Breast cancer screening during the Syrian crisis: A cross-sectional study


Breast cancer
healthcare inaccessibility
breast self-examination
breast cancer screening



Although breast cancer has a lower incidence in developing countries, mortality rates are higher, mainly due to delay in diagnosis and the poor diagnostic and therapeutic capacities. Although screening tests have been available for quite a long time, delayed and advanced presentation is still common especially in developing countries. The decade-long Syrian crisis has severely crippled the healthcare system and depleted the already-limited capacities of the healthcare services, which underprioritized the care provided to unurgent cases like breast cancer. This study aimed to investigate the practices of breast cancer screening among breast cancer patients.


A cross-sectional study conducted in Al-Beiruni Hospital at Damascus University in 2019, through personal interviews using a structured questionnaire.


The sample consisted of 532 patients of breast cancer. One-hundred twenty-three (23%) of them reported undergoing one or more of the different screening methods at least once every six months prior to diagnosis. Several factors had a statistically significant association with the probability of applying screening methods including living in large cities, having less children, having a full-time or part-time job, and the level of education. Patients who reported having a relative diagnosed previously with breast cancer or any other malignancies were also more likely to screen themselves. Inaccessibility to healthcare services, which was exaggerated by the armed conflicts, had a significant association with less practicing of the screening methods too.


The Syrian war and its direct and indirect consequences negatively affected the practice of screening methods for breast cancer.


[1] Research AI of C. Worldwide cancer data | World Cancer Research Fund n.d. (accessed January 10, 2021).
[2] Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018;68:394–424.
[3] Unar-Munguía M, Torres-Mejía G, Colchero MA, González De Cosío T. Breastfeeding Mode and Risk of Breast Cancer: A Dose-Response Meta-Analysis. J Hum Lact 2017;33:422–34.
[4] Research AI of C. Breastfeeding & cancer | World Cancer Research Fund International n.d. (accessed January 10, 2021).
[5] Arslan AA, Formenti SC. Mammography in developing countries: The risks associated with globalizing the experiences of the Western world. Nat Clin Pract Oncol 2009;6:136–7.
[6] Anderson BO, Cazap E, El Saghir NS, Yip CH, Khaled HM, Otero I V., et al. Optimisation of breast cancer management in low-resource and middle-resource countries: Executive summary of the Breast Health Global Initiative consensus, 2010. Lancet Oncol 2011;12:387–98.
[7] Pace LE, Mpunga T, Hategekimana V, Dusengimana J-M V., Habineza H, Bigirimana JB, et al. Delays in Breast Cancer Presentation and Diagnosis at Two Rural Cancer Referral Centers in Rwanda. Oncologist 2015;20:780–8.
[8] Porter P. “Westernizing” Women’s Risks? Breast Cancer in Lower-Income Countries. N Engl J Med 2008;358:213–6.
[9] Coleman C. Early Detection and Screening for Breast Cancer. Semin Oncol Nurs 2017;33:141–55.
[10] Siu AL. Screening for breast cancer: U.S. Preventive services task force recommendation statement. Ann Intern Med 2016;164:279–96.
[11] Zahl P, Kalager M, Suhrke P, Nord E. Quality‐of‐life effects of screening mammography in Norway. Int J Cancer 2020;146:2104–12.
[12] Norsa’adah B, Rampal KG, Rahmah MA, Naing NN, Biswal BM. Diagnosis delay of breast cancer and its associated factors in Malaysian women. BMC Cancer 2011;11:2–9.
[13] Arndt V, Stürmer T, Stegmaier C, Ziegler H, Dhom G, Brenner H. Patient delay and stage of diagnosis among breast cancer patients in Germany – a population based study. Br J Cancer 2002;86:1034–40.
[14] Rivera-Franco MM, Leon-Rodriguez E. Delays in breast cancer detection and treatment in developing countries. Breast Cancer Basic Clin Res 2018;12.
[15] Sahloul MZ, Monla-Hassan J, Sankari A, Kherallah M, Atassi B, Badr S, et al. War is the enemy of health pulmonary, critical care, and sleep medicine in war-torn Syria. Ann Am Thorac Soc 2016;13:147–55.
[16] Sahloul E, Salem R, Alrez W, Alkarim T, Sukari A, Maziak W, et al. Cancer care at times of crisis and war: The Syrian example. J Glob Oncol 2017;3:338–45.
[17] Commission for Western Asia S. Syria at War: Five Years On. 2016.
[18] Syrian Arab Republic | UNESCO UIS n.d. (accessed January 11, 2021).
[19] Syria Female labor force participation - data, chart | n.d. (accessed January 11, 2021).
[20] Al-Gburi ASA, Alwan NAS. Correlation between breast self-examination practices and demographic characteristics, risk factors and clinical stage of breast cancer among iraqi patients. Open Access Maced J Med Sci 2019;7:3216–20.
[21] Othman A, Ahram M, Al-Tarawneh MR, Shahrouri M. Knowledge, Attitudes and Practices of Breast Cancer Screening Among Women in Jordan. Health Care Women Int 2015;36:578–92.
[22] Opoku SY, Benwell M, Yarney J. Knowledge, attitudes, beliefs, behaviour and breast cancer screening practices in Ghana, West Africa. Pan Afr Med J 2012;11:28.
[23] Truong Donnelly T, Al Khater AH, Al Kuwari MG, Al-Bader SB, Al-Meer N, Abdulmalik M, et al. Do socioeconomic factors influence breast cancer screening practices among Arab women in Qatar? BMJ Open 2015;5:e005596.
[24] Bouya S, Balouchi A, Ahmadidarehsima S, Badakhsh M. Knowledge and Source of Information About Early Detection Techniques of Breast Cancer Among Women in Iran: A Systematic Review. J Cancer Prev 2018;23:51–60.
[25] Syria “the most dangerous place on earth for healthcare providers” – study | World news | The Guardian n.d. (accessed January 11, 2021).
[26] Physicians for Human Rights - Syrias Neighbors Must Let Doctors Practice n.d. (accessed January 10, 2021).
[27] Kherallah M, Sahloul Z, Jamil G, Alahfez T, Eddin K. Health care in Syria before and during the crisis. Avicenna J Med 2012;2:51.
[28] Wu Z, Liu Y, Li X, Song B, Ni C, Lin F. Factors associated with breast cancer screening participation among women in mainland China: A systematic review. BMJ Open 2019;9.
[29] Sharp JW, Hippe DS, Nakigudde G, Anderson BO, Muyinda Z, Molina Y, et al. Modifiable patient-related barriers and their association with breast cancer detection practices among Ugandan women without a diagnosis of breast cancer. PLoS One 2019;14.
[30] Hwang JJ, Donnelly TT, Ewashen C, McKiel E, Raffin S, Kinch J. Sociocultural Influences on Arab Women’s Participation in Breast Cancer Screening in Qatar. Qual Health Res 2017;27:714–26.
[31] Mamdouh H, El-Mansy H, Kharboush I, Ismail H, Tawfik M, El-Baky M, et al. Barriers to breast cancer screening among a sample of Egyptian females. J Fam Community Med 2014;21:119.
[32] Abdel-Aziz SB, Amin TT, Al-Gadeeb MB, Alhassar AI, Al-Ramadan A, Al-Helal M, et al. Perceived barriers to breast cancer screening among Saudi women at primary care setting. J Prev Med Hyg 2018;59:E20–9.
[33] Al-Mousa DS, Alakhras M, Hossain SZ, Al-Sa’di AG, Al Hasan M, Al-Hayek Y, et al.

