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In 2020, more than four million women all over the world lost their lives to cancer []. For these deaths, breast cancer (BCa) was the biggest culprit. The mortality associated with BCa is largely concentrated in middle- or low-income countries, which harbor around 72% of cases []. This vast difference in BCa mortality between socioeconomic regions has worsened between 1990 and 2019, and the trend is expected to continue []. But what do these numbers mean for a low-income, South Asian country like Pakistan? One in four female cancer-related deaths in Pakistan is attributable to BCa, and the incidence is more than 4.5 times that of the next most common cancer []. Between 1990 and 2019, Pakistan has seen a >300% increase in BCa incidence and a 200–300% increase in BCa-associated mortality []. As of 2019, along with the Solomon Islands, Pakistan had the highest BCa death rate all over the world [].

In light of this massive cancer burden, one would expect comprehensive and meticulous systems in place to document and promote BCa awareness in the Pakistani population. Unfortunately, this is not so. Pakistan’s cancer-related predicament begins with the National Cancer Registry which is limited in its ability to gauge the actual BCa burden due to obscure statistics, and ends with the lack of national policies to address it [–]. According to a recent review, Pakistan has only witnessed one national policy, in its history, to raise awareness regarding cancer’s early warning signs []. Therefore, with an alarming BCa burden, and shareholding the highest BCa death rate across the world, one would further question how aware are Pakistani women of BCa and its related information. Although several observational studies have sought to answer this question over the years, a consolidated assessment of BCa awareness amongst Pakistani women through a systematic review of the literature was hitherto non-existent.

Synthesis of data through a systematic review of literature is crucial for decision-making and subsequent health policies []. In doing so, an assessment of current BCa awareness amongst Pakistani women forms the backbone for future public health-related interventions and/or awareness campaigns. Such health policies are geared towards prevention by teaching the population simple methods to detect and identify BCa through physical examination, or tests like mammography. Inculcation of basic clinical knowledge which is tailored for the common people can help Pakistan catch BCa in its early stages, if not prevent it by addressing modifiable risk factors. Furthermore, by teaching women about available BCa treatments, Pakistan can hope to lose its current spot at the top of the BCa-associated mortality ladder []. Therefore, we undertook this study to fill the knowledge gap in the literature regarding BCa awareness amongst Pakistani women. The objectives of our study were to answer the following questions: What is the prevalence of knowledge of BCa in general, its risk factors, symptoms, diagnostic modalities, and treatment? What is the attitude of Pakistani women towards BCa? How prevalent are BCa screening practices amongst Pakistani women?

On September 1, 2023, MAR and ET, individually, searched the following databases for relevant studies: MEDLINE, Embase, Scopus, and Google Scholar. The search strings used for each database are present in . MAR and ET also performed a citation search of included studies.

We included observational cross-sectional studies that were published in/after 2010 and satisfied the following criteria: 1) measured BCa awareness, 2) conducted in Pakistan, and 3) the population was women. Studies were excluded based on the following criteria: 1) did not measure BCa awareness, 2) was not conducted in Pakistan, 3) the population was other than women, 4) women who were medical students or physicians, 5) case reports, editorials, letters, and reviews.

MAR and ET individually screened titles and abstracts against the inclusion/exclusion criteria to short-list studies for full-text screening. Shortlisted studies underwent full-text review to select studies eligible for inclusion in this study. The PRISMA flowchart is shown in .

MAR and ET individually applied the National Institute of Health’s (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies to each study and resolved discrepancies with a consensus []. The NIH tool is a 14-item questionnaire that evaluates the integrity of the following characteristics: objective, study population, participation rate, temporal and participant uniformity, sample size, exposure, time frame, effect of varying variables on outcome, validity of variables, frequency of variable assessment, outcome definition, blinding, data loss to follow-up, confounding.

The measure of effect for our study was the pooled prevalence of knowledge about BCa and its associated information: risk factors, symptoms, diagnostic modalities, treatments; and the pooled prevalence of practices associated with BCa.

We used Canva to build upon the map of Pakistan which was obtained from the Central Intelligence Agency’s Map Library. We used MetaAnalyst to generate forest plots for the analysis []. The PRISMA flowchart was created using PRISMA2020 []. Funnel plots were created using JASP [].

We analyzed responses from 9,766 Pakistani women across 18 studies over the past 14 years (2010–2023) [–]. The geographical distribution of responses across Pakistan is shown in .

