Knowledge, Attitude and Breast Cancer Screening Practices in Ghana Essay

INTRODUCTION   Ã‚   Breast cancer in its simplest definition is the cancer of breast tissue. It is the most common nonskin cancer that affects women in the United States and the highest fatality rates of cancer deaths among women in low-resource countries (Anderson et al 2006). Severity of breast cancer differs based on its level of tissue invasion. Ductal carcinoma in situ is the most common noninvasive breast cancer while infiltrating or invasive ductal carcinoma is the most common breast cancer that accounts for about 80% of invasive breast cancer. Breast lumps presentation is the commonest form of presentation regardless of the breast cancer type (ACS 2005). Epidemiologic factors are attributed to dietary and environmental risk factors, although association of diet and breast cancer had varied results. Environmental risk factors involve the exposure to several toxic elements which accounts for the increased incidence of breast cancer in Western countries. Alcohol intake is also considered to effect in the increase of the number of cases in the US population. Age is also considered as cancer risk factor and can be attributed to hormonal change. Genetic variation and ethnicity are not out of scope for the investigation of breast cancer risk factors (Barton 2005). Diagnosis and Pathology of Breast Cancer: In 2002, Breast Health Global Initiative (BHGI) together with panel of breast cancer experts and patient advocates develop a consensus of recommendations for the diagnosis of breast cancer in limited-resource countries (Shyyan 2006). Histopathologic diagnosis included fine-needle aspiration biopsy which was recognized as the least expensive, core needle biopsy and surgical biopsy and had a consensus of choosing the method based on the availability of tools and expertise. They gave emphasis on the correlation of histopathology, clinical and imaging findings. They agreed on the need of histopathologic diagnosis before breast cancer treatment. In 2005, BHGI panel recommended an additional strategy of breast cancer management. They stratify diagnostic procedure and histopathology methods into – â€Å"basic, limited, enhanced, and maximal—from lowest to highest resources†. Basic level includes medical history of the patient, clinical breast examination, tissue diagnosis and medical record keeping. Limited level includes the increasing resources that enable diagnostic imaging utilization such as ultrasound with or without mammography, tests that can evaluate metastasis, use of image-guided sampling and hormone receptor sampling. Enhanced level includes diagnostic mammography, bone scanning and an onsite cytologist. Maximal level includes mass screening mammography (Shyyan 2006). Treatment of Breast Cancer: Treatment includes surgery, radiotherapy or chemotherapy or combinations of these three treatment modalities. According to American Cancer Society (2005), treatment can be local or systemic. Local treatment of the tumor is done without affecting the rest of the body. Surgery and radiation are examples of this treatment. On the other hand, systemic treatment which includes chemotherapy, hormone therapy and immunotherapy, is given into the bloodstream or by mouth to reach the cancer cells that may have spread the beyond the breast.    Radiotherapy is a treatment of breast cancer with high-energy rays to help shrink the cancer cells. It can be given outside of the body (external radiation) or can be placed directly into the tumor as radioactive materials (ACS 2005). It may be given external to the body.   Radiotherapy requires safe and effective application requiring appropriate facilities, staff and equipment. Radiotherapy should be applied without delay, should be accessible to all but without prolongation of the overall treatment time exposure. It is part of an integral part of breast-conserving treatment. It is required in almost all women with the breast cancer, and therefore should be available (Bese 2006).   Ã‚  Chemotherapy is the use of anticancer drugs that are administered through injection in the vein or taken orally as a pill. It may be given before breast cancer surgery to reduce the size of the tumor or may be given after the surgery to reduce the chance of   recurrence (ACS 2005). This treatment is done in cycle the most common of which is 3-6 months. Most common side effects of these drugs usually stop   once the treatment is over such as in hair falling. Some of   drugs used as chemotherapy     are tamoxifen, cyclophosphamide, methotrexate, 5-fluorouracil doxorubicin, epirubicin, taxane and aromatase . These are usually prescribed in combination, and treatment is done with adjuvant therapy such as radiotherapy and pre- and post operation ( Eniu 2006).   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Surgical management in breast cancer is very common. This is done to remove as much as the cancer as possible and to find out whether the cancer has spread to the lymph nodes under the arm. Surgery can also restore the appearance of the breast and relieve the symptoms of advanced cancer. ACS (2005) released some of the common surgical procedures in breast cancer. These are lumpectomy, partial or segmental mastectomy, simple or total mastectomy, modified radical mastectomy and radical mastectomy. RESULTS    Breast cancer patients in Ghana. The present study which included women with mean age population of 48 years   revealed an almost consistent perception with regards to breast cancer.  