http://doi.org/10.33698/NRF0046
Tara Shah , Indarjit Walia, Amarjit Singh
Abstract : A descriptive cross-sectional study on prevalence of Brest lump among women aged between 2—45 years was undertaken in a low socio economic locality of Chandigarh .the locality had 2714 houses. Of these only 2208 houses could be surveyed as 173 houses were being used as shops. 66 houses were vacant and 267 houses were found locked. in the surveyed houses 2548 women resided but only 2020 (79.3%) of the women were registered ,as 528 women were not available at home. Total 505 women were of the selected age group .only 435 women participated in the study and 70 women refused to participate. Data was collected at homes of the participants and privacy was maintained .selected women were assisted to conduct self breast examination followed by physical examination of the Breast by one of the investigator,among those who participated in the study ,410 (94.2%) women were married .total 287 (66%) women were illiterate and 354 (82%) women were housewives and did not work to earn . of the total study subjects ,395 (90.8%) had history of breast lump .whereas 101 (23.2%) subjects had asymmetry in size of breast .total 40 (76,9%) subjects had single lump .thirty –four (53.1%) subjects had lump at the upper outer quadrant of one of their breasts .out of these 37 (57.8%) lumps were movable and none of the subject had dimpling off nipples, whereas three of the subjects had axillary lymph nodes too.
Key words:Prevalence rate, breast lump, women , breast cancer
Introduction :Breast cancer is the leading cancer among women world wide, with more than 540,000 new cases occurring each year. Over 40% of these cases are in the developing countries1 cancer of the breast is the fifth most common cancer in India. Incidence of breast cancer in India is estimated to be 20.1 per lac population2. Breast cancer is more easily treated and often curable if found early .self –breast examination and screening mammography combined with clinical breast examination is the most effective detection method3. Breast lump is a localized swelling , protuberance ,or mass in the breast .it is one of the prime indicators of breast disorder .A lump might be a cyst ,a benign tumor or a malignancy .when a breast lump is found in women ,there is apprehension ,anxiety and fear of dreaded breast cancer, although most of the breast lumps are not cancerous ,as 80% of the breast lumps are benign .but the clinical signs of breast cancer are not easily distinguished from those of benign lump. A lump is usually the size of a pea before a skilled examiner can detect it. There is no mass careening program in india for the early detection of breast cancer ,therefore the responsibility of early detection lies with the patyient ,family and the health professionals .it has been recommended that women over 40 years of age should have an annual clinical breast examination .Women in the age group of 20-39 year should have once in three years and women above 20 years of age should practice monthly self breast examination .at present all women are not practicing self breast examination due to ignorance ,and mammography is costly affair for screening female population . To plan strategy to help women to early diagnose and prevent delay in seeking help for breast lumps, it is important to estimate the workload and prevalence of breast lump among general public in a given community .hence the present study was conducted in a community setting with the purpose to find out the prevalence of brest lump among women of low socio economic communities.
Materials and methods
To study prevalence of breast lump ,the ‘iceberg theory’4. Is kept in mind for the fact that majority of the cases do not report the problem and seek treatment for Varity of reasons and thus lie undetected in the community .this phenomena is more in the early phase. Methodology to study prevalence of breast lump was developed with concept borrowed from orem’s self care deficit theory5. as per this concept ,the individuals should have power and capability to engage in self –care .where as the trained nurses (nursing agency) engage in helping people to know and meet their therapeutic self care needs and demands. thus all three components of demands. thus all three components of Orem’s theory that is self care, therapeutic self care demands and self care agency are utilized to selected study population ,develop tool and execute the method of data collection of concept of study. Study is descriptive in nature and is cross sectional .it was conducted at a resettled colony sectional .it was conducted at a resettled colony of Chandigarh .the colony has about 16,500 people migrated from different states of India like Punjab ,Haryana, Himachal Pradesh ,utter Pradesh ,Bihar ,Rajasthan etc. most of these people are daily wage earners and work AS rickshaw pullers ,drivers,maids and run petty business and some are employed as workers in private or government agencies. The colony has modern sanitary facilities such as supply of clean tap water and underground drainage system .other available amenities include electrical supply ,a market ,post office ,government high school and an adult education center. There is regular bus services in the area. A part from government dispensary ,there are large number of private medical practitioners.Target population for the study were women between 20 to 45 years age residing in the colony ,irrespective of their education occupation ,income ,religion, marital and obstetrical status .by survey of 2208 houses in the locality a total of 2548 women of 20 to 45 years of age were listed. how ever 528 women were not available at home during study period and among the other 2020 women ,505(1/4 of women ) were enrolled for the study .during study ,70 women did not give consent for data collection .thus 435 women were included as study subjects (table1).