All included studies were observational cross-sectional studies. A total of 14 studies used self-made questionnaires, two studies used the Breast Cancer Awareness Measure (BCAM) tool, one used the Breast Cancer Inventory (BCI) tool, and one did not specify [, ]. A majority of studies ( n = 10) had good quality based on the NIH tool. No study showed signs of poor quality although several had concerning copy-writing issues. A detailed quality analysis report is present in . The mean age across studies ranged from 23 years to 35 years. Seven studies evaluated BCa awareness by collecting responses from women who were visiting the outpatient department (OPD), and six studies evaluated responses from non-medical university or college students. Characteristics of included studies are shown in .

Out of 18 studies, only seven studies segregated the overall level of BCa knowledge into pre-defined scores [, , , , , , ]. In four of these studies, the overall BCa knowledge score was poor for a majority of respondents [, , , ]. A majority had moderate BCa knowledge in the rest [, , ]. Significant associations of overall BCa knowledge scores were reported between educational status ( n = 7) [, , , , , , ], a higher monthly income ( n = 6) [, , , , , ], age ( n = 4) [, , , ], and women who were employed ( n = 3) [, , ]. Forest plots for overall knowledge about BCa risk factors, symptoms, diagnostic modalities, and treatment are shown in . Pooled knowledge for individual variables for each category is highlighted in . Funnel plots for assessment of publication bias are shown in .

The pooled overall BCa risk factor knowledge was 42.7% (95% CI: 34.1%-51.4%). The most commonly assessed risk factors were: family history ( n = 13), obesity ( n = 12), and nulliparity ( n = 10). The least well-known BCa risk factors were: lack of exercise, 24.3% (95% CI: 16.8%-31.7%); menopause at age >50 years, 25.4% (95% CI: 14.8%-36.1%); menarche at age <11 years, 25.7% (95% CI: 16.8%-34.6%); use of hormone-replacement therapy, 26.3% (95% CI, 16.6%-35.9%). The most well-known risk factors were: not breastfeeding, 69.8% (95% CI: 59.2%-80.4%); breast trauma: 67.8% (95% CI: 58.2%-77.5%).

The pooled symptom knowledge was 41.8% (95% CI: 26.2%-57.5%). The most commonly assessed symptoms were: bloody nipple discharge ( n = 8), and breast lump ( n = 7). The least well-known symptom was the presence of a breast ulcer, 28.8% (95% CI: -2.0–59.5). The most well-known symptom was the presence of a breast lump, 54.7% (95% CI: 32.4–76.9). Breast pain ( n = 7) was considered a BCa symptom by 53.5% (95% CI: 33.1, 73.9) of women.

Only four studies evaluated treatment knowledge of BCa [, , , ]. The overall treatment knowledge was 46.6% (95% CI: 13.5%-79.8%). Treatment methods in descending order of popularity were surgery, chemotherapy, and radiotherapy.

Around 90% of women, across five studies, agreed that they would consult a doctor if they were to discover a breast lump [–, , ]. Similarly, the need for BCa screening was also hailed as necessary for early detection of BCa [, , , , ].

Barriers for women were evaluated in seven studies [, , , , , , ]. The most common barriers to consultation were affordability ( n = 5), unavailability of a female doctor ( n = 5), and the fear of detecting BCa ( n = 5).

Practice related to BCa was most frequently reported in the form of breast self-examination (BSE) ( n = 13), clinical breast exam(s) (CBE) ( n = 7), and screening by mammography ( n = 5). The frequency of regular BSE was specified in only four studies, the rest made no clear distinction [, , , ]. Only two of five studies evaluated mammography amongst women aged >40 years, where less than 25% of women older than 40 years had had a mammogram [, ]. The pooled prevalence of regular BSE and ever having undergone a CBE were 28.7% (95% CI: 17.9%-39.6%) and 15.3% (95 CI: 11.2%-19.4%), respectively, as shown in . The distribution of BSE practice across studies is shown in .

This is the first review of literature that consolidates 14 years of data to examine the level of BCa awareness amongst Pakistani women. Where a plethora of existing literature has highlighted the paucity of BCa awareness amongst Pakistani women at discrete timestamps and locations in Pakistani history, the lack of a consolidated study was a major gap in BCa literature, and our understanding of BCa awareness in South Asia. Our study shows that the prevalence of knowledge for various aspects of BCa is very low: risk factors, 43%; symptoms, 42%; diagnostic modalities, 36%; treatment, 47%. Only 38% of women knew mammography as a diagnostic tool. The prevalence of regular BSE is much lower with only 29% of Pakistani women performing regular BSE. Furthermore, only 15% of women have ever undergone a CBE. It is worthwhile to discuss the poor knowledge among Pakistani women about mammography as a diagnostic tool. Over 30 years ago, the benefit of BCa screening by mammography was established []. Although some debates have arisen regarding the benefits and harms of mammography, the International Agency for Research on Cancer, in 2014, concluded that mammography holds an overall net benefit for women []. However, the merits of such a tool may be questionable in a country such as Pakistan given that only two in five women are aware of mammography, as highlighted in our study.

