No More Breast Self-Exams?
For decades, cancer experts have urged women to examine their breasts monthly and report any lumps to the doctor. But the lack of scientific evidence proving breast self-exams save lives has prompted the American Cancer Society (ACS) to make such exams an option. Many women who have found lumps during breast self-exams and some doctors disagree with this decision.
]]>Breast cancer]]> survivor Diane Ford, of Melbourne, FL, calls the change foolish, because despite regular ]]>mammograms]]>, she found both of her breast cancers through breast self-exam (BSE). “If I had ignored [BSE], it could have progressed into something far worse,” says Ford, who is currently receiving ]]>chemotherapy]]>.
“I’d never tell a woman not to do this.” Ford’s doctor, Nikita Shah, MD, a medical oncologist and breast cancer specialist at MD Anderson Cancer Center Orlando, concurs. She tells her patients to continue doing the self-exams. “I don’t agree with the guidelines,” Shah says. “This is something so simple. There’s no cost to it.”
Not Enough Supporting Research
Officials from the ACS expected the new guidelines would generate controversy. After all, it has been promoting BSE for 50 years. But the ACS has moved toward recommending things shown to be effective during clinical trials. “We don’t have evidence breast self-exams are contributing to the early detection of breast cancer,” says Debbie Saslow, PhD, director of breast and gynecologic cancers for ACS.
Saslow draws a distinction between BSE and self-awareness about the breast. The monthly exam refers to a series of specific techniques. “That has not been shown to have any added benefit to a woman knowing what is normal for her.” The ACS suggests doctors should tell women about the benefits and limitations of BSE, and let women decide whether to do it. Saslow says she would not discourage any woman who wants to perform BSE from doing so. But 10 reference materials used by the committee failed to prove a benefit.
“We’ve never had very good data on the utility of BSE in this society,” says Georgiana K. Ellis, MD, at the Fred Hutchinson Cancer Research Center. Structuring a clinical trial to determine BSE’s value would be extremely difficult and expensive, according to Ellis. Saslow says she hopes the new guidelines will lessen the guilt some women feel about not checking their breasts. And women who find the exams anxiety provoking can stop.
Many Women Disagree
“I think making BSE optional is the most horrible thing that could be put out there,” says Lyn C. Wasserman. She is founder and director of Breast Friends Inc., an Atlanta-based support network. She found lumps twice during BSE. Both times, it was cancer. “It doesn’t cost me anything to do it, and [not doing it] could have cost me my life,” she says.
Wasserman will continue promoting monthly BSE. She gives women shower cards from the Susan G. Komen Breast Cancer Foundation, Dallas, which continues to recommend BSE in its screening guidelines.
“We believe BSE is a way for women to become familiar with their breasts and be in partnership with their healthcare providers,” said Susan Brown, RN, health education specialist with the foundation. “And it’s possible that more treatment options may be available if breast cancer is found between mammograms.”
Barbara Brenner encourages women to think for themselves and know their bodies. She is executive director of Breast Cancer Action, a San Francisco-based national advocacy organization. Brenner found two cancerous lumps in her breasts during BSE, neither picked up by regular mammography. Her organization supports letting women decide about using all forms of detection—BSE, clinical exams by doctors, and mammograms. “What saves lives is early enough detection and having the kind of breast cancer that benefits from currently available treatment and getting that treatment in a timely way,” says Brenner.
Too Many Biopsies?
The US Preventive Services Task Force also did not find proof that BSE saves lives. It reported evidence that BSE actually increases the risk of false positives. That means more trips to the doctor and more ]]>biopsies]]> to check if a lump is cancerous. “All of these detection methods lead to some unnecessary biopsies,” says Brenner. “If you want to diagnose cancer, you have to look at tissue under a microscope. And the only way to look at tissue under a microscope is to do a biopsy.”
Saslow says the false biopsy rate was considered, but not a factor in, the ACS’s decision. The number of negative biopsies resulting from BSE is about the same as from mammography.
What Is Recommended?
The ACS strongly supports annual mammograms starting at age 40. Women also should receive a physical exam every three years starting at age 20 and annually starting at 40. “Mammography saves lives, assuming women get them regularly, meaning annually. And if anything is found, they go for follow-up,” Saslow says. According to Saslow mammograms detect 80-85% of breast cancers. Experts continue to search for better screening methods.
“Unfortunately now, the best tools we have are not good enough,” says Shah. “We have to combine mammograms, breast self-exam, and exams by a physician to detect early breast cancer.” The painless, monthly inspection of their breasts has become routine for many women. Doctors, like Shah, and many breast cancer survivors do not think women should stop BSE.
“We continue to say technology is the answer,” Brenner concludes. “When you do it through a recommendation like the one ACS issued, you take the power out of women’s hands. And that is not a good thing.”
American Cancer Society
The American College of Obstetricians and Gynecologists
Susan G. Komen Breast Cancer Foundation
US Preventive Services Task Force, Screening for Breast Cancer
Canadian Breast Cancer Foundation
Canadian Cancer Society
Screening breast cancer. Update 2002 release. US Preventive Services Task Force website. Available at: http://www.ahcpr.gov/clinic/uspstf/uspsbrca.htm. Accessed June 7, 2003.
Smith R, Saslow D, Sawyer KA, et al. American Cancer Society guidelines for breast cancer screening: update 2003. CA: A Cancer Journal for Clinicians. 2003;54:141-169.
Last reviewed May 2008 by ]]> Ganson Purcell Jr., MD, FACOG, FACPE]]>
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