This study was conducted as a descriptive and cross-sectional study.

This study was conducted in Istanbul with a total of 1000 women who were willing to participate. Data revealed the existence of approximately 3,000,000 women over 18 years of age in Istanbul and breast cancer was seen 24.1% in Turkey during the period 2005 and 2006. It was used following the calculation formula:

$n=\frac{{P.Q.Z}_{}^2}{d^2}$

Inclusion criteria in this study included women who did not have breast or any other gynecological from of cancer, were able to speak Turkish and were over 18 years of age.

Exclusion criteria for the study included women diagnosed with breast and any other gynecological from of cancer, women who were unable to speak Turkish or were health professionals. Eleven survey forms were incompletely filled out by participants therefore they were not included in the study.

Alcohol Consumption: Respondents reported their alcohol consumption status as yes or no. Quantity of alcohol consumed per month was grouped into four categories: 1-4 glasses, 5-8 glasses, 9-12 glasses and ≥13 glasses.

Cigarette Smoking: Participants reported their current cigarette smoking status as yes or no. Quantity of cigarette smoking per day was grouped into five categories: 1-4 cigarettes, 5-9 cigarettes, 10-14 cigarettes, 15-19 cigarettes and ≥ 20 cigarettes.

Nutritional Habits: The questions included the women’s consumption of fresh fruits and vegetables and the consumption of fatty food.

Physical Activity: The participants reported their sports activity and walking status and duration of these activities per day.

Routine Mammography and Breast Self Examination: The questions were directed at determining health related behaviors whether the subjects had ever had a routine mammography and Breast Self Examination. In case they had, they reported the time of Breast Self Examination.

Researches were instructed to maintain records of the patricipants’s including age, age at menarche, education level, marital status, employment status and type of occupation, pregnancy and menopausal status and the use of hormonal replacement therapy.

A survey form with questions about the risk factors of breast cancer was filled in by 20 women in a pilot test, followed by essential revisions in the form, as a result of which the final survey form included 50-questions.

Study data were collected in collaboration with a clinic practice by research staff. Researhers were assigned to collect information about healthy women through conducting interviews of women who visited the university hospital in Istanbul. Researchers filled out the survey form for the illiterate women after receiving their permission.

Data were loaded in the Microsoft Excel software program and evaluated for number and percentages. Chi square tests were conducted to evaluate the relationships between cigarette smoking, alcohol consumption, exercise and nutritional status with age, educational status, marital status and employment status. The confidence interval of 95% was accepted.

All of the hospital directors of nursing, staff nurses and ethics board were informed about the study and their permission was received. The women were informed about the objective of the study and the contents of the survey form and were told that their identity would be kept confidential. These subjects were then asked to give their informed consent.

All of the 1000 women in the study were 18 years or older, with 29.7% being in the age group of 35 and 44 years, 33.4% being university graduates, 66.2% were married and 62.6% were employed (Table 1).

The majority (65.8%) of the women started menarche between 13 and 15 years of age, 62.7% had given birth, 93.1% gave birth to their first child before the age of 30 (mean 22.5±4.4) and they breastfed for 7 and 12 months (29.5%). It was noted that 81.5% of the women continued to menstruate, 66.5% of the women who had stopped menstruating had entered menopause under the age of 50 (mean of 46.5±5.7 years), and 19.0% were taking hormone replacement therapy after menopause (Table 2).

About 87.9% of the women had never used alcohol and 73.6% of the alcohol consumers drank 1-4 glasses of alcoholic beverages per month. One third of the women (32.9%) smoked cigarettes and about half of them used a pack or more of cigarettes per day (Table 3).

On examining the women’s nutritional habits, it was determined that all of 61.9% women (619 individuals) ate three meals a day; 84.3% consumed fresh fruits and vegetables, 75.5% low fat products and 77.4% milk and dairy products with meals (Table 3).

The mean body weight of the women was 63.42 kg and their mean height was 161.64 cm. These results indicated that their mean body mass index was 24.3 (within normal limits). Although only 14.6% of the women reported that they regularly participated in sports activities, 53.4% stated that they walked regularly. Those regularly participating in sports and walking were spending an average of one to two hours a day for those activities (Table 3).

