Self-Examination and Screening Barriers Associated With Breast Cancer Stages Among Patient Women in Baghdad,Iraq

Abstract

Background

Breast cancer remains a major public health concern among Iraqi women, with limited awareness and practice of self-examination and screening contributing to late detection. This study aimed to evaluate the impact of self-examination and screening barriers on breast cancer detection and to examine the relationship between these barriers and cancer stages.

Materials and Methods

A cross-sectional survey was conducted in Baghdad, Iraq, among 325 women aged 18–63 years who had been diagnosed with breast cancer. The questionnaire assessed self-examination practices, screening experiences, and perceived barriers to early detection. Statistical analyses included chi-squared tests to determine associations between variables.

Results

The findings revealed poor engagement in self-examination: 68.3% of participants never checked for lumps, 89.8% had not been trained to feel a lump, and 79.4% had not undergone screening before diagnosis (p=0.021, 0.001, and 0.002, respectively). Significant screening barriers were reported, including difficulties communicating with doctors (90.8%, p=0.014), limited decision-making power to undergo testing (81.2%, p=0.035), and reluctance to waste doctors’ time (81.2%, p=0.029). A strong association was found between cancer stage and health insurance (χ²=47.646, p=0.001), and between fear of visiting doctors and cancer stage (χ²=6.961, p=0.031).

Conclusions

Low awareness and barriers to screening significantly delay breast cancer detection. Enhancing women’s knowledge and empowerment through sustained health education, accessible screening services, and targeted awareness campaigns is essential to promote early diagnosis and reduce the disease’s health and social impact.

Keywords

early detection self-examination breast cancer stages screening barriers mammography

1. Introduction

Breast cancer affects millions of people globally, making it a significant health concern, and it is in the top three cancers common worldwide.^1-6 In Iraq, this formidable disease presents a considerable challenge to public health, necessitating comprehensive awareness, prevention, and early detection strategies.^7-11 The impact of breast cancer in Iraq is magnified by various factors, including cultural norms, limited healthcare resources, and the social stigma surrounding women’s health. Iraq, with its rich history and diverse population, faces unique challenges in combating breast cancer.¹² Limited access to healthcare facilities, especially in rural areas, often hinders timely diagnosis and treatment.¹³ Additionally, societal perceptions and cultural norms related to women’s health may contribute to delays in seeking medical attention, further exacerbating the problem.¹⁴ In Iraq,¹⁵ the total number of the most prevalent cancer sites reached 29,149, representing 67.7% of all newly diagnosed cancer cases in 2023. The breakdown includes breast cancer at 8,849 cases (20.5%), colorectal cancer at 3,108 cases (7.2%), lung cancer at 3,020 cases (7%), thyroid cancer at 2,823 cases (6.6%), brain and central nervous system cancers at 2,818 cases (6.5%), and bladder cancer at 2,018 cases (4.7%). Collectively, these six types of cancer account for over half (52.6%) of all newly diagnosed cancer cases. Among Iraqi males, lung cancer was the most frequently diagnosed, with 2,129 cases (11.8%), followed by prostate cancer with 1,656 cases (9.2%) and colorectal cancer with 1,606 cases (8.9%). In contrast, breast cancer was the most common cancer site among females, with 8,708 cases (34.8%), followed by thyroid cancer at 2,265 cases (9.1%) and colorectal cancer at 1,502 cases (6.0%). The age-standardized rate (ASR) for the Iraqi female demographic was recorded at 65.5 per 100,000 individuals. The five governorates exhibiting the highest ASR included Erbil at 92.3 per 100,000, followed by Baghdad at 83.8 per 100,000, Karbala at 80 per 100,000, Al-Najaf at 71.4 per 100,000, and Al-Basrah at 69 per 100,000. The average age at which diagnosis occurred was 53.7 years, while the median age was 53 years.

Early detection remains a cornerstone in the battle against breast cancer and dramatically increases the likelihood of a successful course of therapy and recovery. Therefore, fostering awareness about breast cancer, promoting routine screenings, and empowering women to prioritize their health are crucial components of an effective public health strategy.^16-18

The objective of the study is to identify and analyse the barriers to self-examination and breast cancer screening among infected women in Baghdad, Iraq, with a focus on how these barriers are associated with different stages of breast cancer. The study aims to understand the factors that prevent women from conducting regular self-examinations and seeking professional screening, and how these factors may impact early detection and outcomes of breast cancer.¹⁹

This study was conducted to shed light on the challenges and barriers that women face in Baghdad, which may lead to late-stage diagnoses, and to provide insights into improving public health strategies for early detection and prevention of breast cancer. By identifying the specific barriers, the research also aims to contribute to better awareness programs and policies that could help reduce the incidence of late-stage breast cancer among Iraqi women.

