Early Detection of Breast Cancer Among Women in the Middle Region of Syria
Conditions: Breast Cancer Detection
Sponsor: Al-Hawash Private University

Al-Hawash Private University  
 
Detection of Breast Cancer Among Women in the 
Middle Region of Syria: A Cross-Sectional Study 
Protocol 
Date: June 29th, 2025 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 
Abstract 
Breast cancer remains the most prevalent malignancy among women globally and 
constitutes a significant cause of cancer-related mortality. In Syria, particularly in the 
middle region, the incidence of breast cancer has been steadily increasing, exacerbated by 
the ongoing humanitarian crisis that has disrupted healthcare infrastructure and services. 
This cross-sectional study aims to assess the awareness, knowledge, and practices related 
to early detection of breast cancer among women in the middle region of Syria. 
Approximately 1,000 women aged 18 years and older will be recruited through online 
platforms and community health centers. Data will be collected using a structured 
questionnaire covering demographic information, awareness of breast cancer symptoms 
and risk factors, knowledge of breast self-examination techniques, history of professional 
screenings, and perceived barriers to seeking medical help. Statistical analysis will be 
performed to identify associations between awareness levels and demographic factors. 
The findings from this study will provide crucial insights into the current state of breast 
cancer awareness and screening practices in the region, informing the development of 
targeted public health interventions aimed at improving early detection rates and, 
consequently, survival outcomes among Syrian women. 
 
Introduction 
Breast cancer represents a significant global health concern, particularly for women, as it 
is the most diagnosed cancer and a leading cause of cancer-related mortality worldwide. 
The World Health Organization estimates that approximately 2.3 million women are 
diagnosed with breast cancer annually, with mortality rates being disproportionately higher 
in low and middle-income countries due to late-stage diagnosis and limited access to 
treatment (WHO, 2023). 
In Syria, the healthcare system has faced unprecedented challenges due to the protracted 
conflict, resulting in disrupted services, damaged infrastructure, and limited resources. 
These circumstances have significantly impacted cancer care, including breast cancer 
screening, diagnosis, and treatment. The middle region of Syria, which encompasses 
several governorates including Homs and Hama, has been particularly affected by these 

disruptions, potentially leading to delayed diagnoses and poorer outcomes for breast 
cancer patients. 
Early detection of breast cancer is crucial for improving survival rates and reducing the 
burden of advanced disease. When detected at an early stage, breast cancer has a five-
year survival rate of over 90%, compared to less than 30% when diagnosed at advanced 
stages (American Cancer Society, 2023). Early detection strategies include breast self-
examination (BSE), clinical breast examination (CBE), and mammography, all of which 
require adequate awareness and knowledge among women. 
 
Recent studies indicate that many women in Syria lack adequate knowledge about breast 
cancer risk factors, warning signs, and the importance of early detection. For instance, a 
study conducted in 2023 revealed that a sizable portion of Syrian women demonstrated 
insufficient awareness regarding breast cancer symptoms and preventive measures. This 
lack of awareness is compounded by the ongoing humanitarian crisis, which has disrupted 
healthcare services and education. 
 
The present study aims to address this critical gap by assessing the awareness and 
practices related to early detection of breast cancer among women in the middle region of 
Syria. By identifying barriers to effective screening and intervention, this research will 
contribute to the development of targeted public health strategies that can enhance early 
detection efforts, ultimately improving health outcomes for women in this region. 
 
Methods 
Study Design and Setting 
This research will employ a cross-sectional study design to evaluate breast cancer 
awareness and early detection practices among women in the middle region of Syria. The 
cross-sectional approach allows for the assessment of prevalence and associated factors 
at a specific point in time, providing a snapshot of the current situation. The study will be 
conducted in both urban and rural areas within the middle region of Syria, encompassing 
the governorates of Homs, Hama, and surrounding areas. Data collection will occur over a 
six-month period, tentatively scheduled from September 2025 to February 2026. 
 