Table-1: Houses surveyed, study population and sample selection
| No. (%) |
| Houses surveyed
Total constructed houses 2714 (100.0) Surveyed 2208 (81.4) Could no be surveyed* 506 (18.6) Study population (women 20 to 45 years) Total women 2548 (100.0) Women contacted 2020 (79.3) Women could no be contacted# 528 (20.7) Sample population (every fourth women) Total subjects selected 505 (100.0) Subject studied 435 (86.1) Could not be studied 70 (13.9) (Refused consent for study) |
*total 267 houses were locked ,66 houses were vacant and 173 houses were used as shops, schools ,factory and post office.
# 528 women were not available at home.
Table 2 depicts that about one fourth of the subjects were below the age of 24 years and 50% of the subjects were less than 30 years of age .about 19 % of the subjects were in the age range of 40 to 45 years. Mean age of the subjects was 30.4±0.71 years. Total 410 (94%) respondents were married and only 14 respondents were unmarried .literacy rate was 66% and 20 subjects (4.7%) were graduates /postgraduates. Three hundred and fifty four (82%) of the respondents did not work to earn and were housewives .as per the social characteristics of the respondents, majority of them (84.1%) were Hindu and rest were Sikh ,Muslim ,Christians and Buddhist (fig.2). two third of the subjects were of upper lower class economically as per modified socio economic scale given for urban population by Kuppaswamy (fig.3).
Table-2: Age, marital status ,education and occupation of the respondents
(N=435)
| Characteristics No. (%) |
| Age (in years)
20-24 121 (27.8) 25-29 90 (20.6) X= 30.4±0.71 year 30-34 71 (16.3) 35-39 72 (16.5) 40-45 81 (18.8) Marital status Married 410 (94.2) Unmarried 14 (3.2) Widow 08 (1.9) Separated /divorced 03 (0.7) Education IIIiterate 148 (34.0) Upto 8th standard 146 (33.5) 9th to 12th standard 121 (27.8) Graduate/postgraduate 20 (4.7) Occupation Household work 354 (82.0) Private work 40 (9.0) Maid servant 23 (5.0) Government employees 18 (4.0)
|
Table 3 depicts that menstruation period was over just 10 days before interview for 149(34.2%) of subjects whereas for 110 (25.3%) of the subjects the menstrual cycle was over 11-20 days prior to interview for the study .thirteen (3%) subjects had attained menopause and 3 (0.7%) subjects have had hysterectomy and for 160 (36.8%) of the subjects. The menstrual cycle was due with in aweek or so total 134 (30.9%) subjects were pregnant /lactating .sixty (13.8%) respondents were primigravida ,7had conceived once nd had conceived once and delivered once and were with full term pregnancy whereas 26 (6.0%) out of nulligravida,14 respondents were unmarried and 12 had not conceive at all. Rest were multi –gravid .seventy six (17.5%) respondents were primipara including 53 respondents who had conceived once and delivered once while 18 had conceived twice and delivered once whereas 2had conceived three times and delivered once and one respondent conceived four times but delivered once .one respondent conceived five times ,but delivered once, one respondent conceived six times and delivered once,one respondent conceived six times and delivered once after 28 weeks of gestation .thirty five (8.1%) respondents were nullipara that included 26 respondents who did not conceived at all,7 conceived twice ,and did not deliver after 28 weeks of gestation .rest were multipara. There was no history of breast feeding in 40 (9.2%) respondents. the remaining had current and past history of breast feeding.
