INTRODUCTION:

Breast cancer is a condition in which the breast's cells proliferate uncontrollably. From the beginning, the cancerous growth is retained in the duct or lobule ("in situ") wherever it typically shows no symptoms and has a low potential for spread (metastasis). Later, these in situ (stage 0) cancers could develop and attack the encircling breast tissue (invasive breast cancer) and then invade the adjacent lymph nodes (regional metastasis) or other organs within the body (distant metastasis)¹.

According to the American breast cancer statistics, 685000 deaths worldwide and 2.3 million new breast cancer diagnoses in women. One of the most common forms of cancer found in India among women is Breast cancer. While it is typically found among women of age 40 and above, it can develop in females, at any time. One in twenty-eight Indian women is likely to develop breast cancer during her whole life (Nair et al, 2001)².

There are different varieties of invasive breast cancers exist³. Some invasive breast cancers have special characteristics or spread in different ways that affect their treatment and prognosis⁴. The oldest treatment of breast cancer that is used to treat breast cancer is Mastectomy. People used to rely on mastectomy before the development of lumpectomy and Quadrantectomy⁵. After mastectomy, women will opt for breast reconstruction surgeries and have a normal life⁶. Immediate reconstruction refers to breast surgery done immediately after a mastectomy, while delayed reconstruction refers to breast surgery done after the mastectomy incisions have healed and breast cancer treatment has been finished⁷.The benefits of breast reconstruction surgery are for those women who need their chest to appear more balanced when she wears a bra or swimsuit or to regain the shape of their breast or improve the fit of their clothes after mastectomy⁸. In India, thousands of breast removal surgeries for cancer have been done every month but among them, less than one percent of patients choose breast reconstruction⁹. It is very essential to support women who have been diagnosed with breast cancer, their family members, and caregivers. Most of them even don't know about breast reconstruction surgeries and they believe that breast reconstruction surgeries solely have aesthetic benefits. Even though, it is far more than that. Breast reconstruction not only just shapes the breasts of women who may have lost their breast shape or the whole of it but also gives them power. Reconstructive plastic surgery can improve body function and also create a normal appearance/ it also helps to improve the self-esteem issues of people.¹⁰

BRA Day is not an attempt to speak to people having a reconstruction but merely to ensure all women and their doctors have a conversation about breast reconstruction so women undergoing a mastectomy have become aware of their choices.¹¹

Following breast cancer surgery and mastectomy, most women feel less confident about their body and lose of their self esteem. Moreover identification with new body image is often difficult, and women need time to accept their new appearance. According to Cancer statistics, 2020 Female breast cancer survivors with younger age were more likely to commit suicide due to fear, hopelessness, and a negative attitude about their body. There's currently bigger stress on the quality of life among patients undergoing breast surgery. Despite the poor reporting system in India, it is very evident from the various statistics that the incidence of breast cancer is rapidly rising, amounting to a significant percentage of all cancers in women. Although the incidence of breast reconstruction surgery for any purpose is very uncommon. Despite the oncoplastic gaining quality, seventieth ladies bear a cutting out in India, which remains the most typical procedure offered for all stages of carcinoma. This might be attributed to the late stage of presentation, myths, and misconceptions among ladies, where removing the breast is decreasing the probability of recurrence, and infrastructural inequalities like lack of radiation units. Unsurprisingly, there's very little to no information on data, attitudes, and Practices of Breast Reconstruction Surgery in the developing nation of India. A woman who underwent surgery to treat breast cancer will have to go for additional surgery to rebuild the shape and look of her breast. This is called breast reconstruction surgery. So it is very necessary to assess the awareness about breast reconstruction surgeries among women to improve the quality of life^{1, 12}.

