Breast cancer is a leading cause of morbidity and mortality among women worldwide [1]. Early detection through screening is essential for improving outcomes and reducing mortality rates [2, 3]. Various screening methods, including mammography, clinical breast examination, and breast self-examination (BSE), are available [4, 5, 6]. Mammography is considered the gold standard for breast cancer screening and has been shown to reduce mortality by detecting cancer at an early stage [6, 7, 8]. However, access to mammography may be limited in some populations, highlighting the importance of other screening methods, such as BSE that could be done at home and do not need hospital visits or medical equipment [9, 10, 11, 12, 13]. Guidelines recommend starting mammography by the age of 40 for average-risk women, while for younger women, BSE is an option for breast cancer screening [3, 4, 5, 6]. Regular performance of BSE can aid in the early detection of breast abnormalities and prompt further evaluation [11, 12, 13]. Despite the availability of these screening methods, many women remain unaware of their importance or do not regularly participate in screening [13, 14]. Increased awareness and utilization of breast cancer screening methods are essential for improving early detection and ultimately reducing breast cancer mortality [4, 15]. In Saudi Arabia, breast cancer is the most prevalent form of cancer among women over the age of 40 [16]. However, more than half of all cases are diagnosed at an advanced stage, in contrast to only 20% in developed countries [1, 2, 3, 16, 17]. This leads to a higher mortality rate, lower chances of successful treatment, and increased healthcare costs [17, 18, 19]. Early detection through screening techniques such as mammography can greatly improve the likelihood of successful treatment and survival [2, 20]. Therefore, initiatives to raise awareness and promote the use of breast cancer screening methods are crucial in mitigating the impact of this disease in Saudi Arabia [21, 22].

Published studies investigating awareness in males in Saudi Arabia are scarce [23, 24]. The majority of the published studies investigated the awareness of breast cancer among Saudi females only [21, 22]. The current study aimed to assess awareness levels, attitudes, and practices regarding breast cancer and its screening methods in the general population (males and females) in Saudi Arabia using a validated reliable questionnaire. We believe that increasing awareness of the whole population will increase health awareness regarding breast cancer, rather than choosing only the target affected population, females.

A total of 714 participants completed the study questionnaire. The age range of the participants was 18–70 years, with a mean age of 29.9 $\pm$ 11.5 years. The majority of participants were female (60.1%, n = 429) and Saudi nationals (96.5%, n = 689). In terms of marital status, 44.8% (n = 320) were married, and 53.4% (n = 381) were single. With regard to education, the majority of participants were university graduates (73.8%, n = 527), while 24.1% (n = 172) had a secondary school education. A total of 26.1% (n = 186) of participants reported having a family history of breast cancer, while 3.5% (n = 25) had a personal history of the disease and 8.8% (n = 63) reported having a breast mass. Of the participants surveyed, 39.2% (n = 280) reported having attended a breast cancer awareness program or activity and derived benefit from it, while 7.8% (n = 56) reported attending but did not perceive any benefit (Table 1).

In terms of risk factors for breast cancer, the most commonly reported risk factors among study participants were female sex (38.8%), smoking (35.8%), obesity (25.6%), intake of fat-rich food (23.9%), alcohol consumption (23.6%), sedentary lifestyle (21.6%), vitamin D deficiency (8.4%), and exposure to high doses of radiation (6.2%). With regard to awareness of warning signs of breast cancer, the most commonly known among study participants were the presence of a hard, painless lump or nodule in the breast or armpit (79.7%), breast swelling (62%), discharge from the breast (59.5%), changes in the size and shape of the breast or wrinkling of the skin (58.8%), changes in the nipple (58.3%), and breast pain (51.5%). The least known warning signs were itching, crusty sores, or a rash around the breast (36.1%), with 11.5% of participants reporting no knowledge of the warning signs of breast cancer (Table 2).

A total of 75.8% of participants reported that physical examination by a physician was one screening method, followed by BSE (70%), mammography (67.5%), and ultrasound (32.5%). Of the participants, 36% reported having good or excellent knowledge regarding BSE, compared to 23.6% for physical breast examination and 23.8% for mammography. Approximately 80% of participants were aware that BSE can help detect the presence of lumps in the breast, and 47.3% reported that it can help detect masses in the lymph nodes under the armpits. Of the participants, 37.7% reported that BSE should be performed monthly after menstruation, while 56% were aware that mammography should begin at the age of 40 years. Additionally, 59.9% knew that mammography should be performed annually, while 45.7% were aware that it is not painful, and 25.4% believed that a mammogram should only be performed when there are symptoms of breast cancer (Table 3).