Ã‚   They were aware that breast cancer is highly increasing in their place but not informed of the cause of disease. All of the responders were not aware of family breast cancer history except one. Information about breast cancer was acquired through television and radio programs. Only after   consultation with doctors due to lumps or   pains in their breast and some due to liquid coming out of their breast, that they were informed that they have breast cancer. Most of them underwent breast tissue exam for confirmation of the disease. Afterwards, they were advised to undergo surgery with medical treatment. The responders were ignorant of the breast cancer screening and prevention. In fact, out of 10 responders, only 2 (20%) of them were aware of breast self examination and clinical breast examination and admitted that they occasionally practice BSE. None of the responders knew about mammogram except for one (10%) of them who has heard of it but never had tried one. The feeling towards the knowledge of acquiring the disease was also the same; the feeling of being a burden in the family was common. They were afraid to face the reality but have realized that they have to fight the disease through the encouragement and support of family members and   help of medical professionals. The sample population was aware of the herbalist and faith healers but they did not submit themselves into that kind of treatment because herbalist have not   proven cure for breast cancer.   The most common complaint of the responders was the high cost of therapies, hospitalization and doctor fees. The treatment cost ranged to    ¢250,000- ¢24 million except to one of them who received a free treatment for being enrolled to a clinical trial. Sentiments of the participants were the same. Delay of treatment was attributed to their distant place from the health clinics; some facilities like x-ray were not available in the clinics and   high cost of treatment. These people asked for the betterment of breast cancer management through education dissemination to the community by health care providers and a help from the government to provide financial support to those who cannot afford to submit themselves for treatment. Patients in breast cancer clinic. In this part of the study, women with mean age of 42 years who were in breast cancer clinic were included. Most common medical complaint was lump and pain in the breast while others submit themselves for screening because they have just heard it from the radio/TV.   The study revealed that women who were attending the clinic were not actually informed of the cause breast cancer but aware of its increasing rate of mortality. Misconception about the cause of breast cancer such as exposure to coins was not common but did not exclude the form of trauma due to manipulation of the breast. Others correlate breast cancer with smoking and taking alcoholic beverages. They were not aware of their family history of breast cancer.   Information regarding breast cancer was acquired through television and radio programs and others were through their friends and family members. Most of the respondents believed that early detection and prompt treatment of the disease can prevent the unfavorable outcome of breast cancer such as removal of their breast or the worst would be cancer death. Only one out of   10 participants (10%) actually practice breast self examination (BSE). Most of them were informed of BSE but not actually practicing it. They were also aware of healers and herbalist but they did not believe that they can cure breast cancer but did not disagree of the possibility that herbalist and healers could treat other diseases or illnesses like hypertension. The participants suggested that it would be better if the government would provide or establish more health care clinics for breast cancer screening and provide free screening programs especially to those who cannot afford to   pay for high cost of treatment of the disease and for an open-easy access to all especially to those in rural areas. One of the participants suggested   that doctors should study further about the treatment of breast cancer instead of resorting to breast surgery. Healers involved in breast cancer management. Many of the population of Ghana are still patronizing healers and herbalist as a resort   of treatment. Two healers from Ghana were interviewed regarding their management of breast cancer. The healers have been into this practice for about 20-50 years. According to them, breast cancer is very common in Ghana and they are aware of the increasing incidence of   the disease. They described breast cancer as an â€Å"obosam† disease and the other was a supernatural disease. Healers believed that their ability to cure   the disease inherited from their forefathers who taught them how to prepare herbs and provide them with dwarfs. They believed that doctors have no right treatment towards breast cancer because according to them they just remove the breasts of women   and subsequently die. According to the healers they do not promote breast   examinations to their patients because these are useless and cannot stop women from getting the disease. Despite the big machines available in the hospitals, women with breast cancer still die, according to them. Healers charge their patients with as much as  ¢200,000- ¢1( £15-60) million depending on the patients’ condition. The healers admitted that there were cases of recurrence of the disease due to lost to follow up and missed spiritual sessions. Healers do not refer patients to hospitals rather, they encourage hospital doctors to refer their patients to healers because they are more capable of treating breast cancer. Breast cancer consultants.   