What makes women receptive to breast self-examination, animation, or simulation? – a comparative study

Abstract

Background:

Breast self-examination (BSE) plays an important role in the early diagnosis of breast cancer in India owing to the stigma attached to cancer. The authors compared the efficacies of animation video versus simulation techniques in BSE.

Methods:

Women with no previous history of conditions affecting the breasts were included in this prospective observational study and divided into an animation or simulation arm. The latter was further divided into three subgroups as per the simulation models used : the German (Delta Healthcare), British (Health Edco), and Indian (low-cost, validated) models used for teaching BSE. The hybrid animation video had a 9 min runtime with a lecture on BSE and a virtual character performing BSE. In both the arms, participants filled in a validated modified patient satisfaction questionnaire.

Results:

A total of 500 women participated. The mean age of the participants in the animation video arm was 20.21±3.88 years and 19.34±2.27, 22.94±9.6, and 18.97±1.31(20.41±5.99) years in the Indian, German, and British simulation models arm, respectively. The age difference between the two arms was statistically significant (P<0.05). Both animation video and simulation models were found to be useful by the participants. The participants’ response to animation video being a better organized tool for learning BSE was statistically significant (90.48±7.98 vs. 84.02±15.09 P≤0.001) when compared to simulation models. The younger women (≤20 years) found these tools significantly more useful than those aged >20 years.

Conclusions:

All models had good efficiency and utility as learning tools for BSE. However, large studies in BSE set up with combination models are needed.

Introduction

Highlights

• Breast self-examination is a valuable tool in developing countries where tumors are fairly large.

• Simulation models are useful; however, may be costly and animation models are also useful.

• We have compared our animation and simulation models.

Breast cancer is the most common cancer among women worldwide¹. According to the WHO, a woman dies in the world every minute due to breast cancer. Early detection in order to improve breast cancer outcome and survival remains the cornerstone of breast cancer control. Breast cancer is ranked number one among Indian females, with an age-adjusted rate as high as 25.8 per 100 000 women and mortality 12.7 per 100 000 women^1,2. The burden of breast cancer is very high in our country due to the vast population. Indian women with breast cancer are found to be a decade younger in comparison to western women suggesting that breast cancer occurs at a younger premenopausal age in India¹. This is substantiated by the fact that the incidence of breast cancer in India is high among women aged between 30 and 40 years compared to older women. However, they are still being diagnosed at later stages¹. Breast cancer is more aggressive in younger women when compared to older women³. Young females below 40 years have more denser breast tissue, which makes them less amenable to routine screening programs making women in this age group more likely to present with a palpable mass with a tumor, which tends to be larger and are more likely to have nodal involvement at the time of presentation. Younger aged patients tend to be triple negative – a significant poor prognostic factor⁴. Prevalence of TNBC in India is considerably higher compared with that seen in Western populations as suggested by various meta-analysis studies⁵.

Multiple studies have reported the association of various risk factors with breast cancer in Indian women. Women from north India have revealed a strong association of risk factors like lack of breast-feeding, location (urban/rural), increased BMI (increased waist-to-hip ratio), tobacco chewing, smoking, lack of exercise were strongly associated with breast cancer^1,3.

The reasons for the delayed disease presentation of such cases to the healthcare centers are illiteracy, lack of awareness, and financial constraints in some regions of India. This, in turn, increases the mortality rate. While the 5-year survival rate is 90.2% in the US, it is only 66.1% in India⁶. Lack of organized breast cancer screening programs, paucity of diagnostic aids, and general indifference toward the health of females in the predominantly patriarchal Indian society are also the drawbacks leading to increased breast cancer incidence. Hence, majority of patients here are still present to us at locally advanced and metastatic stages.

Early detection of breast cancer can save lives³. India is an ethnically and culturally diverse country, hence, a multidisciplinary approach to breast cancer including awareness programs, preventive measures, screening programs for early detection, and the availability of treatment facilities are vital for reducing both the incidence and mortality of breast cancer in Indian women. Indian women unlike their western counterparts, are reared with different cultural values and they may not be comfortable in learning from simulators made for teaching women from other countries.

