Background

Breast cancer (BC) is the most common cancer and the leading cause of cancer-related mortality among women worldwide [1]. In 2022, 2.3 million cases of BC and 670,000 related deaths were reported globally [1]. In Afghanistan, breast cancer is one of the five top commonly diagnosed cancers in women, with 3,173 confirmed cases and 1,783 deaths reported in 2020, accounting for 26% of newly diagnosed cancers in women according to the Global Cancer 2020 statistics [2,3]. According to WHO estimates from 2012, Afghanistan has the highest number of breast cancer cases compared to its neighboring countries – excluding Pakistan – including Iran, China, India, Uzbekistan, Tajikistan, and Turkmenistan [4]. A recent commentary article has demonstrated potential challenges in cancer care in the current sociopolitical context of Afghanistan [5].

Breast cancer is a preventable disease, with age as an important risk factor – particularly affecting women in their most productive years. While the disease is prevalent globally, more cases are identified in developing countries among women aged of 15–49 [6]. Other risk factors include modifiable lifestyle choices such as obesity, physical activity (PA), food choices, smoking, and alcohol use [4,7–12]. Treatment efficiencies vary significantly between high and low- and middle-income countries [1]. In high-income countries, advances in early detection and treatment have greatly improved survival rates, with 90% of women surviving for at least five years post-diagnosis [1]. Survival rates in low-income countries range from 40 to 66%, primarily due to inadequate treatment options and limited access to early detection [5,13]. This inequality is concerning.

In Afghanistan, as in many low-resource settings, breast cancer treatment options are scarce. The healthcare system is heavily dependent on international aid to address issues related to and manage breast cancer [2]. While it is possible to continue relying on comprehensive treatment plans provided by high-income countries, the situation in Afghanistan is far more challenging, particularly due to underdeveloped healthcare infrastructure, shortage of medical supplies, and unskilled personnel [5]. As a result, many patients need to seek treatment in neighboring countries like Pakistan and Iran [5]. The lack of domestic treatment and infrastructure, combined with a healthcare system mainly focused on communicable disease and reproductive health, underscore the need for effective prevention strategies [13]. Furthermore, while Afghanistan has a national cancer policy, it may be outdated, and cancer registries remains limited [4]. The only known cancer registry operates in Kabul at Jamhuriat Hospital; however, national data collection continues to be a challenge.

Given the limitations in Afghanistan’s healthcare system, the most viable approach to reduce breast cancer burden is prevention through early detection and prompt diagnosis [6,7,14]. Screening practices are essential for rapid diagnosis – improving the likelihood of early treatment, and significantly reducing mortality risk [4]. Breast cancer is almost completely curable when detected early and by seeking medical care in the course of the disease. The three major methods to detect breast cancer are mammography, clinical breast exams (CBE), and breast self-examination (BSE). In resource-limited settings, where mammography and clinical breast exams are difficult to implement, BSE becomes the most cost-effective method for early detection [6]. BSE is a process whereby women examine their breast for any swelling or other abnormalities [6]. With proper training and counselling from healthcare professionals, combined with regular practice, women can increase their awareness of breast health and seek medical care earlier, when treatment is most effective [6,7,15,16].

Studies suggest women’s knowledge about breast cancer risk factors and early warning signs contribute to their likelihood of accessing medical care or early intervention [12,17,18]. Despite the benefits of BSE, knowledge and practice among Afghan women remain relatively low, largely due to lack of education and cultural barriers. Therefore, this study is designed to assess the knowledge, practice, and associated factors of BSE among Afghan women aged 20–80, accessing care at the Oncology department of Ali Abad Teaching Hospital in Kabul city.

Methods

Sample size determination

The sample size was calculated using the anticipated 28% frequency of breast self-examination practice in the general female population in Afghanistan [4], due to the absence of prior estimates specifically among women diagnosed with breast cancer. Using a 5% maximum allowable error, and a 95% confidence interval, the formula (z2p[1‑p])/d2 was applied, where z = 1.96, P = 0.28 and d = 0.05. This yielded a sample size of 257, however with a non-response rate of 10%, the final sample size obtained was 282, rounded to 290 (Fig 1).

