Assessment of Levels of Knowledge towards Hormonal Related Breast Cancer Risk Factors in Qurayyat, Northern Saudi Arabia

Background: Continued exposure to sex hormones such as estrogen is a critical risk for subsequent breast cancer. Thus the present study aimed to assess the levels of knowledge towards hormonal related breast cancer risk factors in Qurayyat, Northern Saudi Arabia. Methodology: This descriptive study included 737 Saudi volunteers living in the city of Qurayyat, Northern Saudi Arabia. For females, only those agreeing to participate in the breast self-examination workshop were included, and non-respondents were included in the questionnaire. Results: For the question apropos “Inheritance as a risk factor for BC,” 405/607 (66.7%) females signposted certainly “Yes,” as well as, 70/130 (54%) males signposted certainly “Yes.” The odds ratio (OR) and 95% confidence interval (95% CI) were not statistically significant, but the level of knowledge was relatively higher among females OR (95% CI) = 1.4321 (0.9597 to 2.1370), P = 0.0786. “Are early puberty and late menopause risk factors for breast cancer?” No statistical significant differences were eminent between males and females, OR (95% CI) = 0.8878 (0.5932 to 1.3287), P = 0.5629. Conclusion: Saudi women are enthusiastically willing to raise their knowledge and awareness of breast cancer prevention and control. Although women have greater knowledge about breast cancer risk factors compared to men, still some gaps need to be filled.


Introduction
Breast cancer is the commonest, complex, and heterogeneous neoplasm and the most common cause of cancer death among females worldwide [1] [2].
Although the information on the epidemiology of breast cancer is frequently changing, it is increasingly dominant females' cancer, accounting for 25.1% of all cancers, according to GLOBOCAN [3].The prevalence of breast cancer is higher in the developed world compared to developing countries with the most significant mortality in the later.Education of women, early detection, and increasing awareness are the primary prevention and control measures, particularly for the less developed countries [4].Such efforts have reduced the age-standardized mortality, as well as, improved the relative survival for many countries.The recent positive changes in the epidemiology of breast cancer are strongly linked to early detection programs, such as mammography screening [5].
In Saudi Arabia, breast cancer is the commonest females' cancer with a prevalence of 21.8% [6], and it represents the 9 th leading cause of death in the country [6] [7] [8].In recent years there was a significant increase in the number of new patients with breast cancer, particularly among younger females population compared to new patients in Western nations [9].Sex hormones extra exposure, exactly estrogen is incriminated in the etiology of breast cancer.The majority of breast cancer risk factors may interact through hormone-related pathways, particularly estrogen, which is firmly connected to the elevated risk of breast cancer in postmenopausal women [10].Consequently, the present study aimed to assess the levels of knowledge towards hormonal related breast cancer risk factors in Qurayyat, Northern Saudi Arabia.

Materials and Methods
This descriptive study included 757 Saudi volunteers living in the city of Qurayyat, Northern Saudi Arabia, during the period from October 2018 to February 2019.Sample size was calculated using software calculator.net:available at: https://www.calculator.net/sample-size-calculator.html.Participants were targeted in different public settings in the city.Participants were randomly selected by simple random method regardless of age, gender, education level or occupation.For females, only those agreeing to participate in the breast self-examination workshop were included, and non-respondents were included in the questionnaire.A total of 130 men were enrolled as an internal control.
Males' participants were added to serve as an internal control for the obtained information regarding breast cancer previous knowledge.A purposeful inquiry was designed and used for getting the necessary data.Besides, age, sex, and education level, the questionnaire included questions: Inheritance as a risk factor for BC; early puberty and late menopause are risk factors for BC; delayed childbirth is a risk for BC; natural breastfeeding is a risk for BC; hormonal usage is a risk for BC.

Data Analysis
Statistical Package for Social Sciences (version 16) was used for analysis and to perform a Pearson Chi-square test for statistical significance (P-value).The 95% confidence level and confidence intervals were used.A p value less than 0.05 was considered statistically significant.

Ethical Consent
Each participant was asked to sign a written ethical consent during the questionnaire's interview.The informed ethical consent form was designed and approved by the ethical committee of the Applied Medical Science (Qurayyat.Jouf University, Saudi Arabia) Research Board.