There are no uniform guidelines available for the screening of breast cancer due to the varying standards of medical care provided depending on income levels. Therefore, increasing the awareness of this disease among our women is imperative. The best way forward is to involve them as active participants in detecting their own disease and raise awareness on breast cancer by a means as simple as breast self-examination (BSE)¹.

Early detection of breast cancer is an important factor in the success of its treatment. The earlier the breast cancer is diagnosed, the more easily and successfully it can be treated. The three commonly used methods for the detection of breast cancer are BSE, clinical breast examination, and imaging (usually mammography). BSE is an optional screening tool for women to check their breasts for early signs of breast cancer. Few studies have proved that BSE can help in early detection and thereby decrease the risk of associated mortality. Indeed, women who perform regular BSE can detect 90% of all breast lumps. Although 80% of breast lumps are not cancerous, serious malignant changes can be caught early, improving survival.

The major barrier to BSE is the lack of confidence. BSE is an option for all women from the age of 20 years. Women who regularly examine their breasts become aware of how they feel normally. BSE is cost-effective and by practicing it, a woman becomes her own physician. It is simple to perform in personal time and requires limited space for examination^7–14. Women should be made aware that cancerous tumor is more likely in certain parts of the breast: about 41% are in the upper and outer quadrant, 14% in the upper and inner quadrant, and 34% in the area behind the nipple. Hence, they should concentrate more on the upper and outer quadrant and the area behind the nipple^7–14.

Previously, we have conducted studies on thyroid disorders for better patient and relative understanding using three different models for explaining the operations: the diagram, plastic toy, and animation models¹⁵ and the patients found these models useful. We have also assessed a technique of storytelling in explaining the operative procedure¹⁶ and outcomes for patients undergoing thyroidectomy and found this as a useful tool.

Likewise, we feel that teaching women using simulation and/or animation models could help to increase awareness and understanding of BSE among women. We aimed to evaluate the efficacy of video with an animation model using story telling technique versus a simulation model as tools for educating about BSE in Indian women.

Methods

Registration and ethics

Ethical and institutional committee approval was obtained for this prospective study. Participants were clearly explained about the study and informed consent was obtained.

Study design

This was a prospective, observational study conducted by a team of breast surgery specialists at a tertiary care center. Through an estimation from 20 patients (10 each in the animation and simulation model groups), BSE was found to be useful in 89 and 77%, respectively. At a two-sided 95% CI and 90% power of study, an estimated sample size for each group (animation and simulation arm) was calculated as 199.

A total of 500 women between the ages of 18–60 years with no prior history of conditions affecting the breast were included in the study (Algorithm 1).

Women not willing to participate and with previous history of treatment for breast disorders or surgery were excluded from this study.

Setting and participants

The 500 participants were allocated into two groups by simple random sampling. The first group (n=200) was taught about BSE using a hybrid animation video. The total duration of the video was 9 min wherein a senior resident from the Department of Breast Surgery, delivered a lecture for 6 min on the importance of BSE. This was then followed by an animation video showing the techniques of breast BSE (3 min). The participants in this group were then asked to fill in the modified patient satisfaction multimedia questionnaire.

The second group (n=300) was subdivided into three groups of 100. Women in each subgroup were shown a three-dimensional (3D) breast simulation model as follows: Model 1 group: British (Health Edco, ITEM: 26547) model, Model 2 group: German (Delta Healthcare, 000047/1000344) model, and Model 3 group: a low-cost Indian model (SGPGI model) (Fig. 1).

Figure 1.

Three-dimensional breast self-examination simulation models. (A) German model – three breast mounds, one each of normal breast, breast with a benign lump and breast with a malignant lump; (B) British model. Left breast is normal and the right breast has a malignant lump palpable; and (C) Indian (SGPGI model) – Clothed mannequin with a right normal breast and a malignant lump in the left breast.

The British model comprised of a pair of breast mounds, one being a normal breast and the other containing a malignant lump. The German model had three breast mounds, a normal breast, one with a malignant lump, and one with a benign lump. The Indian model was based on a clothed mannequin with one normal breast and the other breast having a stony hard malignant lump¹⁷. The breast surgeon explained the method of BSE and also about the model to the participants, then the participants palpated the models. They then filled in the modified patient satisfaction multimedia questionnaire online on a dedicated website. The work has been reported in line with the Strengthening the Reporting of cohort, cross-sectional and case–control studies in Surgery (STROCSS) criteria¹⁸. The research was registered with CTRI (CTRI/2021/03/032057).