Medical health professionals play a significant role in the awareness of breast cancer. They have the power to influence their patients toward right management of the disease. In the present study, surgeon/breast cancer consultants were interviewed. Consultants as expected were aware of the increasing incidence of breast cancer but they cannot give an exact figure due to absence of cancer registry in the place however they were able to attend to 200-300 new cases of breast cancer annually with age range starting from 20 years and above. They revealed that women in Ghana associate breast cancer to death because after undergoing breast caner surgery they usually die. People in Ghana link medical intervention and death which made the women in this place afraid of   the disease and lead them to negative attitude towards the disease. Consultants believed that there were several misconceptions about the disease. They were also aware that healers and herbalist delay the   presentation of patients to   hospital which accounted for the late stage of diagnosis. National Screening Program would benefit the people in Ghana for early detection of breast cancer and prompt treatment, however, they did not deny the fact it would be difficult to establish such program due to lack of funds by the government at present time. Consultants were aware of the limited resources of the needed for the implementation of the program. They believe that it is much easier and feasible to educate the women on simple screening methods such as regular breast self examination and encourage practitioners to take advantage of examining the breasts of their patients. There are also NGOs who are engaged in some activities like providing health care assistance. Consultants revealed that they receive referrals from district regions and from private practitioners. All patients with breast cancer are candidates for surgery. There are just some procedures that lead to untoward incident which cause the people to blame the doctors. According to consultants, one big problem that they encounter is the delay of the result of tissue exam from the pathologists which sometimes lead them to acquire the high cost of private laboratory. According to consultants the 5-year survival rate in Ghan is 25% which is disappointing. According to radiology consultant, patients present themselves to treatment once they are already in advanced stage, most at stage 3 and 4. They revealed the common factors that influence the delay of treatment among Ghana women. Most of the patients were scared of the procedure of   breast cancer treatment like in breast surgery which have many social and marriage implications. The high cost of the procedure hinders the patient to go to the doctors. Consultants revealed that surgical procedure may cost    ¢2-3million   ( £ 150-200), radiotherapy is about    ¢3-4 million (  £ 200-300) and chemotherapy is around  ¢6 million ( £400). Although surgical treatment cost is covered in National Health Insurance, the cost of radiotherapy and chemotherapy are excluded. Mammography which is an effective tool in breast cancer screening costs  ¢400,000 ( £30) in private health institution and around  ¢250,000 ( £20). DISCUSSION WITH REVIEW OF RELATED LITERATURES   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   The present study aimed to increase the awareness of the women in Ghana to breast cancer and the benefits that can be gained from breast cancer screening. The knowledge, attitude, behavior and practices of the women regarding early detection of breast cancer were analyzed. The ultimate aim of the study was to reduce the mortality rate of   breast cancer.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   The study revealed that there were still misconceptions about breast cancer despite the information gathered from televisions and radio programs. Attendance of Ghanaian women in breast clinic did not mean that they were informed of the nature of their disease. Only few of them were also aware of preventive procedure in detecting breast cancer. Local healers and spiritualists also delayed the presentation of the patients to the hospital which contributed to the late diagnosis of the disease. Difference in the disease management of health professionals can be attributed to the location of practice and availability of resources. Several factors   thought to affect the breast cancer screening program were the poor education of the Ghanaian towards prevention awareness against breast cancer; lack of initiative of the people to spread the knowledge of   breast cancer screening such as simple breast self examination and clinical breast examination; the inaccessibility of the of primary health care and the organizers; the unavailability of the appropriate screening tools like x-ray and mammography in the community and its high cost   and the lack of support from the government.   The following   review of related literatures will help in the understanding of breast cancer and breast cancer screening. Because of the continuous increasing prevalence of breast cancer and high cost of treatment, breast cancer screening remains the most cost effective way of cancer management (Parkin and Fernandez 2006).   