The Level of Awareness Among Healthcare Practitioners Regarding the Relationship Between Breast Density and Breast Cancer

Background Breast cancer is the most prevalent cancer in women, accounting for around 23% of all cancer-related deaths across 140 nations. The awareness about breast density (BD) has a significant impact on early diagnosis of breast cancer. Aim and objective This study aims to assess the awareness of healthcare providers about BD in King Abdullah Medical City. Methods This is an analytical cross-sectional questionnaire-based study among the healthcare practitioners of KAMC in Makkah, Saudi Arabia. Questions measured knowledge about BD and a pass mark indicated participant awareness. The collected data were analyzed using SPSS, and a chi-square test used for bivariate analysis. Results Out of 124 participants, 41% were well aware. Physicians (37% of the sample) were significantly more aware than allied healthcare practitioners and nurses (awareness: 59.6%, 33.3%, 30.4% respectively, (p = 0.03)). Regarding specialty, radiologists and surgeons had the top level of awareness (62% and 64%, respectively) as compared to oncologists (47.1%) and other specialties (29.7%), (p= 0.016). Those above 40 years of age were more aware than those below 40 years (awareness: 62.1% and 34%, respectively, (p=0.007)). Non-significant factors included: gender, years of experience, screened versus non-screened, and receiving information before about BD (p > 0.05). Conclusion The results of this population-based study indicate the existence of moderate deficits in the general knowledge about BD and its relation to breast cancer. This might lead to a late diagnosis. The results showed no dramatic differences in the awareness among healthcare providers.


Introduction
The most prevalent cancer in the world and the main reason for cancer mortality is breast cancer, accounting for around 23% of all cancer-related deaths across 140 nations.Its prevention is still difficult to achieve worldwide since it is a multi-step process involving several cell types.Early detection of breast cancer can increase relative survival rate [1].In the world as a whole, one in eight women are at risk of having breast cancer in their lifetime [2].According to estimates, in Saudi Arabia, 17.3% of all new cancer cases (2282) in 2016 were breast cancer cases [3].Early detection of malignant breast lesions helps reduce morbidity and mortality [2,4].
Two categories can be made up of all the risk variables that start the process.Age, sex, race, the genetic composition that encourages the familial occurrence of the neoplastic disease, and the occurrence of benign proliferative lesions of the mammary gland would all fall under the first category of intrinsic factors.They are all independent parameters that do not simply change a person's life.The second category would be extrinsic variables, which may have some degree of impact on the neoplastic process depending on lifestyles, food, or long-term medical interventions such as utilizing oral hormonal contraceptives or hormonal replacement treatment.Finding modifiable factors may aid in the creation of prevention methods that lower the incidence of breast cancer [5].
The most popular approach for screening breast cancer is standard (2D) mammography, which requires radiologists to inform patients about breast density (BD) and the potential need for additional screening [2].This implies that BD may be a risk factor for breast cancer due to its ability to cover disease symptoms and act as a key risk factor for the development of cancer [5,6].Dense breast is known to be one of the primary risks for the development of breast cancer [2].Each woman has a different BD that can be only assessed under mammography.The level of BD can be affected by several factors including age, childbearing, menopausal status, hormone replacement therapy, and body mass index [2,7].
More than 90% of cancer fatalities are caused by women's neglect and ignorance, which frequently results in delayed diagnosis and advanced breast cancer presentations [1].

Data collection and population
Between July and August 2022, the present study attempted to assess healthcare practitioners' knowledge of BD and its relationship to breast cancer.The study included 124 practitioners and was approved by King Abdullah Medical City in Makkah, Saudi Arabia (Approval number: 22-968).
An analytical cross-sectional observational design was employed.Because the study was conducted at a single center, King Abdullah Medical City, in Makkah over a brief period of time, it was able to estimate the level of knowledge among medical professionals regarding BD as a risk factor for breast cancer.
All healthcare practitioners in King Abdullah Medical City were included, with the only exclusion being the refusal to participate in the study (n=2).As previously stated, the sample size was 124, and it was a probability sampling that was measured by n = N / (1 + N e 2 ) equation.The majority of respondents were females (78.4%) followed by males (21.6%), we also observed that females were more enthusiastic than males to participate.This demonstration was seen because breast cancer is more likely to occur in females than males.The practitioners' educational level in the health field was at least a diploma degree.
The data for this study was collected in a survey of two sections.The first section included sociodemographic questions such as gender, age, job field, department of work in a hospital, and years of clinical practice.Another section included to assess the main objective containing nine questions written by the author, such as whether they had a breast examination before by mammogram, or received any information about BD or mammogram before, where they got the information, and whether the dense breast will require more examination for early diagnosis.We also considered their perspectives on the effect of hormone replacement therapy in dense breasts, breast cancer diagnosis in dense breasts, and image clarity of dense breasts in mammograms.Furthermore, the associations between dense breasts and the risk of breast cancer, age, childbearing, and breast size.
Google Forms were used to collect and maintain the data.Informed consent was included on the cover page in two languages Arabic and English, and the data collectors used a barcode connected directly to Google Forms to reduce the number of refusal practitioners because the majority of practitioners were at work, though the barcode helped to delay practicing until their breaktime and prevented any distraction to them.The data were collected from a random sample to estimate the prevalence of unknown parameters from the target population.