 

 
Study Population and Sampling 
Inclusion and Exclusion Criteria 
 The study population will consist of women aged 18 years and older residing in the middle 
region of Syria. Women with a previous diagnosis of breast cancer will be excluded from the 
study, as their knowledge and practices may be influenced by their experience with the 
disease, potentially introducing bias into the results. 
Sample Size Determination 
 A sample size of approximately 1,000 participants will be targeted to ensure statistical 
significance and representativeness. This sample size was calculated using the formula for 
cross-sectional studies with a 95% confidence interval, 3% margin of error, and an 
estimated prevalence of breast cancer awareness of 50% (to maximize sample size). The 
sample size was further adjusted to account for a potential non-response rate of 15%. 
Sampling Technique 
  A multi-stage sampling technique will be employed to select participants. First, districts 
within each governorate will be randomly selected. Within each selected district, 
communities will be randomly chosen. Finally, eligible women from these communities will 
be invited to participate through various recruitment channels, including community health 
centers, women's organizations, and online platforms. 
Data Collection Instruments and Procedures 
Data will be collected through a structured questionnaire that has been developed based 
on a comprehensive literature review and adapted to the Syrian context. The questionnaire 
will be translated into Arabic and back translated to ensure accuracy and cultural 
appropriateness. It will be pre-tested on a sample of 50 women who will not be included in 
the final study. 
The questionnaire will consist of the following sections: 
1. Demographic Information: This section will gather data on age, education level, marital 
status, occupation, income level, place of residence (urban/rural), and access to 
healthcare services. 
2. Awareness of Breast Cancer: This section will assess knowledge about breast cancer 
symptoms, risk factors, and warning signs. Participants will be asked to identify common 

symptoms and risk factors from a list, and their responses will be scored to determine their 
level of awareness. 
3. Breast Self-Examination (BSE) Knowledge and Practice: Questions in this section will 
evaluate participants' knowledge of BSE techniques, frequency of practice, and confidence 
in performing the examination correctly. 
4. Professional Screening History: This section will gather information on participants' 
history of clinical breast examinations and mammography, including frequency, most 
recent screening, and factors influencing their decision to undergo professional screening. 
5. Barriers to Early Detection: This section will identify perceived barriers to seeking 
medical help for breast-related concerns, including financial constraints, accessibility 
issues, cultural factors, and knowledge gaps. 
The questionnaire will be administered through two main channels: 
1. Online Survey: An electronic version of the questionnaire will be distributed through 
social media platforms, email lists of women's organizations, and other online channels to 
reach a diverse audience. 
2.  In-person Data Collection: Trained female research assistants will administer the 
questionnaire at community health centers, women's gatherings, and other community 
settings to ensure inclusion of women with limited internet access. 
Methods of Breast Cancer Detection 
Early detection of breast cancer significantly improves treatment outcomes. Various 
methods are employed for screening and diagnosis, each with specific applications and 
benefits. The study aims to assess awareness and practices related to these methods 
among the target population. 
Mammography: A mammogram is an X-ray picture of the breast, widely used for both 
screening women without symptoms and for diagnostic purposes when symptoms or 
abnormalities are present. This low-dose X-ray technique can detect tumors that cannot be 
felt during a physical examination, as well as microcalcifications, which can sometimes 
indicate the presence of breast cancer. During the procedure, the breast is compressed 
between two plates to obtain clear images. While highly effective, the sensitivity of 
mammography can be reduced in women with dense breast tissue. Advanced techniques 
like 3D mammography (tomosynthesis) can provide more detailed images, particularly 
beneficial for dense breasts. 

Breast Ultrasound (Echo): Breast ultrasound uses high-frequency sound waves to create 
detailed images of the internal structures of the breast. It is a non-invasive procedure that 
does not involve radiation. Ultrasound is particularly valuable as a complementary tool to 
mammography, especially for women with dense breast tissue, where mammography's 
effectiveness may be limited. It is highly effective in distinguishing between solid masses 
and fluid-filled cysts, providing crucial information about the nature of suspicious areas. 
While ultrasound can detect small, invasive cancers that might be missed by 
mammography, it cannot definitively diagnose cancer; a biopsy is typically required for 
confirmation. Ultrasound can also be used to guide biopsy procedures. 
Blood Testing: Complete blood counts were conducted for each participant.  
Ethical Considerations 
 