| Obstetric variables No (%) |
| Last data of menstruation prior to interview
Within 10 days 149 (34.2) 11to 20 days 110 (25.3) 21 to 30 days 77 ( 17.7) 31 days 83 (19.1) Attained menopause 13 (3.0) Had hysterectomy 3 (0.7) Pregnancy plus lactating status Pregnant 21 (4.9) Pregnant as well lactating 5 (1.1) Lactating 108 (24.9) Gravid Multigravida 188 (43.2) Grandmultipara 161 (37.0) Primigravida 60 (13.8) Nulligravida/not applicable 26 (6.0) Parity Multipara 216 (49.6) Grandmultipara 108 (24.8) Primipara 76 (17.5) Nullipara /not applicable 35 (8.1) History of breast feeding Yes,in past 282 (64.8) Yes,at present 113 (26.0) No/not applicable 40 (9.2) |
Table 4 depicts the lump detected in the breasts on palpation of the respondents .twenty six (6.0%) respondents had lump in the right breasts while 15 (3.4%) in the left breasts ; and remaining 11 (2.6%) had a lump in both the breasts
Table -4 : prevalence of breast lump among the respondents
| Breasts lump No (%) |
| Right breast 26 (6.0)
Left breast 15 (3.4) Both breasts 11 (2.6) |
| Total 52 (12.0) |
Table 5 brings forth the differences in size of the breasts during the inspection of the respondents .out of 435 respondents ,alteration in size of the breast was observed in 101 (23.2%) subjects wherein 73 (16.8%) respondents had the right breast bigger while 28(6.4%) respondents had bigger left breast overall alteration in size of breast was seem in 23.2% of the respondents .engorgement on both the breasts was observed for 3 (0.7%) respondents .two (0.4%) respondents had external growth (cyst) on the breasts.
Table-5 : Gross breast abnormalities detected among the respondents
| Appearance on breasts No (%) |
| Larger Right breast 73 (16.8)
Left breast 28 (6.4) Total 101 (23.2) Engorgement Both breasts 3 (0.7) External growth Right breast 1 (0.2) Left breast 1 (0.2) Total 2 (0.4) |
Table 6 reveals the abnormalities /lump detected durning the examination in the breasts of the respondents .in 298 (68.5%) cases, there was neither any change in the size ,nor any lump was present .in 85 (19.5%) respondents ,size of the breast was altered but there was no lump ,while in 36 (8.3%) there was no alteration in size ,but the lump was present .in 8 (1.8%) respondents the size was altered and lump was also found in same breast ; whereas in 5(1.2%) respondents ,the size of breast 3(0.7%) respondents had alteration in size of the breast with a lump present in both the breasts .
Table -6: Gross abnormalities detected in breasts and lumps present among the respondents (N=435)
| Size of the breast and lump No (%) |
| No alteration in size ,no lump 298 (68.5)
Altered in size, but no lump 85 (19.5) No alteration in size, but lump present 36 (8.3) Altered in size with lump in same breast 8 (1.8) Altered size in one breast with lump present in another breast 5 (1.2) Altered in size with lump in both breasts 3 (0.7) |
Table 7 shows as under the prevalence of single or multiple cases of breast lumps in the respondents .on palpation ,out of 52 breast lumps detected ,40 (76.9%) respondents had a single breast with a lump while 12 (23.1%) had multiple breast lumps.
Table- 7: Distribution of respondents as per the number of breast lumps. (n=52)
| Breast Lumps No (%) |
|
Single 40 (76.9) Multiple 12 (23.1) |
Table 8 shows that there were 38 lumps in the right breast of the respondents .twenty eight (73.7%) lumps were in the upper outer quadrant while none of the lump was found in lower outer quadrant. 4 (10.5%) were in the upper inner quadrant; and 6 (15.8%) were in lower inner quadrant of right breast of the respondents. There were 26 lumps in left breast of the respondents .around half of them 12 (46.2%) lumps were found in upper inner quadrant ; while none of the lump was found in lower outer quadrant .4 (10.5%) were in the upper inner quadrant; and 6(15.8%) were in lower inner quadrant of right breast of the respondents .there were 26 lumps in left breast of the respondents. Around half of them 12 (46.2%) lumps were found in upper inner quadrant ; while 6(23%) lumps were in upper outer quadrant .one (3.8%) was in lower outer quadrant ,7 (26.9%) were in lower inner quadrant of the breast .
Table -8 : Location of the breast lumps among subjects
| side of the breast Location of the Single Multiple total
Brest lump No. (%) No. (%) No. (%) |
| Upper outer quadrant 18 (72.0) 10 (76.9) 28 (73.7)
Lower outer quadrant – – – RIGHT Upper inner quadrant 2 (8.0) 2 (15.4) 4 (10.5) Lower inner quadrant 5 (20.0) 1 (7.7) 6 (15.8 Total 25 13 38
Upper outer quadrant 3 (20.0) 3 (27.3) 6 (23.1) Lower outer quadrant – 1 1 (9.1) 1 (3.8) Upper inner quadrant 6 (40.0) 6 (54.5) 12 (46.2 LEFT Lower inner quadrant 6 (40.0) 1 (9.1) 7 (26.9) Total 15 11 26
|
Table 9 reveals the shape of the breast lumps among the respondents .thirty seven (57.8%) breast lumps were oval in shape whereas 26 (40.6%) were round ; and one (1.6 %) breast lump had ill defined borders.