In the end, this study should answer the following questions:

1. To what extent do obstacles to breast cancer screening influence the stage at which the disease is diagnosed?

2. Is there a statistically significant relationship between delayed screening and the advancement of breast cancer stages among diagnosed women?

3. How do awareness levels and misconceptions impact women’s participation in early detection practices?

2. Methods

A cross-sectional survey was carried out in Baghdad, Iraq, targeting 325 women aged 18 to 63 who have been diagnosed with breast cancer. The purpose of this study was to investigate the effects of self-examination and the barriers to screening, in addition to exploring the correlation between these screening barriers and the stages of cancer. Data continuously collected for 18 months. This study reporting adheres to the Observational studies — STROBE/observational cross-sectional study. This study has been approved by the Institutional Review Committee in University of Diyala/College of Medicine under code No. (2026KA996).

Patients inclusion criteria:

1. Female patients diagnosed with breast cancer (confirmed by medical records).

2. Age 18 years and older.

3. Patients who have been diagnosed within the last 5 years (to reduce recall bias and ensure recent screening practices).

4. Patients at any clinical stage of breast cancer (Stage I to Stage IV).

5. Patients who are able and willing to participate in an interview or complete a questionnaire.

6. Patients who have not undergone a mastectomy prior to diagnosis (to ensure screening behavior before diagnosis can be studied).

Patients exclusion criteria:

1. Patients with a history of another type of cancer (to avoid confounding results).

2. Patients who were diagnosed incidentally during unrelated surgeries or exams (i.e., not via screening or self-exam).

3. Patients with severe cognitive impairment or mental illness that would interfere with informed consent or participation.

4. Patients who are currently receiving palliative end-of-life care (to reduce emotional and ethical burden).

5. Patients who were diagnosed more than 5 years ago, to avoid inaccuracies in recalling their screening behavior.

Survey developing: The survey was developed based on a comprehensive review of existing literature related to barriers to self-examination and breast cancer screening.¹⁸ The survey tool was designed to capture data on various factors influencing the decision of women to engage in self-examination and seek professional screening, including cultural, socioeconomic, psychological, and educational barriers.

Validation Process: To guarantee the validity of the survey tool, the survey was subjected to a content validation procedure utilizing the Content Validity Index (CVI) method. A group of specialists in public health, oncology, and survey design assessed the items of the questionnaire for their relevance, clarity, and suitability concerning the study objectives. Considering the experts’ feedback, essential adjustments were implemented to enhance the content validity and thoroughness of the instrument.

Pilot Testing: Before the final deployment of the survey, a pilot study was conducted with (30) patients women which not included in the final study sample. This pilot was used to test the reliability and clarity of the survey questions and to identify any issues in the survey design. Adjustments were made based on the feedback from the pilot test, including modifying questions for better comprehension and refining the response options to better capture the data required.

Sampling Frame: The sampling frame for this study was composed of 325 women aged between 18 – 63 years old who were living in Baghdad, Iraq, and had access to healthcare facilities. The study targeted women who were diagnosed with breast cancer. Systematic random sampling was used by selecting every third eligible patient attending the clinic during the study period until the necessary sample size was reached.

Recruitment: Women were recruited through various healthcare settings, including Government and private hospitals and clinics. Flyers and posters were placed in these locations to inform women about the study, and healthcare providers were asked to assist in informing patients. Women who expressed interest in participating were provided with additional information about the study, including its purpose, confidentiality measures, and how their responses would be used. Consent was obtained from all participants prior to their involvement in the survey. The recruitment process aimed to ensure diversity in terms of age, socioeconomic status, and education level to capture a broad range of experiences and barriers.

Survey results have been analyzed by Statistical Package for the Social Sciences (SPSS) V.22.

Ethical consideration: Ethical approval for this study was obtained from the relevant institutional ethical committee prior to data collection (Approval Code: 2026KA996). Participation in the study was voluntary, and informed consent was obtained from all participants before completing the questionnaire. Confidentiality and anonymity of participants’ information were maintained throughout the study in accordance with ethical research principles.

The study did not involve any medical interventions, invasive procedures, or the collection of biological samples. The data collected were limited to responses from structured interviews or questionnaires related to demographic background, cancer diagnosis stage, and personal experiences with screening and self-examination practices.

All data were stored securely and used exclusively for research purposes. The researcher adhered to ethical codes related to dignity, privacy, and the psychological well-being of participants, ensuring that no harm, stigma, or emotional distress resulted from participation.