Most of the world faces resource constraints that hinder the capacity to improve early detection, prompt diagnosis and sufficient treatment of the breast cancer. Every country finds its way to develop evidenced based, economically feasible and culturally appropriate guidelines that can be utilized by countries of limited health care resources to improve breast cancer outcomes (Anderson 2006). Adaptive strategies should be applied to ease the growing burden of breast cancer. In 2005, according to Smith and his colleagues (2006), the Breast Health Global Initiative (BHGI) held its second summit in Bethesda, MD with the intention of reaffirming the principle of requiring all women of all resource levels to support in seeking health care and assuring the access to affordable and appropriate diagnostic tests and treatment intervention against breast cancer. They recommended breast health awareness to all women including the basic resources. They enhanced the basic facilities for effective training of relevant staff in clinical breast examination (CBE) or breast self examination and even the feasibility of mammography. MRI: Magnetic resonance imaging is one of the breast cancer screening procedures. It has been increasingly used as tool for early diagnosis of breast cancer. This screening tool has shown to detect cancers even they are small and potentially proven to be more curable than mammography alone. However, MRI is more costly than mammography and can lead to unnecessary breast biopsies, thus causing anxiety and discomfort to patient. On the other hand, a research study about the cost-effectiveness of breast MRI screening by cancer risk where they included the cancer detection ability of MRI, characteristics of women with dense breast tissue and women with high inherited breast cancer risk, revealed mortality reduction and cost effectiveness of breast MRI screening added to mammography in BRCA1 and BRCA2 mutation carriers (Kurian 2006).    The hallmark of morality and morbidity of breast cancer can be attributed to the late presentation of the patients at an advanced stage of breast cancer. It is when there is no or little benefit that can be derived from any treatment modality. In a study conducted by Okobia and colleagues (2006), the knowledge, attitude and practice of community dwellers of Nigeria towards breast cancer were analyzed. They recruited urban-dwelling women with conducted an interviewer-administered questionnaires to elicit sociodemographic information regarding knowledge, attitude and practice towards breast cancer. It was found out that the participants had poor knowledge of breast cancer. Only 214 out of 1000 participants knew that breast cancer is presented initially with breast lumps. Breast cancer examination practices were low. Only 432 participants were able carry out breast self examination while only 91 participants had clinical breast examination. This study revealed that participants with higher level of education were significantly more knowledgeable about breast cancer. Ethnicity or race-related culture and beliefs are factors that affect the increase in prevalence of breast cancer mortality. Paterniti (2006) investigated how ethnically diverse women who are eligible for tamoxifen prophylaxis because of their breast cancer risk decide about tamoxifen use for risk reduction. Prior to the study, there was discussion of the benefits and risks of tamoxifen as prophylaxis. The study which included African-American, White, and Latina women, of 61–78 years, revealed that fear of breast cancer was not prominent and they were not inclined to take tamoxifen as preventive therapy after receiving the information. Participants showed limited unwillingness to take the medication with potential adverse effects. This study revealed that women felt that they had other options other than taking the risk of tamoxifen to reduce their risk of breast cancer, including early detection, diet, faith and other alternative therapies.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Graham (2002) conducted a research about   the relationship between beliefs and practice of breast self examination (BSE in a black women population of 20-49 years of age. It was found out that health beliefs were much stronger in determining BSE performance for a given individual than were demographic characteristics. Breast self examination was related to increased perceived seriousness of breast cancer, benefit of the procedure and health motivation and was noted to have inverse relationship with perceived barriers. A related study was reported by Mitchell and colleagues (2002), about the effects of religious beliefs with other variables on breast cancer screening and the intended presentation of self-discovered breast lump. This study included women aging 40 years and above and were interviewed in their homes. Most of the interviewees believed that doctors cure breast cancer with God’s intervention which was labeled as â€Å"religious intervention with treatment†. This dimension was found out to be correlated with self-reported mammography but no clinical breast examination or intention to delay presentation of self-discovered breast lump. Minority of them believed treatment of breast cancer was unnecessary because only God could cure the disease which was labeled as â€Å"religious intervention in place of treatment†, and was significantly more common among African-American women who   are less educated and older. This was correlated with the strong intention of delaying the presentation of self-discovered breast lump. It was concluded that   religious intervention in place of treatment contributes significantly the delay presentation of breast cancer among African-American that contribute largely to the advanced-stage cancer diagnosis. The cause of breast cancer is still unclear. Adjei (2006) who grew up in Ghan and had some work about breast cancer. In his letter, he revealed his sentiments about the genetic differences in breast cancer. He had been aware of the incidence of breast cancer in Ghana since 1974 to 1999. He noted that the peak incidence of breast cancer in Ghana is in younger women with age range of 40-45 years while in United States and Caucasians, the peak incidence is in older age groups. Adjei (2006) pointed out that women of different places and environments, with