Quality of life has become a vital side of the management of breast cancer. Many ladies still ought to bear a changed mastectomy. Factors influencing women to select breast reconstruction (BR) surgeries are unclear and are hypothesized to be influenced by sociodemographic variables. The prevalence of breast cancer cases in India is not solely increasing by the day however additional young patients also are falling prey. Our plastic surgeons do breast reduction and augmentation surgeries all the time however breast reconstruction surgeries are only a few. The quantity is nearly non-existent. After being diagnosed with breast cancer, then having mastectomy people leads a healthy life and comfortable life even though mentally they are not happy. They feel additionally depressed. Therefore, it is crucial to involve and empower women so they can make the decision that is best for them. This entails letting everyone know that the breast cancer loop is still open until a woman is aware of her options for breast reconstruction, including women, family members, carers, and the media. The impact of cosmesis on quality of life has typically been mentioned. We would like to dispel the myths around Breast reconstruction and also the role of the treating surgeon ought to spearhead the efforts in subject matter women concerning reconstruction choices.¹²

MATERIALS AND METHODS:

Materials:

A problem can be solved systematically using research methodology. It is the science of studying how research is to be carried out. Research methodology is the general term used to describe the processes researchers use to describe, explain, and forecast events. It can also be described as the study of knowledge acquisition methodologies. It aims to give the work plan of the research.¹³

Thus, this chapter deals with the methodology adapted for the present study which includes the research approach, research design, setting, population, sample and sampling techniques, variables, development and description of the tool, ethical consideration, pilot study, data collection procedures and plan for data analysis. In addition to mentioning the research techniques, research methodology also takes into account the reasoning behind the methods we employ in the context of our research study and explains why we are utilising a specific approach or technique.

RESEARCH APPROACH:

The strategy to be used to investigate the phenomenon under question is described in the research approach.

Descriptive research is a class of non-experimental study. Descriptive studies are designed to observe, describe, and record specifics of a phenomenon as it actually happens. (Polit and Beck)”.¹⁴

Quantitative research is an inquiry into an identified problem, based on testing a theory composed of variables, measured with numbers and analyzed by using descriptive or inferential statistics (Sharma, Suresh K.)¹⁵

A descriptive quantitative approach was found to be appropriate for the present study as the study deals with getting information from the samples.

Research design:

Study design, according to Kothari (2004), is "the setting up of circumstances for data collection and analysis with the aim of combining relevance to the research approach with economy in procedure." The conceptual framework through which research is carried out is called the research design. The selection of the design depends on the purpose of the study, the research approach, and the variables to be studied. The research design selected for the present study is a Survey research design.¹⁶

A survey aims to learn more about a population's prevalence, distribution, and relationships among various occurrences. (Polit and Beck)¹⁴.

A Survey research design was found to be appropriate for the present study as the study deals with getting information from the samples to assess the awareness of breast reconstruction surgeries.

Variables:

A variable is anything that varies in quality and quantity. In other words, variables are attributes, qualities, or characteristics of a person, things, or circumstances that change or are different.

The selected variables for the present study are:

1. Socio-demographic variables

2. Research variable

1. Socio-demographic Variables:

Socio–demographic variables included in the present study were age in years, Age in years, Marital status, Education, Education status of head of the family, Occupation of the head of the family, Monthly family income, Reason for acceptance of reconstruction surgeries, Reason of refusal, Duration ofdiagnosis, Family history of breast cancer, Status of patient surgery.

2. Research variables:

In the present study, the research variable was awareness of breast reconstruction surgeries among women with breast cancer

Research Setting:

The study setting is the location in which the research is conducted – it could be natural, partially controlled, or highly controlled.¹⁶ In the current study, the research setting was the Outpatient department of Radiation Oncology, AIIMS Patna.

Population:

The entire set of individuals or objects having some characteristics selected for a research study, the entire population in which the researchers are interested, and to which they would like to generalize the research finding is termed as the target population.¹⁶

In the current study, the research population consists of the students of the outpatient department of AIIMS Patna.

Sample:

The sample can be defined as a subset of the population, selected to participate in the study.¹⁶ In the current study, the research population consists the women with breast cancer.

Sampling Technique:

The sampling technique is a strategic technique of selecting the individuals or sub-set of the population which represents or defines the characteristics of the entire population. In the study, a nonprobability convenient sampling technique was adopted to select women with breast cancer.

Criteria for Sample Selection:

The inclusion and exclusion criteria of the study for the sample were Inclusion criteria:

a Inclusion criteria: Women diagnosed with breast cancer attending outpatient departments of AIIMS Patna.

b Exclusion criteria: Women who are on any psychiatric medications.