Of the participants, 158 (36.4%) reported having performed BSE, with 109 (69%) performing it weekly and 6 (3.8%) performing it monthly. The most commonly reported reasons for not performing BSE were forgetfulness (41.5%), being below the age of 40 years (33.8%), lack of concern (30.9%), doubt about its efficacy (21.7%), and fear of discovering a mass (13.2%) (Table 4).

In terms of participants’ attitudes toward breast cancer and its screening methods in Saudi Arabia, 304 (42.6%) believed that there was sufficient awareness of breast cancer in their area. Of the participants, 30.1% reported confidence in their ability to notice changes in the breast area, while 53.1% reported having a good or excellent attitude toward the importance of early detection of breast cancer (Table 5).

Data on overall knowledge and awareness regarding breast cancer and its screening methods in the study population is presented in Fig. 1. Of the participants, 48 (6.7%) demonstrated a good level of knowledge, while 666 (93.3%) had poor knowledge regarding breast cancer and its screening methods.

Regarding factors associated with participants’ knowledge regarding breast cancer and its screening methods. Good knowledge was detected among 8.5% of university-educated participants, compared to none of those with below a secondary education, with a statistically significant difference (p = 0.005). Similarly, 10.2% of participants with a family history of breast cancer had good knowledge about the disease, compared to 1.8% of those without such a history (p = 0.045). Of the participants with a personal history of breast cancer, 14.3% had good knowledge about the disease, compared to 1% of those without such a history (p = 0.004). Additionally, 11.8% of those who reported having benefited from attending a program or activity related to breast cancer awareness had good knowledge, compared to 4% of those who did not attend (p = 0.001). Furthermore, 14.6% of participants who performed BSE had a good level of knowledge, compared to 4.3% of those who did not (p = 0.001) (Table 6).

In Saudi Arabia, breast cancer is frequently diagnosed at advanced stages and has more cases among young premenopausal women than in Western countries [26, 27, 28, 29, 30]. The Saudi Health Council [31] reported that the incidence of new cases of breast cancer in 2018 was 2814, which represents 17.9% of all cancers. In the United States, half of new breast cancers are detected in women above 65 years of age, while in Saudi Arabia, breast cancer mostly occurs among women aged 30–44 years [8, 29, 30]. Furthermore, developed countries assess breast cancer mainly in the early stages compared with developing countries where there are large numbers diagnosed at advanced stages [2, 32]. The awareness of breast cancer has an important role in the early detection and prevention of the disease [2, 33].

The current study aimed to assess public knowledge regarding breast cancer and screening methods. In terms of awareness and knowledge of breast cancer, this study revealed that the most commonly recognized risk factors were female sex, smoking, obesity, consumption of high-fat foods, and alcohol consumption while the rest of the stated risk factors were recognized by a small percentage of the participants. This could be attributed to the low breast cancer (BC) awareness programs attended by the study participants. With regard to the warning signs and symptoms of breast cancer, the most commonly recognized signs among study participants were the presence of a hard, painless lump or nodule in the breast or armpit, breast swelling, discharge from the breast, changes in the size and shape of the breast or wrinkling of the skin, changes in the nipple, and breast pain. A smaller percentage of the participants (36.1%) knew that changes that happened to breast skin are considered signs of breast cancer as the least known warning signs were itching, crusty sores, or a rash around the breast. The correct technique of BSE could detect a lump in the breast as well as lumps in the axilla due to lymph node invasion [2, 3, 4]. there is a trend towards good knowledge regarding breast cancer screening modalities. When we asked the participants about screening methods, approximately 70% were aware that BES can help detect lumps in the breast, but only 47% reported that it can also help detect masses in the lymph nodes under the armpits. This could indicate the deficient knowledge and improper way applied by the participants to perform BSE. Overall, the level of knowledge regarding breast cancer and its screening methods was very low. Higher levels of knowledge were reported among participants with higher levels of education, those with a personal or family history of breast cancer, those who had attended health education sessions, and those who performed BSE. This highlights the importance of health education in improving the knowledge of the population. Women who have less knowledge about the risk factors and screening methods for breast cancer tend to check their breasts less frequently or not at all.