The study protocol will be submitted for approval to the relevant ethical review 
committees. Informed consent will be obtained from all participants before data 
collection. Participants will be assured of confidentiality and anonymity, and they will have 
the right to withdraw from the study at any time without consequences. All data will be 
stored securely with password protection, and only the research team will have access to 
the raw data. 
Data Analysis Plan 
Data will be analyzed using Statistical Package for Social Sciences (SPSS) version 27.0. The 
analysis will proceed as follows: 
1. Data Cleaning and Preparation: The dataset will be checked for completeness, 
consistency, and accuracy. Missing data will be handled according to appropriate 
statistical methods. 
2. Descriptive Statistics: Demographic characteristics of the participants will be 
summarized using frequencies, percentages, means, and standard deviations as 
appropriate. Levels of awareness, knowledge, and practices related to breast cancer early 
detection will be presented using similar descriptive statistics. 
3. Inferential Statistics: Chi-square tests will be used to assess associations between 
categorical variables, such as the relationship between education level and awareness of 
breast cancer symptoms. For continuous variables, t-tests or ANOVA will be employed as 
appropriate. Multivariate logistic regression analysis will be conducted to identify factors 
independently associated with breast cancer awareness and screening practices, 
controlling potential confounders. 

4. Thematic Analysis: Responses to open-ended questions about barriers to seeking 
medical help will be analyzed using thematic analysis to identify common themes and 
patterns. 
A p-value of less than 0.05 will be considered statistically significant for all analyses. 
Anticipated Results 
While the actual results will be determined following data collection and analysis, several 
anticipated outcomes can be projected based on existing literature and the Syrian context: 
Demographic Distribution 
It is anticipated that the study sample will reflect the demographic diversity of the middle 
region of Syria, with variations in age, education level, and socioeconomic status. Given 
the current situation in Syria, a considerable proportion of participants may be internally 
displaced persons, which could influence their access to healthcare services and 
information. 
Awareness and Knowledge Levels 
Based on previous studies in similar contexts, it is expected that overall awareness of 
breast cancer symptoms and risk factors may be moderate to low, with significant 
variations based on education level, urban/rural residence, and age. Younger, more 
educated women from urban areas are likely to demonstrate higher levels of awareness 
compared to older, less educated women from rural areas. 
Specific knowledge gaps may be identified regarding: 
*   Non-lump symptoms of breast cancer (e.g., skin changes, nipple discharge) 
*   Modifiable risk factors (e.g., physical inactivity, alcohol consumption) 
*   Appropriate age to begin regular screening 
*   Recommended frequency of breast self-examination and professional screening 
Breast Self-Examination Practices 
It is anticipated that while many women may have heard of breast self-examination, a 
smaller percentage will report practicing it regularly and correctly. Barriers to regular BSE 
may include lack of confidence in performing the examination correctly, fear of finding a 
lump, and misconceptions about the necessity of the practice. 
Professional Screening Utilization 

Given the disrupted healthcare system in Syria, utilization of professional screening 
services (clinical breast examination and mammography) is expected to be low. Factors 
associated with higher utilization may include higher education, higher income, urban 
residence, and having a family history of breast cancer. 
Barriers to Early Detection 
Multiple barriers to early detection are likely to be identified, including: 
1.  Structural Barriers: Limited availability of screening services, geographical distance to 
healthcare facilities, cost of services, and lack of female healthcare providers. 
2. Knowledge-Related Barriers: Insufficient awareness of breast cancer symptoms and the 
importance of early detection, misconceptions about the disease, and lack of knowledge 
about screening recommendations. 
3.  Psychosocial Barriers: Fear of diagnosis, embarrassment, fatalistic beliefs about cancer, 
and competing priorities due to the challenging living conditions in Syria. 
4. Cultural Barriers: Traditional beliefs, gender norms that discourage women from seeking 
healthcare for breast-related concerns, and stigma associated with cancer. 
Associations Between Variables 
Significant associations may be found between: 
*   Education level and breast cancer awareness 
*   Socioeconomic status and utilization of professional screening services 
*   Urban/rural residence and knowledge of breast self-examination techniques 
*   Age and perceived barriers to seeking medical help 
*   Family history of breast cancer and screening practices 
These anticipated results will provide a foundation for the development of targeted 
interventions to address specific gaps in awareness and barriers to early detection. 
Discussion 
The findings of this study will provide valuable insights into the current state of breast 
cancer awareness and early detection practices among women in the middle region of 
Syria. These insights are particularly important given the context of the ongoing 
humanitarian crisis, which has significantly impacted healthcare delivery and access to 
information. 