3. Results

The subsequent socio-demographic variables were gathered to offer a thorough overview of the participants.

Table 1 illustrates the sociodemographic characteristics of the participants involved in the study. In terms of age distribution, the largest group of women fell within the 50–59 years range (41.23%), followed by those in the 40–49 years category (20.00%). The smallest segment of the sample comprised women under 20 years of age, accounting for 1.85%. With respect to educational attainment, nearly half of the participants possessed graduate or postgraduate qualifications (46.2%), while 36.3% had completed primary to secondary education, and 17.5% were classified as illiterate. In relation to marital status, the majority of participants were married (64.6%), in contrast to 35.4% who were single. Regarding geographical proximity to screening centres, over half of the participants resided close to these facilities (51.4%), while 25.2% lived at a considerable distance, and 23.4% were situated at a moderate distance from the centres.

Table 1.

Sociodemographic Characteristics of the Study Participants (n = 325)

Variable	Category	Frequency	Percentage %
Age group (years)	<20	6	1.85
	20 – 29	42	12.92
	30 – 39	47	14.46
	40 – 49	65	20
	50 – 59	134	41.23
	≥ 60	31	9.54
Educational level	Illiterate	57	17.5
	Primary – Secondary education	118	36.3
	Graduate – Postgraduate	150	46.2
Marital status	Single	115	35.4
Marital status	Married	210	64.6
Geographical location relative to screening centre	Near	167	51.4
	Moderate	76	23.4
	Far	82	25.2

3.1. Self-Examination

Table 2 summarizes findings on patients’ understanding of breast health and cancer screenings.

Table 2.

Patient Self-Examination Results (n=325)

Variable	Yes n (%)	No n (%)	P value
Checking breasts for lumps	103 (31.7)	222 (68.3)	0.02*
Feeling a breast lump	138 (42.5)	187 (57.5)	0.04*
Breast cancer screening before cancer detection	67 (20.6)	258 (79.4)	0.002*
Trained to feel for a breast lump	33 (10.2)	292 (89.8)	0.001*

*Significant (p-value < 0.05).

Among the study participants, 103 women (31.7%) reported performing breast self-examination, whereas 222 women (68.3%) did not, with a statistically significant difference observed (p = 0.021). In addition, 138 participants (42.5%) reported having previously felt a breast lump, while 187 (57.5%) had not (p = 0.048). Only 67 women (20.6%) had undergone breast cancer screening prior to diagnosis, compared with 258 women (79.4%) who had never undergone screening (p = 0.002). Furthermore, only 33 participants (10.2%) had received training on how to detect breast lumps, whereas 292 women (89.8%) reported no prior training, demonstrating a statistically significant difference (p = 0.001). These findings indicate limited awareness and low utilization of breast cancer screening and self-examination practices among the study population.

3.2 Patient Knowledge

A key factor in the early diagnosis of this illness is the patient’s knowledge. The results shows that (103) of the participated females know how to check their breast for any lumps. While more than twice of that number, (222) have no knowledge in this matter. One hundred eighty seven (187) females said that they have felt lumps in their breasts. While (144) of them said that they did not feel any lump as shown in Figure 1.

Figure 1.

Patients’ knowledge for feeling lumps according to their B.C stage

3.3. Screening Barriers

Table 3 demonstrates the major barriers related to breast cancer screening among the study participants. Difficulty talking to a doctor was reported by 295 women (90.8%), showing a statistically significant association (p = 0.01). In addition, 101 participants (31.1%) reported feeling embarrassed to visit a doctor, which was also statistically significant (p = 0.04). Fear of seeing a doctor was reported by 197 women (60.6%); however, this association was not statistically significant (p = 0.08). Similarly, 131 participants (40.3%) reported experiencing pain or discomfort during screening procedures, without statistical significance (p = 0.08).

Table 3.

Screening Barriers (n=325)

Screening barriers	Yes n (%)	No n (%)	P value
Difficulty talking to a doctor	295 (90.8)	30 (9.2)	0.01*
Too embarrassed to see a doctor	101 (31.1)	224 (68.9)	0.04*
Too scared to see a doctor	197 (60.6)	128 (39.4)	0.08
Experiencing pain or discomfort	131 (40.3)	194 (59.7)	0.08
Ability to decide to be tested	264 (81.2)	61 (18.8)	0.03*
Worried about wasting the doctor’s time	61 (18.8)	264 (81.2)	0.02*

*Significant (p-value < 0.05).