different diets have similar epidemiology of breast cancer. In an argument which revealed number of breast cancer in African-Americans but rare in native African has been used to suggest that ethnicity is one factor of acquiring the disease, however, according to Adjei (2006), this information is leading because cancer has not been well-studied in Africa. Researchers are still finding their ways to fully disclose the correlation of genetic signature in breast tumors that are presently noted   to be a powerful predictor of cancer spread and cancer death. In a limited study conducted by Kolata (2002), she included few patients who are relatively. As she stated in her report, scientists said that the activity of a collection of 70 genes appear to predict cancer mortality   better than traditional measures like tumor size, cancer stage or lymph node spread to the axilla of women. She revealed in her study that 5.5% of women with good genetic signature died within the next decade while 45% of women are those of with bad genetic signatures. Adherence to the treatment regimen of breast cancer plays a big role in the improvement of disease outcome. There are no much literature about the factors associated to the behavior that influence the patient to delay or cause an incomplete adherence to the recommended follow up in patients with breast cancer. In a study conducted by Kaplan (2006), race/ethnicity, country of birth, financial issues fear of pain and difficulty of communicating with the healthcare providers are the barriers to seek follow up consultation Breast Cancer Screening: There was decline in breast cancer mortality rate of 0.9% in African American women while 2.1% was the decline in breast cancer mortality rate in non-Hispanic White women (Stewart et al 2004 as stated by Settersten , Dopp, and Tjoe, (2005).    On the contrary, De Koning (2000), questioned in his study the cost effectiveness of breast cancer screening. His idea came out when he analyzed his expectations of the reduction of breast cancer mortality after breast cancer screening. He stated in his study that the Dutch program of 2-yearly screening for women aged 50-70 would produce a 16% reduction in the total population. As stated in his research paper, the actual benefit that can be achieved from breast cancer screening programs is overstated. According to him breast cancer screening need to be carefully balanced against the burden to women and health care system. De Koning (2000) stated that â€Å"effects of breast cancer screening program depend on many factors such as epidemiology of the disease, the health care system, costs of health care, quality of the screening program and the attendance rate†. Groot, M. T. et al (2006) estimated the costs and health effects of breast cancer interventions in epidemiologically different regions of Africa, North America and Asia. They developed a mathematical simulation model of breast cancer using the different stages of cancer, its distribution and case fatality rates in the absence and presence of treatment as predictors of survival. The study resulted to a conclusion that untreated patients were the most sensitive to case fatality rates. This study suggest that treating breast cancer at stage 1 and introduction of an extensive breast cancer program are the most cost effective breast cancer interventions.   Ã‚   This study is supported by the research done by Aylin and colleagues (2005). They recruited women at the mammography clinic to evaluate the knowledge about breast cancer and mammography as breast cancer screening procedure. The striking result of this study is that most of the participants (95.3% of the total participants) were aware that women should have mammography screening periodically. They were informed of the fact that breast cancer screening such as mammography could help in the early detection of breast cancer. However, less than 50% of them admitted that they had never had mammography screening. Majority of the respondents (71.1%) were practicing breast self-examination. Another related study was conducted by Dundar and colleagues (2006), since breast cancer is the second leading cause of cancer deaths in Turkey , they determined the t the knowledge and attitudes of women in a rural area in western Turkey about breast self examination and mammography. They recruited women with age ranging from 20-64 years. Although majority of the participants have heard or read about breast cancer only 56.1% of them had sufficient knowledge about breast cancer and some admitted that they acquired the information from their health care professionals. Those with information of beast cancer were also those who practice breast self examination. This study revealed that health care professionals play a big role in information dissemination about breast cancer. Table 1. Recommendations for routine mammographic screening in North American women aged 40 years or older who are at average risk for breast cancer* Group (date of recommendations) Frequency of screening (yr) Included ages (yr)       40-49 50-69 >70 Government-sponsored and private groups US Preventive Services Task Force (2002)** 1-2 Yes Yes Yes*** Canadian Task Force on Preventive Health Care (1998, 1999, 2001) 1-2 No Yes No National Institutes of Health consensus conference (1997)    No+ — — American Cancer Society (1997) 1 Yes Yes Yes National Cancer Institute (2002) 1-2 Yes Yes Yes Medical societies American College of Obstetricians and Gynecologists (2000) 1-2 if aged 40-49 yr 1 if aged >50 yr Yes Yes Yes American Medical Association (1999) 1 Yes Yes Yes American College of Radiology (1998) 1 Yes Yes Yes American College of Preventive Medicine (1996) 1-2 No|| Yes Yes American Academy