The data were analyzed using SPSS (version 22.0; IBM Corp.) to compare the efficacy of the two arms, that is video animation versus the simulation model, in teaching BSE to women.

Scheme of the study

Results

Out of the total study cohort of 500 participants, 200 were shown the animation video of BSE, whereas 300 were taught BSE using simulation models (100 participants in each subgroup). The mean age of participants in the animation video group was 20.21±3.88 years, and the mean age of those shown the Indian, German, and British simulation models was 19.34±2.27, 22.94±9.6, and 18.97±1.31, respectively. The age difference between the two groups was found to be statistically significant on analysis (P<0.001). Most participants were graduates (83% in the animation model group vs. 51% in the simulation model group) and 98% were working women belonging to the urban areas of Uttar Pradesh.

All women found animation videos and simulation models effective tools for learning about BSE. They also agreed that both of these tools stimulated an interest within them to share the knowledge acquired about BSE with their kith and kin (Table 1).

Table 1.

Distribution of demographic and attitude of the study participants between animation model and three simulation models.

	Intervention
Variable	Video (n=200)	British (n=100)	German model (n=100)	Indian model (n=100)	P
Age (Years)	20.21±3.88	18.97±1.31	22.94±9.6	19.34±2.27	<0.001
Education (graduate and above)	83 (51.9%)	51 (51%)	41 (41%)	50 (50%)	0.349
Profession (employed)	157 (98.1%)	100 (100%)	100 (100%)	100 (100%)	0.129
Residence (urban)	160 (100%)	100 (100%)	99 (99%)	100 (100%)	0.307
Improved understanding of the BSE	89.36±9.18	84.97±14.03	86.95±12.54	85.79±18.95	0.051
Better organization of BSE	90.48±7.98	85.11±12.79	85.45±14.84	81.54±19.22	<0.001
Stimulated interest among relatives regarding BSE	90.68±11.2	88.81±10.23	90.63±10.27	91.12±13.63	0.479

BSE, breast self-examination.

When comparing the animation video with the simulation models, we demonstrated that participants found the animation video of BSE information to be more useful compared to the three simulation models (Table 2).

Table 2.

Distribution of demographic and attitude of the study participants between animation model and simulation models (N=500).

Variable	Animation Model (n=200)	Simulation models (n=300)	P
Age (Years)	20.21±3.88	20.41±5.99	0.709
Education (graduate and above)	83 (51.9)	142 (47.3)	0.353
Profession (employed)	157 (98.1%)	300 (100%)	0.017
Residence (urban)	160 (100%)	299 (99.7%)	0.465
Improved understanding of the BSE	89.36±9.18	85.90±15.41	0.009
Better organization of BSE	90.48±7.98	84.02±15.90	<0.001
Stimulated interest in the relatives regarding BSE	90.68±11.20	90.19±11.50	0.658

Independent samples t-test was used. P<0.05 significant.

BSE, breast self-examination.

Similarly, animation video was found, to have a better organization and a means of learning about BSE as compared to the simulation models, and these differences were statistically significant. When the three simulation models were compared separately with each other, no statistically significant difference was noted among them with respect to usefulness or organization.

When the age cut-off of 20 years was taken to assess the response toward all BSE models, we found that participants in the age group of less than or equal to 20 years were more receptive to this approach. It was noted that this age group found the models to be significantly more useful in helping them understand BSE compared to older women (P<0.007). This group also found the animation video to be better organized for education about BSE (P<0.001) as compared to older women.

Discussion

Breast self-examination helps women be aware of the appearance and nature of their breasts. Any changes noted by a woman during breast self-examination can prompt her to report them to a health care provider. The American Cancer Society does not recommend breast self-examination as a screening tool for breast cancer as it is not associated with decreased mortality independently. In the western part of the world, annual screening mammography is widely available, and it has increased the awareness of the western women to breast cancer detection¹⁹. Moreover, the majority of the population in the developed countries is insured so health concerns are not a burden to them.