Low levels of physical examination practices are also dismaying. Physical examinations are cheap, convenient, and easy to perform. CBEs by trained medical professionals help detect BCa, although the sensitivity of the exam might be low [, ]. The use of BSE is also debated concerning its false-positive results that encourage unnecessary testing, no established effect on BCa mortality, and the anxiety-provoking psychological stress when a lump is detected—for it may not be cancer at all []. However, similar to CBEs, BSEs also help detect BCa, and their use is encouraged in other parts of the medical literature []. This holds especially true for low-income countries like Pakistan, where mass screening programs through mammography testing would be hugely expensive. In Pakistan, BSE could be the only option for many women who do not have access to mammography [, ].

We would like to address the common misconception of breast pain as a potential symptom of BCa. A recent study of almost 11,000 referrals of women to the breast diagnostic clinic, showed no association of breast pain and BCa []. Referrals based on breast pain alone were quoted as “ inefficient ” with “ no health benefit ” but “ increased costs ” []. This information is hardly groundbreaking; breast pain, in the absence of other BCa symptoms, is not an indication for referral to the BCa unit [, ]. However, our study revealed that breast pain was the second most commonly associated symptom with BCa, with approximately 54% of women harboring this belief. This grim statistic underscores the poor knowledge and awareness women in Pakistan have regarding BCa.

An important trend that should not be missed in the chronological forest plots is the stagnant prevalence of BCa knowledge and practice over the years. The unwavering levels of BCa awareness could largely be attributed to Pakistan’s struggling cancer care which, in the face of considerable issues such as a preferential budget that withholds money from healthcare, poor governance, corruption, lack of resources, etc., has largely lacked organized BCa awareness campaigns [, ]. The foundation for cancer prevention lies in educating the population at risk about the disease and what they can do to prevent it through screening. Examples of strategically planned BCa awareness campaigns in the medical literature establish their effectiveness [, ]. Such interventions inculcate knowledge about risk factors and symptoms that women should look out for. Coupled with awareness about screening practices, BCa awareness interventions reduce late diagnoses, which translates into reduced mortality [].

The need for interventions that seek to spread BCa awareness, extends beyond the border into India. BCa screening practices are comparable between the two countries as highlighted by the findings of a recent review in India and our study: BSE, 27% vs. 29%; CBE, 17% vs. 15% []. Low BCa awareness amongst Asians has also been corroborated by another recent meta-analysis []. Another important takeaway from the results of our study and the aforementioned reviews is the significant association between BCa awareness and the level of education or age [, ]. Smaller original studies from Bangladesh [], Afghanistan [], and Nepal [], also highlight the dire need for interventions to improve the situation in South Asia, though a consolidated review is absent from the literature.

We observed a large variation in observed results which were attributable to heterogeneity in the true results, highlighted by high I 2 values (>90%). In light of the nature of this study, where we pooled prevalence data from multiple observational studies, high I 2 values are the norm where they signify a low sampling error which is attributable to the inclusion of several studies, and many individual events []. In addition, although our study focused on one country, we assessed data from nine cities and respondents that differed in their education levels, socioeconomic statuses, age, the year the study was carried out, etc., which could explain the high heterogeneity in the true results [].

We also used funnel plots to detect publication bias in our studies. We observed asymmetrical distributions for knowledge about BCa symptoms, diagnostic modalities, and treatment. A symmetrical distribution around the effect size was observed in funnel plots for knowledge of BCa risk factors, prevalence of BSE and CBE, which was confirmed with the Begg’s and Egger’s tests which did not show significant funnel plot asymmetry. However, we remind and caution interpreters regarding the subjectivity of the funnel plots [], the debated use of Begg’s and Egger’s tests in proportion meta-analyses [], and the limited power of the tests when few studies are included in the analysis []. Furthermore, because asymmetry in funnel plots of proportion meta-analyses can be caused by reasons other than publication bias [], the asymmetry in aforementioned analyses could be attributed to the fewer number of studies that evaluated the symptoms ( n = 8), diagnostic modalities ( n = 11), and treatments ( n = 4). We should also not forget the use of self-developed questionnaires to collect responses which could also play a role in biased data collection methods, leading to varying effect sizes in individual studies, and in turn, dispersed plots.