Table-9: Shape of the breast lumps among the respondents
| Shape of the Single Multiple Total
Breast lumps N=40 N=24 N=64 No. (%) N0. (%) No. (%) |
| Oval 19 (47.50) 18 (7.5.0) 37 (57.8)
Round 20 (50.00) 6 (25.0) 26 (40.6) Difficult to Define Borders 1 (02.50) – 1 (01.6) |
*n=24 as in cases of multiple lumps where more than one lumps were found.
Table 10 brings out that the consistency of the single breast lump was soft in 36 (90%) cases while 4(10%) single lumps were hard .twenty one (87.5%) multiple breast lumps were found to be soft; whereas 2 (12.5%) multiple lumps were hard.
Table -10 : consistency of the breast lumps among the respondents
| Consistency of the Single Multiple Total
Breast lumps No. (%) N0. (%) No. (%) |
| Soft 36 (90.0) 21 (87.5) 57 (89.1)
Hard 4 (10.0) 3 (12.5) 7 (10.9) |
| TOTAL N=40 N=24* N=64 |
N=24* as in cases of multiple lumps more than one lumps were found.
Table 11 indicates the tenderness of the breast lumps among the respondents. Thirty five (54.7%) lumps were tender in both groups.
Table -11: Tenderness of the Breast Lumps among the Respondents
| Tenderness of the Single Multiple Total
the breast No. (%) N0. (%) No. (%) |
| Soft 36 (90.0) 21 (87.5) 57 (89.1)
Hard 4 (10.0) 3 (12.5) 7 (10.9) |
| TOTAL N=40 N=24* N=64 |
n=24*as in case of multiple lumps more than one lump was found .
Measurement of unidimension of the breast lump
Table 12 reveals the size of the breast lumps among the respondents .in 39 cases the size of the single breast lumps were measurable ; length of one (2.06%) single lumps was 1cms while length of 14 (45.9%) single lumps was 2cms,16 9 (41%) single lumps length was 3cms,6(15.4%) single lumps length was 3cms ,6 (15.4%)single lumps width was 4cms ; and 2(5.1%) single lumps length was 5cms .out of 24 multiple breast lumps 2(8.04%) multiple lumps had a length of 1 cm and 6(25%)multiple lumps had a length of 2cms,10 (41.06%) multiple lumps were having a length of 3 cms whereas 9( 37.5%) multiple lumps were having width of 3cms. 6(25%) multiple lumps were with length of 4 cms and 2 (8.04%) multiple lumps were with of 5 cmc. Mean length of single and multiple lumps was 2.93 cms with standard deviation 0.39 cms and length range of 1 to 5 cms. Mean width of single and multiple lumps was 2.2 cmc with standard deviation of 0.29 cm and width range of 1to 4 cms.
Table -12: size of the breast lumps among respondents
| Size of the
Breast lump (in cms) |
Single | Multiple |
| Length
No. (%) |
width width Length
No. (%) No. (%) No. (%) |
|
| 1 01 (2.06) 08 (20.5) 02 (08.04) 6 (25.0)
2 14 (35.9) 13 (33.3) 04 (16.06) 9 (37.5) 3 16 (41.0) 17 (43.6) 10 (41.06) 9 (37.5) 4 06 (15.4) 01 (02.6) 06 (25.00) – 5 02 (5.01) – 02 (08.04) – N=39** n=24* |
||
*n= 24 as in cases of multiple lumps were more than one lump were found.
** in one case the size of the breast lump was not measurable .
Mean length of the lump (x)=2.93 cms SD ±0.39 cms ,range =1-5 cms
Mean width of the lump (x) =2.2 cms ,SD± 0.29 cms ,range =1-4 cms
Table 13 and fig .5 depict the measurement in terms of the size of the the breast lumps as per length and width in cms .of the 63 lumps ,the major variants that have been observed were; 3 (4.8%) lumps of 1×1 cm,whereas 11 (17.5%) were of 2×1 cm .seven (11.1%) lumps were of 2×2 cms .there were 10 (15.9%) lumps of 3×2 cms ,15 lumps (23.7%) were of 3×3 cms; and 8 (12.7%) were of 4×3 cms. The remaining measurements are as shown in the table-13.