Results
Out of the 757 approached women, 473/757 (62.5%) responded to partake in breast self-examination training.The mean age of the contributors was 35.7 ± 10.5 years with a minimum of 17 and a maximum of 72 years old.A total of 130 men were enrolled as an internal control.The question relevant "Inheritance as a risk factor for BC," 405/607 (66.7%) females signposted certainly "Yes," as well as, 70/130 (54%) males signposted certainly "Yes."The odds ratio (OR) and 95% confidence interval (95% CI) was not statistically significant, but the level of knowledge was relatively higher among females OR (95% CI) = 1.4321 (0.9597 to 2.1370), P = 0.0786, as indicated in Table 1, Figure 1.

Discussion
Breast is a highly responsive organ to the levels of hormones, particularly estrogen (ER).Prolonged and increased exposure to ER is known to be risk factors for breast cancer.
The present study attempted to highlight the pertained knowledge and awareness levels of Saudi women toward exposure to variable ER-related conditions.At present, there is amassing regarding the role of endogenous ER as a risk for the development of breast cancer.ERs and ERs-related metabolites were extensively investigated in both premenopausal and postmenopausal women, and the results showed substantial hormonal deviations [10].
In the present study, 66.7% of the participated women stated that the inheritance of breast cancer genes is a critical risk factor for breast cancer.Family history is an essential factor for the determining of the overall risk of breast cancer.
A family history score depends on noticed breast cancers in a family, and the following prediction may offer a better view of breast cancer incidence than classical parameters based solely on affected relatives [11].Individuals carrying a mutation in BRCA1/BRAC2 genes have an elevated lifetime risk of breast cancer (60% -85%) compared to 12.5% of women with intact BECA genes [12].The question "Whether early puberty and late menopause are risk factors for BC," about 30.5% of the females replied "Yes" increase the risk of BC.This relatively lower percentage is indicating poor knowledge in this segment.It was well established that early puberty, late menopause, and later age at first pregnancy are risk factors for breast cancer [13].
The question "Whether delayed childbirth is a risk for BC," only 14.4% of the females replied, "Yes decrease the risk of BC." Modifications in family designs could, however, clarify the elevated risk since giving birth to a first child late in life and bearing few children both upsurge the risk of breast cancer [14].
The question "Whether natural breastfeeding is a risk for BC," 75% of the females replied, "Yes decreases the risk of BC.  [18].
On the other hand, higher levels of awareness were noticed among educated women (university level and secondary).Those less educated showed fewer awareness levels.Therefore, planned educational programs should target less educated women.A recent study from Saudi Arabia indicated educational interventions targeting raising breast cancer awareness and addressing barriers should be merged as the central part of the screening program in Saudi Arabia [18].This calls for educational campaigns to boost breast cancer screening.Addressing the barriers for breast cancer screening is a public health authoritative [19].
In the present study, men showed low levels of awareness in all factors regarding breast risk.Though the incidence of men breast cancer is deficient, the men education may further improve the level of women awareness toward breast cancer and its associated risk factors with respect to the social construction of the Saudi community.

Conclusion
Saudi women are enthusiastically willing to raise their knowledge and awareness toward breast cancer prevention and control.Although women have greater knowledge about breast cancer risk factors compared to men, still some gaps need to be filled.

Figure 1 .
Figure 1.Gender and hormonal-related breast cancer risk factors.

Figure 3 .
Figure 3. Education and hormonal-related breast cancer risk factors.

Table 1 .
Distribution of study subjects by gender and hormonal-related breast cancer risk factors.

Table 2 .
Distribution of study subjects by age and hormonal-related breast cancer risk factors.

Table 3 .
Distribution of study subjects by education and hormonal-related breast cancer risk [15]ticed either two or more childbirths and breastfed for ≥13 months can decrease their breast cancer risk by approximately 50%[15].The question "Whether Hormonal usage is a risk for BC," 43.4% of the females replied, "Yes increases the risk of BC." Endogenous estradiol and estrone Saudi community with a broad culture, better education, and accumulative knowledge.During our search, we didn't come across studies investigated the role of age in the spread of awareness.Low deployment of breast cancer screening has been significantly linked to woman's age (OR = 2.55; 95% CI = 1.71 -3.83), upper educational rank (OR = 2.98; 95% CI = 2.05 -4.34), greater family income (OR = 1.96; 95% CI = 1.31 -2.93), consuming hormonal contraception (OR = 1.46; 95% CI = 0.99 -2.13) and positive history of former breast (OR = 12.16; 95% CI = 6.89 -21.46 " The combination of extended breastfeeding and extra childbirth lowers breast cancer risk powerfully, and that A. M. Elasbali et al.DOI: 10.4236/ojog.2019.93038379 Open Journal of Obstetrics and Gynecology women who