Our findings on the low level of knowledge are far greater than those reported by Naqvi et al. [34] from Pakistan where 446 individuals, representing 34.2% of the study population, exhibited a low level of knowledge concerning breast cancer. Likewise, in Cameroon, Halmata et al. [35] concluded that the knowledge and practice of breast cancer screening were low among women in Douala city. In contrast to previous findings, a systematic review conducted in Nigeria demonstrated a high level of awareness regarding breast cancer (80.6%), BSE (60.1%), knowledge of associated mortality, and the benefits of early detection (73.2% and 73.9%, respectively). However, knowledge of symptoms and signs was lower (45.1%). Furthermore, both perceived susceptibility and the performance of BSE were low, at 26.8% and 22.9%, respectively. Overall, the rate of screening performance did not vary with changes in the level of awareness or knowledge [36]. In Saudi Arabia, previous studies examining knowledge, attitudes, and practices related to breast cancer have revealed low levels of awareness [23, 24, 37, 38, 39]. Based on a study conducted in Makkah among female teachers, the level of knowledge about BC was low and differed significantly by age and marital status. Those aged 46–55 and those who were married had more knowledge about breast cancer than others [37].

With respect to the practice of BSE, the current study revealed that approximately one-third of the participants performed BSE. The most commonly reported reasons for not performing BSE included forgetfulness (41.5%), being under 40 years of age (33.8%), lack of concern (30.9%), doubt regarding its efficacy (21.7%), and fear of discovering a mass (13.2%). A higher rate of BSE practice was reported by Alsaif et al. [40], with their study indicating that 66% of participants performed BSE. Of those who performed BSE, approximately 62% reported having learned about it through their college curricula. This underscores the importance of proper education about breast cancer and its influence on BSE practice [40]. It is crucial to highlight that the incidence of breast cancer in Arab Gulf countries occurs at a younger age compared to Western countries [41]. This phenomenon may be attributed to several factors, including consanguineous marriage, which may result in the accumulation of homozygous recessive mutations, in addition to the adoption of a high-fat Western diet that increases obesity rates [42, 43]. The American and European guidelines recommend starting mammography by the age of 40 because the majority of their breast cancer patients are above 60 and starting BSE by the age of 20 [4, 5, 6, 7, 44]. Consequently, we recommend implementing local guidelines regarding the age at which breast cancer screening using mammography should commence. In the meantime, BSE remains an important tool, particularly for women under 40 years of age, to increase awareness of changes that may occur in the breast due to cancer.

The current study has some limitations. First, Data obtained by a self-administered questionnaire may be subjected to reporting bias. Second, the method of distributing the questionnaire did not allow for enough participants who did not use mobile devices. We tried to overcome this limitation by conducting face-to-face interviews to collect responses from different age groups and areas in Saudi Arabia.

In conclusion, this study revealed that the participants demonstrated a low level of knowledge and awareness regarding breast cancer and its associated screening methods, particularly mammography. Furthermore, the practice of breast self-examination, which is especially important for women under 40 years of age, was below average, with only one out of every three female participants performing it. Educational programs and health campaigns are essential to increase awareness about breast cancer and the importance of early detection to improve the rates of mortality and morbidity.

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

DAE, AA, MAA, and AMAH designed the research study. AA, MAA, AMAH, KMA, and HRA performed the research. AA, MAA, AMAH, KMA and HRA analyzed the results. DAE was responsible for Funding acquisition. AAA, AMAH, AA, KMA, HRA, and MA collected the data. DAE supervised the research. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript. All authors have participated sufficiently in the work and agreed to be accountable for all aspects of the work.

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Ethics Committee of King Faisal University (protocol code KFU-REC-2022-MAR-EA000474 and date of approval 1/03/2022). All participants provided written informed consent.

The authors would like to express their sincere gratitude to all the participants who contributed to this study.

This work was supported by the Deanship of Scientific Research, Vice Presidency for Graduate Studies and Scientific Research, King Faisal University, Saudi Arabia (GRANT 3,967).

The authors declare no conflict of interest.