Development and description of Data collection tool

Tools for data collection-

1. Socio-demographic data

2. Structured questionnaire regarding awareness of breast reconstruction surgeries.

Tool 1: Socio–demographic data of women with breast cancer:

It is a structured tool that was modified froma questionnairerelated to the effects of breast reconstructionby Hatan Mortada et al. / International Journal of Surgery and Medicine, guidance of experts, and recent research reviews¹⁷. It consists of socio-demographic variables based on the study's aim and objective in which 9 items include demographic data of selected Sociodemographic data of women with breast cancer i.e., age in years, religion, marital status, education, economic status, and occupation.

Tool 2: Structured questionnaire regarding general awareness of breast reconstruction surgeries:

It is a structured questionnaire modified froma questionnairerelated to the effects of breast reconstructionby Hatan Mortada et al. / International Journal of Surgery and Medicine, with the guidance of experts and recent research reviews.

The term questionnaire is meant for the “questions in the form of statements" (De Vos, 2006; 166) that are formulated as it requires a single reaction from given responses for a single statement. 21 statements are being asked about the general awareness of breast reconstruction. A total of 21 scores were given for the assessment of awareness. To interpret the level of awareness, the scores were distributed as follows:

Scoring:

Low level of awareness: < 7

Average level of awareness: 7 - 14

High level of awarenes: 15 – 21

Content Validity:

For the validity of the tools, a prepared format of the instrument along with a validity seeking letter, acceptance form, and all necessary information related to the research study was provided to 4 experts and requested their suggestions about the tool content, accuracy, clarity, relevancy, and appropriateness of the items present in the tool and necessary modifications were done as per their suggestions.

Reliability:

The tool was tested for reliability by 10 responses obtained from women with breast cancer after the administration of a structured awareness questionnaire. The reliability was tested and established by using the split–half technique. The reliability of the tool was calculated and obtained as Cronbach's Alpha value is 0.88, which indicated the tool is having good reliability. Therefore, the tool is said to be as reliable.

Ethical Consideration:

The approval was taken from the Institutional Ethics Committee i.e. from the AllIndia Institute of Medical Sciences, the Patna research committee.

1. Informed consent was obtained from the participants after explaining the purpose, possible risks, and benefits of the study.

2. Confidentiality and participation right of autonomy was maintained.

3. IEC number is AIIMS /Pat/IEC/M.Sc.(N)/Nur/04

Pilot study:

A pilot study was conducted by the Outpatient Department of Radiation Oncology, AIIMS Patna. Permission was obtained from the Head of the Department of Oncology to conduct the study. After obtaining consent from the participants, data were collected by interview method from 10 women with breast cancer to check the feasibility and practicability of conducting the study. The modification was made to the tool after the pilot study as suggested by experts. The investigator did not face any problems during the pilot study.

Data collection procedure:

After the approval of the ethical committee and permission from the authorities data were collected. The population who met the inclusion and exclusion criteria of the study were selected as the study sample and explained the purpose, individual benefits, and risk of the study for getting informed consent. The participants were assured about the maintenance of their right to privacy and autonomy throughout the study process.

The data was collected for 1 month (November 14 to December 17). It was collected through interview technique by using a structured questionnaire to estimate the level and identify the correlation between awareness of breast reconstruction surgeries with the selected sociodemographic variables. The questionnaire was in Hindi and 100 responses were included in the study.

Plan For Data Analysis:

The data was collected and coded for analysis in terms of the objectives of the study using both descriptive and inferential statistics. The data obtained and coded were analyzed by entering in SPSS.

Data were analysed by the following steps:

1. Collected data were checked for completeness and clarity.

2. Data was coded and transformed into a master sheet for statistical analysis.

Descriptive Statistics:

Data on Socio-demographic variables and awareness will be analyzed in terms of frequency and percentage.

Inferential Statistics:

Data on the correlation between the awareness of breast reconstruction surgeries with the selected sociodemographic variables will be analyzed by the Karl Pearson coefficient of correlation.

RESULT:

The present study is aimed to assess the awareness of breast reconstruction surgeries among women with breast cancer. The literature review included a search for published and unpublished research, a manual search of recent literature, a citation review of relevant primary and secondary articles, and clinical observations of case studies conducted by the investigators. The literature provided information that enabled the investigator to study the extent of the selected problem, and studies previously done on the topic, to develop a conceptual framework, data analysis, and data interpretation. The conceptual framework of the study is based on the general system model and it provided a comprehensive framework for achieving the objective of the study. A descriptive research design was adopted using the quantitative research approach and 100 women with breast cancer were selected by using a convenient sampling technique who fulfilled the inclusion and exclusion criteria.

