The results of this study suggest that community-dwelling women in Nigeria have rather poor knowledge of breast cancer. This may partly explain the late presentation seen in over 70% of women with the disease [3–5]. A mean knowledge score of 42.3% with only 22.9% scoring 50.0% and above portray the abysmal level of ignorance about risk factors and common symptoms of breast cancer in Nigerian women. Unlike previous studies on this subject in Nigerian women [13, 18, 19], we have recruited community-dwelling women spanning a wide spectrum of age, occupation and educational status. The wide age coverage was deliberate as breast cancer shows a younger age profile in Nigerian women similar to reports in other populations of black descent in the Diaspora but contrary to the older age distribution in Caucasian women; the reported mean ages of 38, 44, and 48 years at presentation reported by various investigators [3–5] in Nigeria support this proposition.
The low level of knowledge found in this study is in keeping with reports of other investigators [13, 18, 19]. In a survey of breast cancer knowledge, Uche  noted that only 32% of the respondents knew that a breast lump was a warning sign for breast cancer, 58.5% were unaware of most warning signs and only 9.8% knew of methods of detecting breast cancer. Our study showed that only 21.4% of community-dwelling women were aware of a painless breast lump as a common presentation of breast cancer and far less proportion of these women were able to identify non-lump presenting symptoms of breast cancer, while only 43.2% were aware of BSE as a screening tool for breast cancer. Even professional health workers such as nurses who are supposed to be leaders in "breast awareness", were reported to have similar low knowledge scores . Odusanya and Tayo  found that only 27% of nurses in a tertiary health institution in Lagos, Nigeria could identify up to 3–4 risk factors for breast cancer. In addition, 51% of these nurses wrongly identified the use of fingertips in performing BSE.
These results in Nigerian women sharply contrast with reports from the Western world. In a study of women's knowledge and belief about breast cancer among British women, Grunfeld et al,  noted that 90%, 70%, and 60% respectively, were able to quantify the relative risk of breast cancer associated with family history, previous history of breast cancer, and smoking, respectively. The same authors found that over 70% of the surveyed women were able to identify painless breast lump, lump under the armpit and nipple discharge/bleeding as symptoms of breast cancer. It should however be noted that a much smaller proportion of these women were able to recognize other non-lump symptoms such as dimpling of the breast skin, inversion/pulling in of the nipple, and scaling/dry skin in the nipple region.
Our results indicate that education and employment in professional jobs significantly influenced knowledge of breast cancer. Women with education greater than High School and those employed in professional jobs such as nursing, teaching and sales had significantly higher knowledge scores compared with those employed in small businesses. Other demographic variables including age, marital status and religion were not significantly related to knowledge score. These results are in agreement with the findings of others but at variance with the report of others. Among a cross section of British women, Grunfeld et al,  found that older women demonstrated poorer knowledge of risk factors for breast cancer; they noted that this poorer knowledge was also apparent among women of lower social economic status (SES). Surveys in the US , and Australia  have demonstrated that older women have poorer knowledge of key risk factors for various cancers. It has been suggested that older women may attribute non-lump breast symptoms to the aging process, and therefore ignore these warning signs of breast cancer . Furthermore, it has been argued that older adults, who may have a number of symptoms of other illnesses, should not be expected to seek help for symptoms that are not causing them any pain or that have little effect on their functioning .
Participants in our study had the right attitude towards breast cancer as majority indicated visiting the doctor for breast complaints. The use of screening methods was very low among our study subjects; only 34.9% practice BSE and only 9.1% had had CBE in the past year and none ever had a mammogram. Odusanya and Tayo  reported that 89% of Nurses in Lagos, Nigeria practiced BSE and 34.3% had CBE although majority of their study participants did not know the correct time or technique for carrying out the procedure. Available data indicates that majority of women in the screening age group in the developed countries undergo routine screening using all three methods including monthly BSE, annual CBE, and annual mammography [24, 25]. In a survey of practice of BSE among black women in the US, Jacobs et al,  found that 89% of respondents indicated practicing BSE during the past year, 74% indicated having done so during the past six months, and 39% indicated performing self exam monthly. Similar percentage of US women reporting practice of BSE monthly or more often have been reported by other investigators .
Higher level of education and higher knowledge score were significant determinants of BSE practice in our study; age and other demographic variables were not significantly related to BSE practice. Similar to our findings, other investigators have reported that demographic characteristics such as higher levels of education and income, marital status, younger age, social support, knowledge and preventive attitudes, a history of breast diseases, a family history of breast cancer, having a regular physician, ethnic background and residence area are significant determinants of adherence to BSE practice [14, 15, 28].
The guidelines for breast cancer screening recommended by a consortium of American medical organizations including the American Cancer Society, stipulates that: between the ages of 40 and 49 years, women should undergo a CBE and mammography every year or two; women older than 50 years should have an annual CBE as well as a mammogram . Mammography and CBE facilitate early detection and treatment of breast cancer, which is responsible for lower mortality rates . In a screening setting, about 10% of breast cancers will only be detected by CBE .
The value of BSE is less established. While the findings of a clinical trial suggested that BSE results in no difference in risk of mortality from breast cancer, a review of case-control studies found that BSE might reduce this risk. Despite inconclusive evidence, it is thought that BSE makes women more "breast aware", which in turn may lead to earlier diagnosis of breast cancer . The rationale behind extending BSE practice as a screening test is the fact that breast cancer is frequently detected by women themselves without any other symptoms. A meta-analysis of studies investigating the possible benefits of BSE has shown that regular practice increases the probability of detecting breast cancer at an early stage . However, BSE is associated with other drawbacks including increased number of biopsies for benign breast lesions, [31, 32] increased anxiety, and physician visits with consequent use of scarce health resources in addition to the distress, scarring and disfigurement that may be associated with breast biopsies.
Routine breast cancer screening is currently not being practiced in Nigeria. Even then, applying the recommended mammography screening guidelines in Nigeria will catch only a proportion of breast cancer cases as about 57% of breast cancer cases in Nigeria occur in women below the age of 50 years . In addition, some other factors militate against routine breast cancer screening in Nigeria. The actual burden of breast cancer in the population is unknown due to lack of adequate cancer statistics. The age specific incidence of the disease needs to be established to make a case for routine screening of women of specific age groups. Women need to be "breast aware" to stimulate their interest in screening. Health care spending for chronic diseases in Nigeria is competing with several basic needs including provision of basic amenities and infrastructure, and control of several endemic childhood infections and parasitic infestations; any money invested in breast cancer screening must be justified by the benefits to the population. Given the non-availability of adequate data to justify mammography screening and the high cost and skilled expertise required for the procedure, current efforts at breast cancer screening in Nigeria must rely on a combination of BSE and CBE. Women can be taught the techniques of monthly BSE and nurses, midwives, and other healthcare providers can be trained to augment physicians in the performance of clinical breast examinations (CBE).
As previously indicated, the interviewer-administered questionnaire developed by the authors was the only instrument employed for recruitment of study participants. Although, this may limit comparability of our findings with that of other investigators, it is important to note that efforts were made to ensure some measure of validity by pre-testing the questionnaire on a convenient sample before commencement of the study.