Regarding decision-making ability, 264 women (81.2%) indicated that they were able to decide to undergo testing, with a statistically significant association observed (p = 0.03). Furthermore, 61 participants (18.8%) expressed concern about wasting the doctor’s time, which was also statistically significant (p = 0.02). Overall, the findings highlight the presence of several personal and communication-related barriers that may negatively influence breast cancer screening practices among women.

3.4. The Association Between Cancer Stages and Screening Barriers

Table 4 shows the association between selected screening barriers and breast cancer stages among the study participants. A highly significant association was observed between health insurance coverage and cancer stage (χ² = 47.646, p = 0.001), as the majority of women without health insurance were diagnosed at advanced stages, particularly Stage IV. Financial difficulty was also significantly associated with breast cancer stage (χ² = 19.99, p < 0.001), with women reporting money shortages more frequently presenting with advanced disease stages.

Table 4.

Screening Barriers Association With Breast Cancer Stages (n=325)

Cancer stage Barriers		Stage I	Stage II or III	Stage IV	Total	Chi-squared	p-value
health insurance coverage	Yes	7	3	1	11	47.646	0.001 HS
health insurance coverage	No	22	35	257	314	47.646	0.001 HS
Money shortage	Yes	6	28	150	184	19.99	<0.001 HS
Money shortage	No	23	10	108	141	19.99	<0.001 HS
Fear of seeing a doctor	Yes	11	23	163	197	6.961	0.03 S
Fear of seeing a doctor	No	18	15	95	128	6.961	0.03 S
Ease of reaching the screening device location	Yes	14	19	148	181	1.438	0.48 NS
Ease of reaching the screening device location	No	15	19	110	144	1.438	0.48 NS

HS: significant association between groups (p-value <= 0.01).

S: significant association between groups (0.01<p-value <= 0.05).

NS: nonsignificant association between groups (p-value > 0.05).

Fear of seeing a doctor demonstrated a statistically significant association with cancer stage (χ² = 6.961, p = 0.03), indicating that fear-related barriers may contribute to delayed medical consultation and diagnosis at later stages. In contrast, ease of reaching the screening device location was not significantly associated with breast cancer stage (χ² = 1.438, p = 0.48), suggesting that geographical accessibility alone may not be a major determinant of disease stage at diagnosis in the studied population.

Overall, these findings indicate that socioeconomic and psychological barriers may play an important role in delayed breast cancer detection and progression to advanced stages among women.

4. Discussion

4.1. Breast Self-Examination and Screening Practices

The present study demonstrated low levels of breast self-examination and breast cancer screening practices among women diagnosed with breast cancer in Baghdad. Most participants reported not performing regular breast self-examination, and a large proportion had never undergone breast cancer screening prior to diagnosis. In addition, only a limited number of women had previously received training on breast self-examination techniques. These findings indicate insufficient awareness and underutilization of early detection practices among the study population.

Similar findings have been reported in previous regional and international studies. Abolfotouh et al.²⁰ reported that inadequate knowledge and limited awareness significantly reduced breast self-examination practices among women. Likewise, other studies demonstrated poor participation in breast cancer screening due to insufficient education and awareness regarding early detection methods.²¹ Studies conducted in developing countries have also shown that lack of awareness, cultural misconceptions, and fear of diagnosis are major contributors to delayed screening behavior.^21,22

Early detection through regular screening and self-examination remains one of the most effective approaches for reducing breast cancer morbidity and mortality. Therefore, the low prevalence of screening practices observed in this study may partially explain the high proportion of women diagnosed at advanced disease stages.

4.2. Screening Barriers

This study identified several important psychological and interpersonal barriers associated with breast cancer screening. Difficulty communicating with healthcare providers represented the most commonly reported barrier, suggesting the importance of improving patient–doctor communication and establishing supportive healthcare environments that encourage women to seek medical consultation without fear or hesitation.

Emotional barriers, particularly fear and embarrassment, were also commonly reported among participants. Fear of visiting a doctor was significantly associated with advanced cancer stages. Similar findings have been reported in previous studies, where fear of diagnosis, embarrassment, and anxiety were identified as major barriers affecting women’s participation in breast cancer screening programs.^21,22 Marmarà et al.²¹ found that emotional concerns and negative perceptions toward healthcare significantly reduced screening uptake among women.

Interestingly, accessibility to screening locations was not significantly associated with cancer stage in the current study. This finding suggests that psychological and socioeconomic barriers may have a stronger influence on screening behavior than geographical accessibility alone.

4.3. Association Between Screening Barriers and Cancer Stage

The present study demonstrated significant associations between several screening barriers and advanced breast cancer stages. Lack of health insurance coverage was strongly associated with late-stage diagnosis, highlighting the important role of financial accessibility in obtaining timely medical evaluation and treatment. Women without insurance coverage may delay seeking healthcare because of anticipated diagnostic and treatment costs.