Implications for Public Health Practice 
The results of this study will have several important implications for public health practice 
in Syria: 
 
1. Targeted Educational Interventions: By identifying specific knowledge gaps and 
misconceptions about breast cancer, this study will inform the development of educational 
materials and campaigns that address these gaps. These interventions can be tailored to 
different demographic groups based on their specific needs and barriers. 
2. Healthcare Service Improvements: Understanding the barriers to professional screening 
will help healthcare providers and policymakers develop strategies to improve access to 
and utilization of screening services. This may include mobile screening units to reach rural 
areas, training more female healthcare providers, or implementing subsidized screening 
programs for vulnerable populations. 
3. Community-Based Approaches: The findings may support the development of 
community-based approaches to breast cancer awareness and early detection, such as 
peer education programs or community health worker initiatives, which can be particularly 
effective in contexts where formal healthcare systems are strained. 
4.  Policy Recommendations: The study results can inform policy recommendations for the 
Syrian health authorities and international organizations working in the region, highlighting 
the need for prioritizing breast cancer early detection within the broader healthcare 
agenda. 
Comparison with Existing Literature 
The anticipated findings of this study will be discussed in relation to existing literature on 
breast cancer awareness and early detection in similar contexts, particularly in conflict-
affected settings and other Middle Eastern countries. This comparison will help identify 
whether the patterns observed in Syria are unique to its specific context or reflect broader 
regional or global trends. 
For instance, studies from neighboring countries like Jordan and Lebanon have reported 
varying levels of breast cancer awareness and screening practices, influenced by factors 
such as education, socioeconomic status, and cultural beliefs. The extent to which these 
factors play a similar role in the Syrian context will be explored. 
Strengths and Limitations 
Strengths 

 
1. Comprehensive Assessment: This study will provide a comprehensive assessment of 
breast cancer awareness, knowledge, practices, and barriers in a population that has been 
understudied due to the ongoing conflict. 
2.  Mixed Recruitment Strategy: The use of both online and in-person data collection 
methods will help reach a diverse sample of women, including those with limited internet 
access. 
3.  Contextual Relevance: The study design and instruments have been adapted to the 
specific context of Syria, enhancing the relevance and applicability of the findings. 
Limitations 
1. Cross-Sectional Design: The cross-sectional nature of the study limits the ability to 
establish causal relationships between variables. Future longitudinal studies may be 
needed to track changes in awareness and practices over time. 
2.  Self-Reported Data:  The reliance on self-reported data may introduce recall bias or 
social desirability bias, particularly regarding screening practices. 
3. Sampling Challenges: The ongoing conflict and population displacement may pose 
challenges to achieving a truly representative sample, potentially limiting the 
generalizability of the findings. 
4. Security Concerns: Security issues in certain areas may restrict access to some 
populations, potentially introducing selection bias. 
These limitations will be acknowledged and addressed to the extent possible in the study 
design and implementation. 
Future Research Directions 
Based on the anticipated findings, several directions for future research can be identified: 
1. Intervention Studies: Developing and evaluating the effectiveness of interventions aimed 
at improving breast cancer awareness and screening practices based on the identified 
barriers and facilitators. 
2. Healthcare Provider Perspectives: Investigating the knowledge, attitudes, and practices 
of healthcare providers regarding early detection of breast cancer, as they play a crucial 
role in promoting screening and early diagnosis. 

3. Qualitative Exploration: Conducting in-depth qualitative studies to better understand the 
cultural, psychological, and social factors influencing women's decisions about breast 
cancer screening. 
4.  Health System Analysis: Assessing the capacity of the Syrian health system to provide 
breast cancer screening and diagnostic services, finding gaps and opportunities for 
improvement. 
5.  Longitudinal Studies: Implementing longitudinal studies to track changes in awareness 
and practices as the situation in Syria evolves and as interventions are implemented. 
Conclusion 
The early detection of breast cancer is vital for reducing mortality rates and improving the 
quality of life for women affected by this disease. This study will provide essential data to 
guide public health initiatives and enhance awareness and screening practices in the 
middle region of Syria, where healthcare resources are limited and the population faces 
numerous challenges due to the ongoing conflict. 
By finding gaps in knowledge and barriers to screening, the study aims to support the 
development of targeted interventions that can enhance early detection efforts, ultimately 
improving health outcomes for women in Syria. Through effective education and 
intervention, we can work towards reducing the impact of breast cancer on women's health 
in this region, even in the face of challenging circumstances. 
The findings of this study will not only contribute to the understanding of breast cancer 
awareness in Syria but may also provide insights relevant to other conflict-affected settings 
where healthcare systems are strained and populations face similar barriers to accessing 
preventive services. 
 
 
 
 
 
 
 
 

 
 
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