Breast cancer (BC) is the most common cancer among females worldwide, with an estimated 2.30 million new cases in 2022, and constitutes the leading cause of cancer death in women globally.1 Types and amounts of treatment, tumor response, and survival and quality of life of the patients depend on the inherent characteristics of the disease like tumor grade and the stage at diagnosis.2,3 Therefore, early diagnosis and management of BC play a key role in its overall prognosis and deeply affect the forthcoming years of life of the patient. Also, detection of precancerous breast lesions4,5, or recognition of BC risk factors including genetic predisposition in women can ease prevention or timely diagnosis of the cancer.6 However, all these can only be achieved in a setting where the patient is seen before any symptom (i.e., opportunistic or organized BC screening) or at the first presentation. This is more practical in health care systems that carry out BC population screening programs. However, even in these circumstances, many women do not adhere to the programs, and Decision Aids have been developed to assist women in their path toward and through BC screening according to the guidelines. These aids present relevant education to women, and help them decide properly based on the instructions.7,8

However, much of this evidence comes from countries with established screening programs. In settings without such programs, the applicability of these findings may be limited. Other factors that affect the probability of following BC screening guidelines have been investigated, and age, personal history of cancer, body mass index, race, health insurance status, and the relationship between the patient and the healthcare provider have been detected as effective factors.9,10 Also, among healthy women, those with higher risks regarding their family history undergo screening more regularly.11

On the other hand, in areas with no national BC screening program, women frequently seek medical attention with a significant delay, which affects the clinical picture negatively.12,13 Two large systematic reviews that assessed the effect of educational interventions on encouraging women for BC screening showed a rise in women’s knowledge and increase in adherence to the BC screening guidelines following relevant education.14,15

Understanding the reasons for this delay is crucial. Among the various barriers identified, psychological factors play a prominent role. Two of the main obstacles in refusing to seek medical attention for breast conditions are the concerns women have about the possible examination results, and a sense of fear of cancer.16-19 In other words, BC worry (BCW) and BC fear (BCF) interfere with appropriate care demand.

Educational interventions have been shown to reduce fear and worry in various medical contexts. For example, it has been reported that patient education could decrease pain-related fear after BC treatment.20 In addition, fear of cancer progression was found to be indirectly related to health literacy levels during BC treatment in elderly women.21

Thus, this study was motivated by the question of whether a greater knowledge of BC would decrease BCW and BCF in women attending a breast clinic. We hypothesized that providing accurate, accessible information about BC would reduce BCF and BCW in healthy women attending the clinic. Therefore, the present study was an attempt to investigate this hypothesis.

One-hundred and four women participated in the study; all except one followed the study to the end. Among the 103 patients, 1 did not fill out the HADS questions, and 2 missed the second half (depression section) of HADS. Given the low rate of missing data (<3% for any single measure) and the absence of a clear pattern in the missing responses, we did not perform imputation or sensitivity analyses. The low attrition rate suggests that bias due to missing data is unlikely to have influenced the findings.

The mean age of the participants was 38.37 (± 9.14) years. Patients’ data including level of education, history of benign breast disease or breast surgery for benign lesions, and consumption of OCP or HRT in all participants are presented in Table 2.

The anxiety and depression scores according to HADS, and the total score are presented in Table 3. These scores show that the general psychological health of the participants at the point of entry to the study was fairly good, and did not change significantly after the intervention. The mean BCW scores and BCF scores before and after the intervention are also presented in Table 3.

Data are presented as mean ± SD for descriptive purposes. Due to the nonnormal distribution and ordinal nature of the data, comparisons between pre- and post-intervention scores were performed using the Wilcoxon signed-rank test. The P values reported are derived from this nonparametric test.

Then, we explored the association of the changes in BCW and BCF of patients with patient characteristics and history. There was no significant association between BCW and BCF and age (BCW: P = 0.981, BCF: P = 0.959); level of education (BCW: P = 0.771, BCF: P = 0.166); benign breast disorders (BCW: P = 0.344, BCF: P = 0.578); OCP use (BCW: P = 0.836, BCF: P = 0.258) and HRT (BCW: P = 0.12, BCF: P = 0.80). Table 4 shows the correlation coefficient among changes of BCW and BCF scores and the level of education, benign breast disorders and HRT.

