hence is a better option to mammography. It can be used to differentiate between solid and cystic breast masses that are palpable of detected mammographically [11]. In addition, ultrasound evaluation of the axilla can be used to detect lymphnodes that are suspicious for axillary metastasis [11] .Ultrasound provides guidance for interventional procedures of suspicious areas in the breast/ axilla [11].

 BRCA testing: Genetic testing does not detect cancers, but may reveal a propensity to develop cancer [7].  Women who are known to have a higher risk of developing breast cancer usually undertake more aggressive screening programs. A clinical practice guideline by the US Preventive Services Task Force recommends against routine referral for genetic counseling or routine testing for BRCA mutations, on fair evidence that the harms outweigh the benefits [7]. It also encourages a referral for counseling and testing in women who has a family history that indicates they have an increased risk of a BRCA mutation, on fair evidence of benefit. About 2% of American women have family histories that indicate an increased risk of having a medically significant BRCA mutation [7].

Scintimammography: scintimammography using 99mTc-sestamibi is a noninvasive and painless diagnostic imaging method that is used to detect breast cancer when mammography is inconclusive [12]. Because of the advantages of labeling with 99mTc-sestamibi and its high efficiency in detecting carcinomas, it is the most widespread agent for this purpose. Its accumulation in the tumor has multifactorial causes and does not depend on the presence of architectural distortion or local or diffuse density variation in the breast [12].

Breast thermography :Thermography is a painless, non invasive, state of the art clinical test without any exposure to radiation and is used as part of an early detection program which gives women of all ages the opportunity to increase their chances of detecting breast disease at an early stage [13]. It is particularly useful for women under 50 where mammography is less effective. 

 Canadian researchers recently found that infrared imaging of breast cancers could detect minute temperature variations related to blood flow and demonstrate abnormal patterns associated with the progression of tumors [13]. These images or thermograms of the breast were positive for 83% of breast cancers compared to 61% for clinical breast examination alone and 84% for mammography [13].

Positron emission tomography: 18F-Fluoro-2-deoxy-D-glucose positron emission tomography (FDG PET) has been evaluated in breast cancer for the characterization of primary tumours, lymph node staging and the follow-up of patients after surgery, chemotherapy and/or external radiotherapy.14  In contrast to both the low sensitivity and moderate specificity of FDG PET in the initial detection and characterization of breast cancer and the low lesion-based sensitivity for lymph node staging, the results from use of FDG PET in re-staging breast cancer patients are very promising. A major advantage of FDG PET imaging compared with conventional imaging is that it screens the entire patient for local recurrence, lymph node metastases and distant metastases during a single whole body examination using a single injection of activity, with a reported average sensitivity and specificity of 96% and 77%, respectively [14].

Computed tomography: Recent advances in technology have shown that breast computed tomography (CT) systems are promising in early detection [15]  Breast CT imagery provides a 3D image of the breast and reduces the superimposition of breast tissue, thus enabling improved tumor detection, using a fast data acquisition time, and providing inclusion of the entire volume of the breast [15]  Additionally, the radiation dose in breast CT is equal to or less than the dose used in mammography; this differs from comparisons of other X-ray procedures to CT exposures [16]

Several studies have been conducted worldwide to elicit knowledge about breast cancer and mammographic screening practices but in traders, few studies have been reported. There is a need to know the awareness level and screening practices among traders in Enugu metropolis, Enugu state, Nigeria. 

Baseline data on traders’ knowledge is essential in developing an effective and targeted awareness campaign and instill practice habits to prevent delayed presentations of breast cancer.