of Family Physicians (2001) 1-2 No+|| Yes No American Geriatrics Society (1999) 1-2 — — Yes*** Advocacy groups National Breast Cancer Coalition (2000)    No –+ No National Alliance of Breast Cancer Organizations (2002) 1 Yes Yes Yes Susan B. Komen Foundation (2002) 1 Yes Yes Yes The above table   was taken from the study conducted by Barton (2005) There are several ways presented and studied for breast cancer screening. Its concern is to reduce the prevalence of cancer mortality and to improve the quality of life as a result of early detection, however, there are still people that are not aware of breast cancer screening In response to increase the worldwide awareness of breast cancer, breast cancer advocacy movement has been analyzing the common experiences of women with breast cancer around the world especially those with limited resources. They found out that although there are language barriers, sentiments were consistent across cultures; cancer survivors have the same experiences and fears. The beliefs and taboos about breast cancer hinder the awareness programs and treatment. There are also limited resources for public education and awareness. Difficulty in understanding and translating the concept of the disease into English also hinders them in the public awareness of breast cancer (Errico and Rowden 2006). In accordance with this, sociological review of the barriers experienced by the women from different traditional cultures is essential not just to understand patterns of late breast cancer diagnosis but also the importance of interventions and programs. This is necessary for them to understand the preventive health care, specifically in breast cancer. This is because many are still ignorant of the breast cancer. According to Remennick (2006), health care providers and policymakers should try to understand and influence women especially those who are cancer risk to be aware of the disease to detect and treat breast cancer early. There are many structural barriers that hinder women especially those living in rural areas. Socioeconomic factors include poor health insurance, distance to medical facilities and inability to take time off work. Organizational barriers include difficulty in navigating complex health care systems and interacting with medical staff. Psychological and sociocultural barriers are poor health motivation, denial of personal risk, fatalism mistrust of cancer treatments and fear of becoming a burden on the family members. Still in other cultural behavior, especially in Muslims, women are strongly controlled by men and therefore may prohibit women in breast cancer screening. Remennick (2006) includes in his study the different approaches that lower the mentioned barriers, including implementation of uplifting the educational programs that would enlighten people regarding cancer myths and fallacies. He suggests that health care professional must outreach to their co ethnics. Primary health care providers play a critical role in   determining the compliance with treatment and preventive practices through direct recommendations to their patients. Family physicians and general internists showed that 70% of women who received a provider referral completed a screening mammography within one year versus only 18% of self-referred women (Grady   et al 1997 as stated by Santora 2003). However, Over 90% of rural women report that a doctor’s recommendation to have breast cancer screening is â€Å"important† (Sparks et al 1996 as stated by Santora 2003). It should be noted that clinician compliance is contributed by several factors such as relation with provider, guideline of the treatment, patient’s behavior and environmental factors. Several studies have been conducted to report the   differences of health services in rural, urban and suburban areas with regards to their   health care services in the family practice clinics. It has been pointed out that lower utilization has been a significant factor. Those rural health practitioners have less access to health care services.   In a study done by   Pol and his colleagues (2001), suggested that rural health services do not lag for patients with access after revealing that 9 out of 16 services examined were as high or higher in rural areas. Another   study to examine the variations in breast cancer screening among primary care clinicians by geographic location of   clinical practice was done by Santora (2003). Physicians, nurse practitioners and physician assistants were included in the study and were classified into urban, rural and suburban categories based upon practice location. The study revealed that although there was no significant difference in the practice location, there was evident variation in the practice of   breast screening. It was reported that urban and suburban health practitioners were less compliant with the use of breast cancer guidelines as compared to clinicians in rural areas.   Primary care clinicians, including physicians, nurse practitioners and physician’s assistants lack a consistent. This study revealed   that geographical location is not the main factor of inconsistent medical approach to breast cancer screening. Although the difference in the approaches to the procedure is uncertain in this study. A related study about General Practitioners’ (GP’s) knowledge, beliefs and attitudes toward breast screening, and their association with practice based-organizations of breast cancer screening, was conducted by Bekker, Morrisona and Marteau (1999). This study revealed that women’s attendance for breast cancer screening may be increased due to raising GP’s perceptions of the   threat of breast cancer. 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