Many barriers affect Saudi woman to achieve the desired health care such as cultural misinterpretation of disease and quality of health care provided (Akhtar & Nardan, 2005;Sarhan,2009). It is very important to implement a program to promote health of Saudi women that educate them toward positive health practice and enhance breast self examination as primary step for early detection of the disease.
Breast cancer could occur at any age starting from 15 to75+ years old. The highest incident rate of breast cancer is between age of 30 to 44 years with percentage of 40.9 (Cancer incidence and survival report, 2007). The mean age of breast cancer among Saudi females is 47 years comparing to 54 years among western European and American women (Amr, Sa'adi, Ilahi, & Sheikh,1995) . The data in table1 presents percentage distribution of breast cancer cases at different ages.
Breast cancer occur mainly in the major provinces such as Eastern region , Makkah region, Riyadh region and Tabuk region with age specific incidence rate (ASR) /100.000 distribution of 30.8, 28.8, 25.7 and 22.7 respectively (Cancer incidence and survival report, 2007) .
The main cause of getting high percentage in the major provinces is not only because of the high number of population but also the availability of health facilities. On the other hand, other provinces that involve small percentage of breast cancer among their population might be as result of limited health services or the conservative characteristics of their families to expose their mother, wife, or sister (Sarhan, 2009).
General health Status
Incident rate
In 2001, cancer registry report mentioned that 12.9 % of all cancers in Saudi Arabia was breast cancer. The age specific incident rate was 11.8/100,000 female population .In 2007, age specific incident rate was 21.6/100.000 female population which represents 27.4% of all cancers among Saudi population (Cancer incidence and survival report, 2007).
Mortality rate
According to WHO (2011) estimates, 9% of total deaths in Saudi population resulted from cancer. The data that show the death rate of breast cancer among Saudi females is not stated (Alothaimeen, Ezzat , Mohamed ,& Al-Madouj,2004)
Disability
Considering mastectomy as one of the major disability that negatively influences women femininity. According to El Saghir et al.(2007) study, mastectomy is performed in 80% of breast cancer population among Arab countries.
Severity
Most of breast cancer cases present at second or third stage due to late detection of the disease. The Percentage of second stage is 44% of all cases and 30% of breast cancer females were in third stage (Ezzat, Ibrahim, Raja, Al-Sobhi, Rostom,& Stuart, 1999).
Also, having the disease at young age resulted in presentation in advanced stage in Saudi females. Moreover, lake of awareness regarding the proper time for breast self-examination can delay detection of the tumor and late seeking to medical support ( Akhtar, Filani, Gadella, &Amri,1995)
Health Determinants
Knowledge
In Saudi Arabia, there are few studies about women awareness regarding breast cancer. However, women knowledge about risk factors and appropriate screening time were inadequate regardless their educational or occupational status (Amin et al, 2009)
Physical health
Bull, Maslin & Armstrong (2009) mentioned that the Physical inactivity is responsible for 10% of breast cancer. Majority of Saudi population did not achieve the benefits of physical activity (Amin ,Al Khoudair, Al Harbi, & AlAli,2012). That means lacking of required healthy activity can cause breast cancer.
Inequity of heath care facilities
Urban populations have more adequate health care services and health care providers comparing to rural societies. That leads to lack of accessibility to health care provider in order to seek to medical advice (Sarhan,2009)
Socioeconomic development
Rapid change in socioeconomic development in the past 3 decades resulted in changing life style and dietary habits among Saudi population (Alothimeen et al,2004). Sedentary life style and poor diet habits can be negatively impact community health (alwan ,1997; Al-Nozha, Al-Maatouq, & Al-Mazrou, 2004) . Lee et al (2004) predicted that the incidence rate of breast cancer will increase continuously due to change in life style that leads to physical inactivity. The risk of breast cancer can be increased due to increase consumption of saturated fat intake (Boyd, 2003). Additionally, there is a relationship between dietary habits and increase number of breast cancer cases in Saudi Arabia (National Cancer Registry, 2000; Alothimeen et al., 2004)
Health Barriers
Culture
Having breast cancer considered as stigma in Saudi population and must kept as secret. Furthermore, the general expression about the disease is a contagious disease. This is hindering Saudi women from exposing themselves to physician or even reporting abnormalities (Amin, Almulhim & Almeqihwi, 2009 ; Sarhan,2009) .
Quality of health care
Due to lack of radiotherapy in many regions in Saudi Arabia, which is considered as basic element of cancer treatment, the care of breast cancer patients might be below standard (Akhtar & Nardan, 2005). Because of the limitation of radiation therapy (RT) centers, the referral to their might need longer time. So the patient well seeks there in advanced stage. The data in table2 shows the availability of radiotherapy in Saudi Arabia.
Table2: The availability of radiotherapy in Saudi Arabia comparing to United States.
Population(X10³)
RTcenters
Radiation oncologists
Radiation technologists.
24573
8
22
34
298213
1875
3068
5155
Source: International Atomic Energy Agency. Directory Radiotherapy centers (DIRAC), September 2004.
Summary
The number of women with breast cancer in Saudi Arabia is increasing. Major administrative regions witness a high percentage of females with breast cancer comparing to smaller regions. However, the health care facilities are concentrated in larger administrative region that make women in smaller region have difficulties to achieve satisfied health care(Cancer incidence and survival report, 2007; Akhtar & Nardan, 2005). Over the last 3 decades, Saudi Arabia has rapid development toward modern life style. This has negative consequences in women health such as physical inactivity and increase body weight, which are important risk factors for breast cancer ( Alothimeen et al. ,2004; alwan ,1997; Al-Nozha et al. ,2004). Knowledge deficit regarding breast cancer is remarkable, that make women with breast cancer face many obstacles which delay their decision about seeking to medical advice (Amin et al.,2009; Sarhan,2009). Firstly: the ability to recognize breast abnormality. Secondly: the courage to mention the problem to family member and expose their breast to health care providers. Health care system is not adequate for breast cancer patients that increase the burden of the disease among Saudi population.
Conclusion
Breast cancer must be detected at the first stage to increase the chance of survival. Health care system must provide national screening program and increase woman awareness regarding this disease. Not only the women but also the community to enhance changing stereotype image of Breast cancer in Saudi Arabia.