Data analysis
Statistical analysis was performed using IBM SPSS version 25 computer statistical software package, frequency test for univariate analysis, and chi-square test for bivariate analysis.A p-value of < 0.05 was considered statistically significant.The study reported a confidence interval of 95%.

Results
Although BD information has been mandated to be disclosed worldwide, it remains largely unknown whether BD can affect breast cancer detection and what impact it has on risk.After getting the informed consent of individuals, 124 people completed the questionnaire.At the start of the study, all completed questionnaires were included, and any partially completed questionnaires were excluded.With the aid of SPSS software, the amassed data were processed and analyzed.

BD knowledge
A comparative study of the relationship between knowledge and participant demographics shows moderate knowledge gaps regarding BD and its connection to breast cancer.Physicians were significantly more aware (n=28, 59.6%) than allied healthcare practitioners (n=8, 33.3%), and nurses (n=7,30.4%).In administration, only one was aware (12.5%), in pharmacy only two (28.6%), and in other professions two (28.6%) with p = 0.03, meaning, it is significantly associated.Regarding specialty, Radiologists and Surgeons had the top level of awareness (62% and 64%, respectively) as compared to oncologists (47.1%) and other specialties (29.7%), with p= 0.016, thus a significant association.Those >40 years of age were more aware than those <40 years (awareness: 62.1% and 34%, respectively) with p=0.007, thus no significant association.Nonsignificant factors included gender, years of experience, screened versus non-screened, and receiving information about BD, with p > 0.05, thus no significant association (Table 3).

TABLE 3: Distribution of Participants' Knowledge Regarding Breast Density by Their Characteristics
The majority of participants, according to the demographics, were unaware of the benefits, the ideal timing, or the correct techniques for measuring BD.The general population and those in the health sector should get health information on risk elements associated with breast cancer and methods for early diagnosis from qualified healthcare experts.

Discussion
BD is defined as the ratio of radiolucent fatty elements to radiopaque both epithelial and stromal tissue elements as seen on the mammogram [8,9].The Breast Imaging and Data Reporting System (BI-RADS) Atlas classifies BD as (a) almost fatty, (b) fibroglandular tissue scattered, (c) heterogeneous that might conceal minor masses, and (d) extremely dense (ACR BI-RADS) [10].In this study, the awareness and knowledge of healthcare providers (HCPs) regarding BD and its association with breast cancer were investigated.Findings showed that the majority of the HCPs were not aware that with high BD, diagnosis of breast cancer becomes difficult (n=72, 58.1%) and the image of the mammogram will be less clear (n=84,67.7%).A similar study was conducted by Brown and colleagues wherein the majority of the physicians were not aware of the risk of BC because of dense breasts.Furthermore, their study found that primary care providers (PCPs) were more unaware of BD laws than the specialists [11,12].Several studies proved or concluded that high BD could make breast cancer less sensitive to detection thus increasing the risk of missed cancer [12,13].Furthermore, researchers identified BD as a distinct breast cancer risk factor [14][15][16].
Factors such as age, childbearing, and breast size in relation to BD were also asked of participants.The study revealed that most of the participants were not aware that BD decreases with age, increases with childbearing, and also has no relation with breast size.Studies done in different regions observed a significant association of BD with age in which BD decreases as women age especially those in the menopausal stage [17][18][19].In relation to childbearing, the study of Yaghjyan et al. found a positive relation between childbearing in terms of breastfeeding and BD of premenopausal women [20].
Knowledge about BD was assessed in the current study by comparing the knowledge of HCPs based on demographic information.Findings showed that physicians were significantly more aware among other participants while surgeons were more aware compared to radiologists, oncologists, and other specialties.It was also observed that participants aged above 40 years old were more aware than those below 40 years old.
In a qualitative interview study conducted in Australia, general practitioners had limited knowledge of BD and little experience talking about BD to women.The findings in the current study also indicate HCPs' limited awareness and knowledge about BD.In contrast to our study, a cross-sectional study of PCPs in the USA showed a high percentage of Australian GPs knowledge and positive attitude in informing their patients about BD [21].The varying results may be due to formal training or guidelines provided to HCPs about BD or the mandated BD notification in the USA.
There has been an increase in global discussion of BD, which includes public dissemination about BD and post-legislation of BD notification in the United States.In other countries, BD notification does not occur resulting in varying views, understanding, and knowledge of women and HCPs about BD and its association with breast cancer.The current study has some potential limitations.First, response bias is possible in this study since this is a self-reporting survey.Second, the participants were from a single center thus results may not reflect the general knowledge and awareness of the population in Saudi Arabia.The HCPs in this study majority are female and have less than 10 years of clinical practice thus may not be representative of all Saudi Arabian HCPs.Nevertheless, we think that the study survey is thorough in terms of respondents and settings, enabling us to evaluate practitioners' knowledge.