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Fig 1. Data source: OpenEpi.

The table provides sample size calculation based on population size of 1500, expected frequency of 28%, and a 95% confidence interval.

https://doi.org/10.1371/journal.pone.0335460.g001

Results

Socio-demographic characteristics

Out of 337 women with breast cancer who completed the questionnaire, 28 were excluded due to missing data on key explanatory or outcome variables, and another 19 were excluded for being under the age of 19 years. In the final analytical population (Table 1), the majority of the participants were of the age group of 50 years and older (mean age: 42.9, SD: 14.7), were married (83.8%), unemployed (95.9%), illiterate (83.8%), and had more than two children (80.3%). Notably, 50.3% and 68.6% of the participants had healthy BMI and lived more than 5 km from the hospital, respectively.

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Table 1. Sociodemographic characteristics of the study participants (n = 290).

https://doi.org/10.1371/journal.pone.0335460.t001

Knowledge and practice pertaining to BSE

Out of 290 participants, 49.7% demonstrated poor knowledge of BSE (S1 Table). While only 19% reported ever practicing BSE; among them, 36.4% performed it at the right time, 34.5% started at the right age, 32.7% practiced it at the correct frequency, and 61.8% knew the correct technique. The main reasons for not practicing BSE were the absence of breast-related problems (49.8%) and lack of knowledge on how to perform BSE (29.2%). The distribution of knowledge and practice is presented in Fig 2.

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Fig 2. Distribution of knowledge and practice of breast self-examination among women with breast cancer (n = 290).

https://doi.org/10.1371/journal.pone.0335460.g002

Multivariate analysis

Variables significantly associated with BSE practice in bivariate analysis (see Supplementary Tables 3S and 4S) were considered for inclusion in the multivariable logistic regression model. After adjustment for potential confounders, the strength and direction of associations of all variables remained largely consistent. Similar to bivariate logistic regression result, women education level [AOR: 3.65, 95% CI (1.06–12.76)], their awareness level of BSE [AOR: 4.31, 95% CI (1.37–19.3)], and knowledge about BSE [AOR: 5.28, 95% CI (2.45–12.48)] continued to show significant association with BSE practice. The AOR associated with these variables were slightly attenuated, but the association remained statistically significant. Other socioeconomic variables such as age, marital status, BMI, distance to the hospital, occupation, and number of children were still not significantly associated with BSE practice after adjustment. Findings of multivariate logistic regression analysis is present in detail in Table 2.

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Table 2. Multivariable analysis of factors associated with BSE practice among women with breast cancer visiting Ali Abad Teaching Hospital.

https://doi.org/10.1371/journal.pone.0335460.t002

Discussion

In this study, we assessed the knowledge and practice level associated with breast self-examination among women with breast cancer in Kabul, Afghanistan. While about half of the population demonstrated good knowledge of breast self-examination, only 19% self-reported its practice. The finding highlights gap in awareness of BSE practice among women already diagnosed with breast cancer. Multivariable analysis identified BSE awareness, knowledge level, and education as significant predictors of BSE practice, while other sociodemographic factors such as age, BMI, marital status, number of children, employment status, and distance from hospital were not significantly associated.

Nealy half of the participants had poor knowledge of BSE. This finding is consistent with studies in Nepal (44%) [21], Banke District (44%) [22], Ethiopia (50%−56%) [19,23], and Ghana (44%) [24]. However, higher levels of BSE knowledge have been reported among female workers in Debre Tabor Town, Ethiopia [25], women of reproductive age in Southeast Ethiopia [7], and women in Malaysia [8]. The relatively low level of knowledge in our study may be due to low employment rate among Afghan women, lack of breast cancer awareness programs, cultural barriers, and lower education levels; only 10% of participants had attained secondary or high education, compared to 59%−84% in other studies [8,25]. These findings suggest that promoting female education and integrating health education into school curricula and adult learning programs may help improve BSE knowledge.