The structured questionnaire was modified from a questionnaire related to the effects of breast reconstruction by Hatan Mortada et al./ International Journal of Surgery and Medicine, with the guidance of experts and recent research reviews. The content validity was obtained from the experts in different fields and the tool consists of section A (demographic profile), and section B (General awareness regarding breast reconstruction surgeries). After obtaining formal permission from the authorities pilot study was conducted from 4-12-2022 to 31-12-2022, with 10 women who satisfied the inclusion and exclusion criteria. The reliability quotient was r = .88 for the questionnaire which indicates that the tool was reliable. Data collection was done during 14 December to 31 January among 100 women with breast cancer who fulfilled the criteria, at the outpatient department of a tertiary care center. The findings of the study showed that a low level of awareness of breast reconstruction surgeries has been present among women with breast cancer. The result showed that there was a significant association between awareness about breast reconstruction surgeries and socio demographic variables such as education and economic status.

Women with breast cancer’s level of Awareness about breast reconstruction.

Data was processed by descriptive statistics. Based on the score categorization, the level of awareness of breast reconstruction classified into low awareness (0-7), average awareness (7-14) and high awareness (15-21) is depicted in the table.

Table 1: Level of awareness about breast reconstruction

Sl. No.	Level of awareness about breast reconstruction	Percentage (N)	Frequency (%)
1.	Low level of awareness (0-7)	83	83.0%
2.	Average level of awareness (8-14)	17	17.0%
3.	High level of awareness (15-21)	0	0

The table above indicated that majority (83%) of sample have low awareness, whereas only 17% of women have average level of awareness. High level of awareness has not been present in this study.

Figure 1: Pie diagram showing level of awareness

DISCUSSION:

The data is organized and presented under the following headings:

Section 1: Socio-demographic characteristics of women with breast cancer

Section 2: Level of awareness of women with breast cancer about reconstruction surgeries.

Section 3: Association between the awareness and selected socio-demographic variables of women with breast cancer.

Section 1: Socio demographic Characteristics of women with breast cancer:

In this study, 100 Women with breast cancer participated of which the majority of the participants were in the age group between 41-60 years (80.6%) and a majority of them were Hindu (79.6%). On the other hand, 28.6% of the sample wer/e illiterate, 20.6% of the sample had a primary level of education, 19.4% of the sample had a middle school level of education, 12.2% of the sample were having high school level of education, 10.2% of the sample were graduates and only 9% of the sample were having an intermediate level of education. Marital status reveals that (93.9%) of the sample were married, 4.1% of the sample was widowed, 1% of the sample were unmarried and 1% were divorced. The occupational status shows that, (82.7%) of the participants were unemployed, 13.3% of the sample had an elementary occupation, 3.1% of the sample were skilled workers and only 1% of the sample were clerks. Out of the total participants, only (54.1%) of the sample was belongs to lower middle class, 36.7% of the sample was upper lower class and 9% of sample was upper middle class.

In the support of demographic findings, similar studies and online data has shown that majority of women come under the 41-60 years of age group. When compared to other religions, the Hindu religion is the highest so as present in the study. A study concerning the same issues conducted by Alkaff TM, Al Taleb RM and Kattan A E (2019) among women with breast cancer to assess the level of awareness of women about breast reconstruction surgeries has also shown that the majority of the participants married (73.2%)¹⁸. At the same time, another study conducted by Nair NS et al (2021) had shown that among 492 samples 50% of participants had a primary level of education.

Section 2: Level of awareness of women with breast cancer about reconstruction as of the item statement,

Out of 100 women with breast cancer 75% of women were not aware that, breast reconstruction surgery is a surgery to recreate breasts after mastectomy, 95% of women not aware that it would perform after surgery for breast cancer, 93% of women had lack of awareness that breast reconstruction following mastectomy is better than living a women with no breast, 84% were not aware it will help women to regain femineity and 92% don’t know that it may conceal the relapse of breast cancer.