Table -13: Size of the breast lumps as per length and width
| Length and width of the breast lump (cms) NO. (%) |
| 1×1 3 (4.8)
2×1 11 (17.5) 2×2 7 (11.1) 3×1 1 (1.6) 3×2 10 (15.9) 3×3 15 (23.7) 4×2 2 (3.2) 4×3 8 (12.7) 4×4 1 (1.6) 5×2 1 (1.6) 5×3 4 (6.3) |
Discussion
Despite advancement and multifold improvement in scientific knowledge, presently there is no known method for primary prevention of breast cancer. Under the present circumstances, therefore early detection and treatment of breast cancer as a secondary preventive measure seems to be the most appropriate approach for reducing mortality due to breast cancer and for improving quality of life in these clients .many clinical methods have been considered for an early diagnosis of breast cancer and for improving quality of life in these clients. Many clinical methods have been considered for an early diagnosis of breast cancer including BSE , regular physical examination of breast and a Varity of methods of imaging for early lesions in the breast ,particularly mammography . At present ,mammography either alone or in conjunction with physical examination is the only detection method of proven value for screening.
Randomized trials of screening of breast cancer have clearly demonstrated a substantial reduction of the order of 40% in the breast cancer mortality among women aged over 50 years i.e. when regularly screened every two to three years by mammography .no other screening modalities has been demonstrated to be benefit ,nor as screening of younger women . the major problem of breast cancer screening at present is the need for greater understanding of the heterogeneous natural history of the disease. The extent to which earlier diagnosis improves, prognosis is poorly understood ,but remains crucial for determining the full potential of screening .6 BSE is a technique that all women can use to assess their own breasts. thus it is a useful self –care activity for all adult women. The American cancer society recommends BSE. Malignancy may be discovered at an early stage and treated accordingly .regular monthly BSE is an essential health maintenance activity. Breast lumps are common and most women will detect a breast abnormality at some time in their lives .this is irrespective of the promotion of breast self –examination (BSE) by the medical profession .it should be possible to increase a women’ s ability to deal better with this anxiety-provoking situation, and to reduce the number of women presenting with locally advanced disease by an appropriate health education .breast cancer is not completely understood. Although stage at diagnosis (often before a lump is palpable) can lead to effective treatment which prolongs life ,earlier treatment of a palpable lump detected by BSE is not guaranteed to improve survival (mant,1991).6 at present the aim of the examination was to screen the respondents for breast lump ,which is considered, as early detection of breast cancer .there are several methods of performing BSE and physical examination of breast, like inspection ;palpation with three or four fingers or using fingers pads. Palpation by concentric or radial movement or combination of the movements (twelve o’clock method ) .however ,American cancer society has recommended circular patter in addition to the inspection .combination of circular and radial methods is likely to have a better screening potential .however ,this comment is invalid in view of lack of comparative studies of the methods .more studies are necessary to arrive at a concrete conclusion for selection of the best method for recommendation .the present study utilized ‘Twelve stroke’ Method for BSE/ physical examination of the breast and this method was found easier by the respondents and less confusing for moving the direction of hand durning palpation (Devi,1997)2. Between the year 1991-1993.donald carried out a cross –sectional age stratified community random sample survey of more than 8,000 subjects 65 years old and above to determine the prevalence of and above to determine the prevalence of and risk factors for dementia in Canada. To avoid the expense of full diagnostic work ups, investigators used modified mini –mental state examination to screen for dementia or cognitive impairment.7 this is similar to the present study as it is descriptive cross –sectional study. it was a community based study on prevalence of breast lump amongst those women in the age 20 to 45 years old women .systematic random sampling technique was used .to avoid the expense for the full diagnosis through mammography ,fine needle aspiration cytology (FNAC) and biopsy tests were avoided and only physical examination was done to screen the target population for the breast lump .breast self –examination (BSE) have consistently identified that a set of limitation were negatively related to BSE practice such as lack of confidence in one’s examination fear of an abnormality ,forgetting ,and lack of time .Therefore ,instruction in BSE has been positively practice (Leuver,1989).8