In this study, only 19% of participants reported practicing BSE, which aligns with low practice rates in Iran (29%) [14], Ethiopia (13%−21%) [7,23,26,27], Nepal (12%) [22], Cameroon (15%) [27], and Kuwait (21%) [28]. Higher practice rates have been observed in Northwest Ethiopia (46%) [19], Malaysia (55%) [8], and Nigeria (43%) [12]. The difference in finding between our study and studies reporting higher BSE practice may be attributable to limited BSE knowledge, cultural factors, and low education levels. Notably, even among those practicing BSE, many did not perform it correctly in relation to its frequency, timing, and technique. This gap highlights the need for not only awareness but also skill-based training and community-level education campaigns.

BSE awareness and higher knowledge levels were significantly associated with BSE practice in our study. In bivariate analyses using Chi-square and Fisher’s exact tests, no sociodemographic variables showed significant association with BSE practice, unlike other studies where age and other factors were associated with practice. This lack of association may be due to the low proportion of women practicing BSE (18%), leading to imbalance in the outcome variable and reduced statistical power within subgroups. After multivariable adjustment, however, BSE awareness and knowledge remained significant predictors, consistent with findings from Ethiopia [7], Malaysia [8], and Nigeria [9]. These results highlight the importance of targeted educational interventions to improve both awareness and practical skills for effective BSE practice.

Education level was independently associated with BSE practice after adjusting for potential confounders. Women with higher education are more likely to adopt preventive health behaviours, consistent with other studies [7–9]. Other sociodemographic factors such as employment status, age, number of children, marital status, BMI, and distance from hospital were not significantly associated in our sample, which may reflect the characteristics of women with breast cancer, who are more likely to receive counselling and regular healthcare interaction than the general population. These findings suggest that integrating BSE education into school curricula, adult literacy programs, and clinical counselling may improve BSE practice among women with lower education.

In Afghanistan, there is only one study focusing on BSE among women visiting hospitals, while the present study aims to explore the knowledge and practice of BSE among women diagnosed with breast cancer [4]. Findings from our study provide critical insight for survivorship care, emphasizing the importance of promoting BSE in a resource-limited setting where clinical follow-ups and diagnostic services are scarce. Policymakers should consider integrating BSE education into national health programs, and healthcare providers should routinely counsel women to empower self-monitoring. Future research should explore cultural and educational barriers to inform targeted, culturally appropriate awareness campaigns aimed at improving early detection.

Strengths and limitations

This study has strengths and limitations. This study focuses on a high-risk population who have already been diagnosed with breast cancer. This approach can provide valuable insight into whether BSE was effective in early detection of the condition or whether it was neglected. Fortunately, this study is conducted in Afghanistan, which appropriately reflects the cultural and social barriers specific to Afghan women.

The present study also has several limitations. First, the observations are based in Kabul, Afghanistan, and while they offer insights relevant to the capital city, the findings may not be generalizable to rural community, where healthcare resources and access are more limited, or to other urban areas across the country. Second, the results are based on self-reported data, which may introduce recall bias, underreporting, or exaggeration, and may not accurately reflect actual BSE knowledge or practice. Third, participants were recruited using convenience sampling, which could introduce selection bias if non-responders differ meaningfully from responders. Fourth, the cross-sectional study design prevents causal inference between the factors studied and BSE knowledge or practice. In addition, some potentially important variables were not captured in our questionnaire, such as residence (urban vs. rural), household income, and family history of breast cancer. Including these variables in future studies conducted in Afghanistan could provide additional insight for policymakers and healthcare providers, particularly regarding access barriers and context-specific interventions. Further research is needed to understand whether some factors have effects beyond association.

Conclusion

This study concludes that about half of the participants had poor knowledge of BSE, but only 19% practiced it. Among those who were practicing BSE, only about 30% knew when to perform the test, at what age to start, and how often to practice. The study also concludes that variables such as women’s education, awareness level about BSE, and knowledge levels are significant predictors of BSE practice. Findings from this study supports implementations of comprehensive BSE educational programs to increase breast cancer awareness. Our result, however, necessitate replication in different provinces of Afghanistan, particularly among the general population, and potentially using a larger sample size.

Supporting information

Acknowledgments

The authors would like to thank Kabul University of Medical Sciences for supporting the study, and the management team of Ali Abad Teaching Hospital for permitting the study to be conducted in their outpatient settings. We also extend our gratitude to the women who participated in the study.