Financial difficulties were also significantly associated with advanced-stage disease. Similar observations have been reported in previous studies demonstrating that low socioeconomic status negatively affects access to preventive healthcare services and participation in cancer screening programs.^21,23 Women with lower income levels were found to be less likely to undergo routine breast cancer screening and more likely to present with advanced disease.²³

Fear of seeing a doctor was another significant barrier associated with advanced breast cancer stages. Psychological distress, fear of diagnosis, and anxiety regarding treatment outcomes may contribute to delayed healthcare-seeking behavior. These findings are consistent with studies conducted in developing countries where emotional and social barriers substantially influence delayed cancer diagnosis.^21,22

Overall, the findings of this study indicate that breast cancer screening behavior is influenced by multiple interacting socioeconomic and psychological factors. Addressing these barriers through awareness campaigns, patient education, and improved healthcare support systems may contribute to earlier diagnosis and improved outcomes.²⁴

4.4. Patient Knowledge and Awareness

The findings also revealed inadequate knowledge and awareness regarding breast cancer symptoms and early detection methods among many participants. A substantial proportion of women lacked the necessary knowledge and training to correctly perform breast self-examination or recognize early breast abnormalities. Participation in educational activities and awareness programs related to breast cancer was also notably limited.

These findings are supported by previous studies demonstrating that poor health literacy and insufficient awareness are strongly associated with reduced screening participation.^20,21 The World Health Organization emphasized that increasing public awareness and improving access to breast cancer education are essential components of effective cancer control strategies.²⁵ Similarly, several studies have shown that educational interventions and community-based awareness programs can significantly improve screening practices and early detection rates among women.^20,22

5. Limitations

Limitations of the Study This research presents several limitations that must be acknowledged when interpreting the results. Firstly, the cross-sectional design restricts the capacity to determine causal relationships between barriers to screening and the stages of breast cancer. Secondly, the study depended on self-reported data, which could be influenced by recall bias and social desirability bias, especially concerning previous screening practices and self-examination behaviors. Thirdly, participants were exclusively recruited from healthcare facilities in Baghdad, which may restrict the applicability of the findings to women residing in rural areas or other regions of Iraq. Furthermore, several potentially significant factors, including family history, psychological well-being, quality of healthcare, and comprehensive socioeconomic indicators, were not thoroughly evaluated. Lastly, although an attempt was made to utilize random sampling, selection bias may have still been present, as participation was contingent upon the willingness to complete the questionnaire. Notwithstanding these limitations, the study offers valuable insights into the primary barriers hindering early breast cancer detection among Iraqi women and underscores critical areas for future public health initiatives and research.

6. Recommendations

Based on the findings of this study, several recommendations are proposed to improve breast cancer screening practices and promote early detection. Expanding health insurance coverage and reducing the financial burden associated with screening and treatment may help minimize delayed diagnosis among vulnerable populations. Public awareness campaigns should focus on improving knowledge regarding breast cancer, emphasizing the importance of early detection, and addressing psychological barriers such as fear and embarrassment.

In addition, healthcare providers should receive training in effective and empathetic communication to improve patient–doctor interactions and encourage women to seek medical advice without hesitation. Educational and community-based programs are also recommended to empower women in making informed health decisions and increase participation in breast cancer screening activities.

Furthermore, strengthening community outreach initiatives, improving access to affordable screening services, and implementing culturally sensitive awareness programs may contribute to reducing late-stage breast cancer presentation and improving overall health outcomes among women.

Supplemental Material

Supplemental Material - Self-Examination and Screening Barriers Associated With Breast Cancer Stages Among Patient Women in Baghdad, Iraq

Supplemental Material for Self-Examination and Screening Barriers Associated With Breast Cancer Stages Among Patient Women in Baghdad, Iraq by Ali Mawlood Ibrahim, Ahmed Khalid Abdulldah, Abderrazek Oueslati and Mohamed Gargouri in Breast Cancer: Basic and Clinical Research.

Footnotes

ORCID iD

Ali Mawlood Ibrahim

Ethical Considerations

Code No: (2026KA996).

Author Contributions

Ali Mawlood Ibrahim: Data Curation, Formal Analysis, Funding Acquisition, Writing – Original Draft Preparation, Writing – Review & Editing. Ahmed Khalid Abdullah: Investigation, Resources. Abderrazek Oueslati: Validation, Supervision. Mohamed Gargouri: Visualization.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

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