Knowledge, Attitude and Practice Around Breast Cancer and Mammography Screening Among Jordanian Women

. Breast Cancer Targets Ther 2020;Volume 12:231–42.
[34] Hassan EE, Seedhom AE, Mahfouz EM. Awareness about breast cancer and its screening among rural Egyptian women, Minia District: A population-based study. Asian Pacific J Cancer Prev 2017;18:1623–8.
[35] Al-Rifai RH, Loney T. Factors associated with a lack of knowledge of performing breast self-examination and unawareness of cervical cancer screening services: Evidence from the 2015 Egypt health issues survey. Asian Pacific J Cancer Prev 2017;18:2763–9.
[36] Noroozi A, Tahmasebi R. Factors influencing breast cancer screening behavior among Iranian women. Asian Pac J Cancer Prev 2011;12:1239–44.
[37] Kardan-Souraki M, Moosazadeh M, Khani S, Hamzehgardeshi Z. Factors related to breast cancer screening in women in the northern part of Iran: A cross-sectional study. Open Access Maced J Med Sci 2019;7:637–42.
[38] Shakor JK, Mohammed AK, Karotia D. Determinants of Breast Self-Examination Practice amongst Iraqi/ Sulaimani Women using Champion Health Belief Model and Breast CAM. Int J Med Res Heal Sci 2019;8:51–9.
[39] Taleghani F, Kianpour M, Tabatabaiyan M. Barriers to breast self-examination among Iranian women. Iran J Nurs Midwifery Res 2019;24.
[40] Avci IA. Factors associated with breast self-examination practices and beliefs in female workers at a Muslim community. Eur J Oncol Nurs 2008;12:127–33.
[41] Kumarasamy H, Veerakumar A, Subhathra S, Suga Y, Murugaraj R. Determinants of awareness and practice of breast self examination among rural women in Trichy, Tamil Nadu. J Midlife Health 2017;8:84–8.