Statement regarding mammograms showed that 91% of sample had no idea that a mammogram is required after breast reconstruction. 91% of participants were not aware that through breast reconstruction women will have permanently the most natural looking and feeling breast with little discomfort. 87% of participants not aware that if the surgeon is not trained to perform reconstruction it may fail sometimes, 90% of participants don’t know that reconstruction could not perform if the woman is too old. However 52% of participants know that breast reconstruction surgery is too costly .89% of sample not aware that immediate breast reconstruction is better than delayed reconstruction and 87% of women participants had no idea that finding right plastic surgeon will ensure success and safety of reconstruction, 93% of sample were not conscious that ideally, breast reconstruction could perform at the same time of the mastectomy and 91% of the study subjects lacked the awareness that breast reconstruction cannot be performed in the last stages of breast cancer.

83% of participants were not aware the benefits of breast reconstruction and that it would reduce depression, anxiety and stress.75% of sample not aware that breast reconstruction is a painful procedure .On the contrary, 82% don’t have enough knowledge that it has long-lasting effects like improvement of self-confidence, self-esteem, ability to work and enjoying social activities. 80% of women not aware that breast reconstruction will help to make their chest look balanced and near to normal as their precancer days. 88% were not aware that after breast reconstruction clothes will fit more better and 96% of the sample had no idea that there is no need to use a breast form inside the bra after reconstruction. Lastly, 92% of participants were agreeing with the statement that general awareness of breast reconstruction is very essential.

Level of awareness of breast reconstruction:

In this present study, the researcher observed that vast majority of women with breast cancer had a low level of awareness (83%) about breast reconstruction surgeries, only 17% had an average level of awareness and no one had a high level of awareness.

This was supported by a study conducted to assess the knowledge and perception of breast reconstruction after mastectomy among the Saudi population by Michael A, et al (2022) conducted on awareness and attitude among women with breast cancer after mastectomy¹⁹. The descriptive cross-sectional study contained 51 women participants and self administration of 45 items structured questionnaire. Results showed that there is a very low level of awareness of breast reconstruction was present. 72.5% of the sample were not aware of breast reconstruction and only 1.96% of women had undergone breast reconstruction.

Another study was conducted by Hatan M, Weaam M and Aljaaly H (2018). The cross-sectional study was done among the general population of Saudi Arabia and via an interview based questionnaire randomly among adult males and females who attended the breast reconstruction campaign. The results had shown that most of the Saudi population had a lack of knowledge and misinformation regarding breast reconstruction. Therefore, generating awareness regarding breast reconstruction is very essential.

Section 3: Association between the awareness and selected socio-demographic variables:

Based on the statistical analysis using Chi square test for significance, the association was found only between awareness of breast reconstruction with education and economic status. Whereas, the other sociodemographic variables like age in years, religion, marital status, and occupation had not shown any significant association with awareness.

Table 2: Association between the awareness about reconstruction and socio demographic variables.

Sl. No	Socio-demographic variable	Awareness of reconstruction
Sl. No	Socio-demographic variable	Low N	Average N	High N	x²	df	*p- value*
1.	Age				5.25	2	0.073
	18-40yrs	11	6	0
	41-60yrs	69	11	0
	61-70yrs	3	0	0
2.	Religion				0.943	2	0.624
	Hindu	63	15	0
	Christian	1	1	0
	Muslim	17	2	0
3.	Education				79.3	5	0.001
	Illiterate	28	0	0
	Primary school	20	0	0
	Middle school	19	0	0
	High school	11	1	0
	Intermediate or diploma	3	6	0
	Graduate	0	10	0
4.	Marital status				5.91	3	0.116
	Married	76	16	0
	Unmarried	1	0	0
	Divorced	1	0	0
	Widowed	4	0	0
5.	Occupation				6.25	3	0.100
	Clerk	0	1	0
	Elementary occupation	12	1	0
	Skilled workers and shop	2	1	1
	Unemployed	67	14	0
6.	Economic status				27.3	2	.001
	Upper middle	2	7	0
	Lower middle	45	8	0
	Upper lower	34	2	0

x = Fisher's exact value

*p- value statistically significant at ≤ 0.05 level, Test statistics: Chi-square test