It was observed that women under the age of 25, though being educated, had an inclination to consume more alcohol. In addition, alcohol consumption was also shown to be higher for employed and single women. There was a statistically, significantly higher percentage of cigarette smoking among women being highly educated and were employed (X²: 19.7; p=0.001). The significant differences were found in the comparison of cigarette smoking status with other variables. The rate of cigarette smoking was higher in the women between 35 and 44 years than in the other age groups.

Menopausal women had a lower exercise level than the premenopausal women and the difference was found to be statistically significant. The number of women getting regular exercise was higher at a statistically significant level in the women who were university graduates (X²: 17.2; p=0.004), employed (X²: 5.44; p=0.02) and married (X²: 23.7; p=0.000).

Consumption of a high fat diet was the highest in employed women and among the age interval of 25-34 years. The higher percentage of the university graduates and married women who ate high fat diets was found to be statistically significant (X²: 40.6; p=0.000).

The majority of the women in this study (79.7%) did not undergo Breast Self Examination (BSE). Of those who did undergo BSE, 32.5% underwent the procedure a week after the end of menstruation. The majority of the women (97.8%) had not had a mammography test and 84.4% did not get a regular health check-up (Table 4).

The frequency of women getting screening methods decreased at a statistically significant level with increasing age, particularly in the post-menopausal period (Fig. 1).

Fig. (1). Distribition of women health screening behaviors by ages groups.

About of 12.1% (52 women) had a member of their family presenting with breast cancer.

The incidence of breast cancer is low in women under the age of 25. It however increases every ten years until menopause and increases significantly in the post-menopausal period after the age of 50 [12].

It has been suggested that a high level of education and socioeconomic status may increase the risk of breast cancer. It has been suggested that starting to menstruate at a younger age (before the age of 12), entering menopause before the age of 50 and giving birth to their children at older ages (after the age of 30) increases the risk of breast cancer [9–11,12,23]. Accordingly, although it is controversial, researchers have shown that hormone replacement therapy for longer than 5 years increases the risk by 50-80% in the post-menopausal period [4,10,14,15].

Breastfeeding is an effective factor in the prevention of breast cancer for women who give birth; it decreases the incidence of breast cancer by 25-35% [16]. Studies have also indicated that there is a close relationship between the duration of breastfeeding and a decrease in the risk of breast cancer [4,16].

In this study, the mean age of the women was 36.6 years, with 66.2% being married, 33.4% were university graduates, 62.6% were employed, and the longest place of residence for 53.8% was the city. Menarche manifested between the age of 13 and 15 for 65.8% of the women, 62.7% had given birth and 93.1% of the women who had given birth did so before their 30s (mean age of 22.5); 29.5% breastfed their children for 7-12 months and 26.8% for 13 months and longer, 81.5% of all women were still menstruating, 66.5% of those who were not menstruating any longer had entered menopause before their 50s (mean age of 46.5 years) and 81% of these were not taking hormone replacement therapy after menopause. Our findings indicated that the women living in Istanbul showed behaviors supporting the results of former studies and were not at increased risk from factors related to age, menarche, menopause and age of giving first birth, or the length of breast feeding.

There was higher alcohol consumption among young (under the age of 25 and younger, the ages of 25-34), single, working women being highly educated and most of them were consuming 1-4 glasses of alcohol per month. Similarly, the rate of cigarette smoking was found to be higher at a statistically significant level among young and working women being highly educated (a packet or more per day). There is evidence showing that alcohol increases the risk of breast cancer, particularly if used together with cigarettes. There are many studies which report that the age when women start to drink alcohol or smoke (especially under the age of 30) and the quantity of consumption (2 glasses of alcohol per day) have a fundamental role in an increased risk of breast cancer [6,8,11,17,24,25]. However, most of the women in our study were not smoking or using alcohol. Risendal et al. [26] reported that women between 30-39 years old, who are single and are highly educated consume more alcohol than normal, but have a lower rate of cigarette use, however, women under 50 years who are single and employed are more active cigarette smokers. Fredman et al. [27] and Hunter and O’Dea [28] reported low rates of smoking and alcohol use.