In this study, we evaluated the effect of providing healthy women with appropriate educational materials about BC fear and worry and found that this intervention could lessen BCW and BCF. Timely diagnosis of BC is of utmost importance in the prognosis of the disease, but several factors deter this crucial issue. BC population screening programs affect the perception of women and assists in timely diagnosis of BC. However, there is not such a national screening program in our country and lack of such a program results in late referrals and late BC diagnosis. Some studies have addressed this issue by interviewing healthy women or patients about the reasons for their delays. By using a structured questionnaire to detect the rate of breast self-examination in 261 participants, Parsa and Kandiah30 found fear from detection of a mass as the reason for avoiding the exam in 17% of the respondents. Similarly, in a large survey recently conducted by Gümüştakim et al.31 on 643 women attending 18 Family Health Centers throughout Turkey, fear from the results was the reason for 15% of evasions from screening. However, Consedine et al.17 explored the emotional factors that affected the rate of undergoing mammography in 1634 African-American women from 6 different ethnicities, and found a significant negative relationship with BCW. Also, Fouladi et al.19 investigated the reasons in 380 women who attended health centers, and detected that around 76% of the participants avoided mammography due to fear of finding a possible malignant tumor. Through in-depth interviews with 22 healthy women based on the Health Belief Model, Noori and Shouten32 showed that while the participants knew the benefits of mammography, fear was one of the main barriers for performing it; this factor also hindered them from performing breast self-examination. Interestingly, El Asmar et al.18 showed that while fear from hearing bad news about their breasts prevented women from undergoing BC screening, a higher knowledge of the disease reduced this effect. Likewise, while detecting BCF as one of the main reasons that induced delays in diagnosis, Cipora et al.16 emphasized that educating women about the importance of early detection of BC and its impact on successful management of the disease should be carried out in order to improve the situation.

Although BCF and BCW have been recognized as the main reasons for late BC diagnosis in these studies, and while providing knowledge about BC and the importance of early detection through screening programs14 or Decision Aids7 has been proposed as a solution, no study has evaluated the effect of these instructions on BCF and BCW together, an issue which has been addressed in our study.

The effect of education on fear has been investigated in other medical conditions. For example, it has been shown that antenatal education of pregnant women could diminish fear of childbirth.33,34 Also, courses of death education reduced fear of death in students.35,36 On the other hand, studies have looked at the effect of psycho-education on the fear of BC recurrence and cancer distress in survivors of the disease. Psycho-education generally comprises both educational points about BC and psychological support for the patients and their families. In a study by Stanton et al.37 on around 400 patients, psycho-education neither decreased depressive symptoms nor distress. However, in a multi-center study carried out by Weis et al.38 on 50 patients with BC, psycho-education induced a significant drop in fear of progression and fear of BC recurrence. In a systematic review of psycho-education for BC, Setyowibowo et al.39 showed that this intervention had no effect on the patients’ depression or their knowledge, but improved their quality of life, and decreased their anxiety. In a very recent study, Larsen et al.40 investigated the relation between education and fear of recurrence among BC survivors, and showed a reverse association. In our study, the effect of education on BCF and BCW was investigated by a very practical method. The instruction material was prepared by a reliable team and consisted of easy-to-understand and attractive messages that had proved to be effective regarding their scientific content and instructive effect, and satisfactory to most patients in a previous study.29 BCF and worry were assessed by standard validated tests23-26, and the general psychological health of all participants was assessed before and after the intervention by a validated test (i.e., HADS).

Within the limitations of a pre-post design, our findings strongly suggest that providing accessible information about BC may reduce fear and worry in healthy women. An important finding of this study is that while BC-specific fear and worry decreased significantly, general anxiety and depression scores (HADS) remained unchanged. This distinction is important. Breast cancer fear and worry are disease-specific emotional responses, but HADS measures generalized anxiety and depressive symptoms. Our educational intervention targeted knowledge and perceptions specifically about breast cancer, which may explain why it affected cancer-specific emotions but not general psychological distress. This pattern suggests that the observed changes were specifically related to the intervention content rather than a non-specific improvement in mood.

Beyond statistical significance, the observed reductions in BCF and BCW are likely clinically meaningful. A decrease in the mean BCW score from 8.0 to 4.0 represents a 50% reduction, moving from "frequently worried" toward "rarely worried" on the scale. Similarly, the reduction in BCF scores, though smaller in magnitude, may lower an important psychological barrier to seeking timely breast assessment. Given that fear and worry have been identified as key obstacles to screening16-19, even modest reductions could translate into improved health-seeking behaviors at the population level.

Our study had some limitations. Firstly, it was conducted in a single center. In addition, baseline HADS scores were relatively low, which may have created a floor effect limiting our ability to detect reductions in general anxiety and depression. Also, the use of a modified 2-item version of the Lerman BC Worry Scale, while previously employed in published research, lacked formal validation in its Persian form. Finally, we could not explore the effect of our intervention on the patients’ behavior regarding BC screening, which could be our ultimate goal and that of similar studies. Although previous studies have shown that knowledge, attitude and reaction of women to the possibility of breast cancer depend on their educational level, we did not find such dependence in the current study. This might be due to the distribution of this variable in our sample or lack of enough power of the study to show the differences.

The results of our study show that educating healthy women about BC may reduce their fear and worry about the disease. These findings have potential public health implications, particularly in settings without organized screening programs. Simple, low-cost educational interventions delivered via widely accessible platforms (e.g., WhatsApp) could address psychological barriers to early detection. Health policymakers in low-resource settings might consider integrating such educational programs into primary care or community health initiatives. We suggest that studies with controlled designs and longer follow-up periods be performed by following the participants for a reasonable time after the instructions to assess potential effects on their health-seeking behavior about BC.