In developing countries like India, no separate guidelines for breast cancer screening exist. Access to mammography for our women is a challenge. The majority of our women belong to low socio-economic strata, have less education, and do not seek care upon feeling a breast lump. This is attributed to their unawareness that what the lump represents, the stigma of being rejected by the community and her partner, the potential fear of loss of the breast, and the major obstacle being the prevailing taboo of not discussing breast cancer topic openly, and their disbelief of the existence of any effective therapy for the disease²⁰.

BSE has been found to be the most reasonable and feasible approach in early detection and reduction of breast cancer mortality in India and other developing countries^21,22. Studies from India suggested BSE can be used as a tool of creating breast health awareness among women and trained female health workers can play a promising role in disseminating this knowledge among women to carry out BSE²¹.

In this study, both the animation video and simulation models were well accepted by the participants. They were regarded as useful tools for learning about BSE and spreading this information acquired to their relatives as well. However, when compared with each other, the animation video scored higher as both a learning tool and a tool that propagates BSE practice among women. When the three simulation models were compared, each was found to be equally useful by the participants and there were no differences in preference. However, the animation video lacked the tactile feeling as it is the case for a young surgeon learning robotic surgery²³ and the feeling of the pathological breast lumps by women may be important for the success of BSE in the long run. Simulation models provide the necessary tactile input; however, the breast surgeons and their teams need to emphasize the right method of BSE and explain the different tumors and when to be alarmed using these simulation models.

We found that most Indian women were not aware of BSE except if any family member had suffered from breast cancer^15,16 and so a combination of both an animation video and a simulation model may provide better results with adequate knowledge from the animation video and the appropriate tactile simulation from the simulation models. In many institutions because of the patient load, where the interaction time between the patient and the consultant is suboptimal²⁴, it may be problematic for surgeons to teach BSE to women, which shall take 12–15 min of the precious time of the surgical team. Therefore, such videos and simulation models and the involvement of breast nurses^25–29 could be of great help in increasing the understanding of various aspects of BSE.

Education around any preventive strategy is a two-way approach. However, most health care initiatives have moved away from a doctor-centered approach to both patient and breast surgeon-centered approach simultaneously to improve the understanding of BSE. Recently, the use of psychotherapeutic interaction on BSE based on the health belief model³⁰ wherein the intervention group received messages aimed at promoting the practice of BSE whereas the control group received messages promoting general health. A significant proportion of participants achieved this wanted behavior. In addition, once a woman has been taught the proper way of BSE, there should be a reinforcement in the form of messages with the help of social media or telemedicine³¹. Animation videos made by experts, incorporating story telling techniques with clear subtitles, could be useful and provide clear information on breast examination even for women with hearing impairment³².

The issues surrounding breast cancer are different in developing countries compared to high-income nations. BSE could enable women to approach the health care system early, resulting in better outcomes^33–36. In low-resource settings, simulation models in accordance with the culture of the women could be useful³⁷. These may yield the best results when combined with storytelling animations, where a popular character narrates the usefulness of issues, such as breast cancer and the benefits of BSE. We have not been able to find similar studies in the literature. The limitation of our study is that most women belonged to the urban area and most of them were less than 20 years of age.

In conclusion, this study shows that simple animation videos and simulation models can be used as effective tools for raising awareness about BSE and also teaching the right method of BSE. These help women understand the procedure better and be more compliant.

Ethical approval

The ethics committee, SGPGI Ethics Committee, approved the study (Institute Ethics Committee No. PGI/2021/3/emp-118).

Consent

Taken.

Sources of funding

This study was not funded by any grants or institutions.

Author contribution

S.M. and S.I.: contributed to the conception and design of the study, did the analysis and interpretation of data, and drafted the article; S.M., S.I., and S.M.: did the acquisition of data. All authors revised the article critically for important intellectual content and also the final approval of the version to be submitted.

Conflicts of interest disclosure

The authors declare no conflicts of interests. A part of this manuscript was accepted as a poster and presented by Sarrah Idrees at the 49th World Congress of Surgery at Vienna, Austria in August 2022.

Research registration unique identifying number (UIN)

CTRI/2021/03/032057.

Guarantor

Sabaretnam Mayilvaganan.

Data availability statement

Not applicable.

Provenance and peer review

Not commissioned, externally peer reviewed.