Breast self-examination scares women who think they might have cancer - but does little to help those who actually do.
According to a report in the Sunday Times (1), research due to be announced at the Fourth European Breast Cancer Conference in Hamburg this April indicates that the technique of breast self-examination may be harmful to women. The organisers are reluctant to release any more of the findings of this World Health Organisation (WHO) trial before the conference.
But the reported conclusion, that breast self-examination may harm rather than help, is not new: two previous large randomised controlled trials have shown similar results.
In China, a carefully designed trial involving 250,000 women, half of whom were taught to carry out formal breast self-examination and half of whom were not, showed absolutely no difference in breast cancer mortality between the two groups. However, women who performed self-examination were more likely to have a benign lesion biopsy – which means that non-malignant changes in their breasts were picked up, then they underwent invasive investigations to prove that these were benign (2).
The Russian trial, involving over 100,000 women, showed similar results: again, an increased risk of benign breast biopsy, but no improvement in mortality rates (3). The authors of these studies conclude that breast self-examination is in fact potentially harmful, causing women to have unnecessary investigations.
Problems of breast self-examination will come as no surprise to anyone who has worked in an NHS breast clinic. Self-examination generates a steady stream of (usually young) women who find a possible abnormality and see their GP. The GP may be uncertain and reluctant to completely reassure the patient, so sends them to a surgical clinic where it is then down to the surgeon to reassure her or send her for further tests and investigations. For a number of reasons, hospital specialists are less and less likely to plump for the reassurance option.
Firstly, public perceptions of breast cancer are now so heightened that women can be very difficult to reassure – in my experience, more so than for any other illness. And of course, it is easier to reassure a patient if you’ve done some tests rather than just examining her, particularly when she has been taught to examine herself in exactly the same way.
Secondly, doctors I have spoken to often cite the high incidence of breast cancer as the reason they over-investigate. If you see a woman in clinic with a nodular area of breast tissue, which you are certain does not feel malignant, you will tend to ask for a mammogram anyway, in case she has an impalpable cancer elsewhere in the breast – a sort of unofficial screening.
So how should doctors respond to these recent findings? Women (and their doctors) over the past decade have been subject to the omnipresent and misleading message that they have a one in 11 chance of having breast cancer. (In fact, this figure relates to their risk of breast cancer if they live to be 85 years old, and don’t die of anything else in the meantime.) Regular breast self-examination has been marketed as one line of protection against disaster. The irony is that younger women, who are the group most sensitive to this advice, are highly unlikely to get breast cancer. They are, however, more prone to benign breast changes and thus unnecessary investigations.
The American Cancer Society guidelines for screening, in a recent review of the evidence, still recommend that ‘beginning in their twenties, women should be told about the benefits and limitations of [breast self-examination]’. However, they concede ‘it is acceptable for women to
choose not to do [self-examination] or to do [self-examination] irregularly’ (4). The NHS guidelines encourage women to check their breasts but do not recommend routine self-examination to a set technique. Rather, women should be ‘breast aware’, learning how their breasts look and feel as part of ‘general body awareness’ (5).
Perhaps we need to be a bit bolder with our advice to women. After all, several studies have shown that breast self-examination is not very good at picking up tumours anyway. In one study, only 7.6 per cent of women with breast tumours who were checking their breasts actually detected the tumour by means of self-examination (6). Serious breast changes are usually easily recognised by patients, without special techniques.
Particularly for young women, the disproportionate fear of breast cancer generates an unhealthy climate of anxiety, and doctors should take responsibility for countering this. Rather than just saying to our patients, ‘its up to you whether or not you examine your breasts’, we should be brave enough to tell them not to waste their time.
Liz Frayn is a surgical trainee working in south-west England.
What mammography misses, by Michael Baum
Screening wars, by Dr Michael Fitzpatrick
(1) Sunday Times, 7 March 2004
(2) ‘Randomised trial of breast self-examination in Shanghai: final results’, DR Thomas et al, Journal of National Cancer Institute 2002; 94:1445-1457
(3) ‘The role of breast self-examination in early breast cancer detection (results of the 5-year USSR/WHO randomised study in Leningrad)’, VF Semiglazov et al, European Journal of Epidemiology 1992; 8: 498-502
(4) ‘American Cancer Society guidelines for breast cancer screening: Update 2003’, CA Cancer journal for clinicians 2003;54:141-169
(5) ‘Breast Aware’, NHS Cancer screening programmes leaflet, 2004
(6) ‘Breast self-examination and survival from breast cancer: a prospective follow-up study’, A Auvinen et al, Breast cancer research and treatment 1996; 38(2):161-168
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