In our study, most of the women had low-fat diets and consumed fresh fruits and vegetables. In particular, the women between 25-34 years who were university graduates and were married stated that they consumed high fat foods. The mean body mass index of the women in our study was within normal limits. An increase of consumption of fast-food was observed in parallel with high level of education, high socio-economic level and a fast-paced work life.

High fatty diets together with alcohol, inadequate consumption of fruits and vegetables, nutritional habits containing low roughage and rich in carbohydrates lead to obesity; consequently, they increase the risk of breast cancer by raising the level of insulin and estrogen in the bloodstream [6,18,26,29,30]. Obesity is regarded as an important factor, which increases the risk of breast cancer in women by 50-250%, however, it is protective in the pre-menopausal period [4,6,31]. In the analysis of 8 cohort studies conducted with 351,825 women, it was determined that the risk of breast cancer had no relationship with the consumption of fruits and vegetables regarding their beneficial effect on decreasing the risk [6]. Malin et al. [32] also reported that nutrition mostly with fruit and vegetables could decrease the risk of breast cancer. The literature and the results of former studies suggested that the women in our study at the age of 45 and older presented eating habits, which decreased their risk of breast cancer development, however, the results are rather alarming for the younger women in our study, as they were more likely to face the risk of breast cancer in the following years due to their habits of smoking, using alcohol and eating fatty food.

The results of this study showed that 85.4% of the women living in Istanbul do not participate in sports regularly and 46.6% do not walk regularly. The women with inadequate physical activity were mostly unemployed women with a low level of education and were in their post-menopausal period. Risendal et al. [26] also reported that women who are 50 years old and over, have a low level of education and the unemployed have inadequate physical activity in parallel with the findings of our study. Although the results of the study clearly stress the role of physical activity on decreasing the risk of breast cancer, it can be seen that women in our country mostly adopt a sedentary lifestyle. There are numerous studies that point to the role of regular physical activity on the possibility of decreasing the risk of breast cancer [4,6,17–21,33].

Researchers are in agreement that intensity and duration of physical activity are also effective in decreasing the risk of breast cancer. They emphasize that the risk of breast cancer may decrease for a quite active woman by 10-70% and the risk may lower by 30-40% more for a woman who regularly exercises for 3-4 hours per week [6,8,9,12].

One of the risk factors, which women define as the most frightening one, which has an effect on the development of breast cancer is the existence of breast cancer within the family. Recent studies indicate that 5-10% of breast cancer is hereditary and that the cancer is caused by alterations and mutations in the genes, BRCA I and II [8,11,12]. When the existence of any type of cancer or breast cancer in the women’s family history was questioned in our study, we determined that the rate was 12.1% for breast cancer. Based on this result, the Istanbul women’s positive family histories of breast cancer were characterized as a considerable risk factor. In a different study conducted by Çolak and Korkmaz [34] in Turkey, having a positive family history of breast cancer was reported to be the most serious risk factor. When we examined the women’s participation in early methods of detection, it was determined that only 15.6% got a regular check-up, only 20.3% underwent regular BSE and only 2.2% would have a mammography examination. The percentages were even lower in the post-menopausal period. This result emphasize the need to increase mammography and breast self examination among the Turkish women. The literature has emphasized the use of mammography to decrease the risk of death from breast cancer by 30% for women who are over the age of 50 [5,35,36] Madlensky et al. [29] noted that women under 40 who have not yet had a mammography screening are a more risky group for cancer. Instead of specifying the top limits, American Cancer Society recommends the age of starting BSE as 20, for breast examination as 20-39 and for mammography as 40 [37]. In the study conducted by Hunter and O’Dea [28] in which they examined how the middle-aged women perceive their risks of health in the future, it was reported that 53% of the women underwent BSE, again the percentage being much higher than the results of our study.