Present study was conducted in an urban slum having low socio-economic class. most of the respondents were housewives and most of the them were grand –multi and multi-gravid/pare. The study revealed that the one out of every eight women had a lump in breast .literature shows that one-fourth of all breast lumps are found to be cancer. Majority of the lumps in the present study were single. The largest portion of glandular breast tissue occurs in the upper lateral quadrants of the breasts .from this quadrant there is an anatomical projection of breast tissue into the axilla .this projection is termed the axillary tail of Spence. The majority of the breast lumps are located in upper laternal breast quadrant and in the tail of Spence. Studies reveal that lumps were located in the upper outer quadrant of the breasts in 60 % cases. Lumps found in the the upper outer quadrant are of maximum concern to the doctors.7
Present study brings out that majority of the lumps were found in upper outer quadrants and very few were found in lower outer quadrants and very few were found in lower outer quadrants of the both breasts. Present study found that majority of the lumps were oval in shape ,while some lumps were round and very few lumps had irregular borders. according to different studies most of the benign lumps are round and oval in shape ,whereas palpable irregularities and poorly defined lumps are very common ,particularly in thin women. irregular shape of the breast lumps are of most concern to be malignant in nature. Present study reveals that most of the lumps were soft and very few lumps were hard in nature .as per literature ,physical findings suggestive of a malignancy include a hard lumps. in the instant study ,11% cases were identified and they need further careful evaluation. Breast cancer is usually noted as a painless lump and discovered incidentally by the client ,by routine physical examination or by mammography .pain and tenderness are non-specific findings .painful lumps reflect inflammation of the breast tissue. present study revealed that majority of the lumps were tender and some were painless. The size of the primary lump, a clinical predictor of outcome, can be determined easily by palpation .lumps less than 2 cms in size are generally associated with the most favourable outcome.9 detection of the breast lump declines as the size is decreased, present study revealed that almost all lumps were 2 to 4 cms long and mean length was 2.93 cms±0.39 cms. almost all lumps were 1 to 3 cms wide and mean width was 2.2 cms ±0.29 cms .multi –dimension (length×width) of 23.7% lumps were 3×3 cms. In the the present study all lumps were movable on palpation. Different studies have brought out that hormonal changes during the menstrual cycle lead to a cystic pattern of change in the breast size along with lumpiness and tenderness,that is maximal just before menses .the breast is smallest 4 to 7 days after of the menstrual cycle .during days 3 to 4 prior to the onset of menses, mammary tenseness, fullness, heaviness ,tenderness and pain are experienced by many women ,and the breast volume is significantly increased .present study brings to the fore that majority of the respondents were in within 20 days after thneir menstruation cycle .on general app[earance normal breasts are reasonably symmetrical in size and shape, though not usually absolutely equal .this symmetry remains constant at rest and with movement .the present study reveals that some respondents had alteration in size of the breast. None of the respondents had alteration in shape of the breast. Present study has revealed that very few respondents had inflammation in their breast , but they did not have breast lump. Very few respondents were found with axillary lymph nodes ,but they did not have breast lump.
Conclusion
The study was helpful in screening women for breast lump . women were taught and encouraged to do self breast examination .Twelve percent of women were taught and encouraged to do self breast examination .twelve percent of women found having breast lump were referred for further investigations .there is a need for follow-up action for detection of breast lump in a larger /whole of female population
References
- Baron RH, Walsh A l. facts everyone should know about breast cancer. American J Nurse 1995 ;95:2-33
- Devi R.A.study to develop a manual on breast self –examination .Thesis of M.Sc. Nursing ,college of
Nursing ,PGIMER ,Chandigarh (Punjab University ).1997,.1-3 (unpublished).
- Freeman RB,Heinrich J.Community health nursing practice .2nd ed.WB Saunders Company ,Philadelphia . 1981;336.
- Park K Park’ s Text book of Preventive and social medicine .16TH ED.M/s Banarsidas Bhanot ,Jabalpur
.2001; 289-90.
- Hortweg DL,Dorothea Orem .Self care Deficiut Theory .Sage Publication ,Newbury Park,London.1991;9-
34.
- Mant D.Breast self examination .British Mdical Bulletin .1991;47 (2): 455-61.
- Lauver d.Instructional information and breast self-examination practice .Research in Nursing and Health
1989; 12:11-19.
- Fulton PJ,Rakowski Wand Jones CA. Determinants of breast cancer screening among inner-city Hispanic
Women .Public Health Reports.1995;110 (4): 455-82.
- Donald A.Verification bias: Apit fall in evaluating screening tests.Nursing Research .1996;45 (6):350-1.