There’s a timeless truth to the old aphorism, “if you want something done right, you have to do it yourself.” Although that might be true for many things in life, when it comes to breast self-exams, do-it-yourself — an approach with a long history in America — may no longer be the name of the game.
According to a historical timeline published by the Circuelle Foundation, a Sarasota, Florida-based breast health education nonprofit, breast self-exams were first introduced to American women in 1930, and in 1947, the American Cancer Society launched an awareness campaign, “Look for a Lump or Thickening in the Breast.”
[See: 16 Health Screenings All Women Need.]
In his 2003 book “The Breast Cancer Wars: Hope, Fear and the Pursuit of a Cure in Twentieth-Century America,” internist and medical historian Barron H. Lerner writes that the 1960s became the heyday of the breast self-exam. “In 1960, the ACS and the National Cancer Institute released a film entitled ‘Breast Self-Examination,’ which, along with a series of educational leaflets on BSE, served as the backbone of a major push to increase the early detection of breast cancer. The campaign met with a good public response. … By 1967, over 13 million women had seen the film.”
By 1970, the first studies evaluating the effectiveness of breast self-exams began emerging, and Circuelle says women were “confused about proper technique and relied on clinical breast exam,” but many doctors continued recommending that women conduct breast self-exams at home monthly. Despite the confusion about how to properly conduct these monthly exams, BSE remained an integral component of women’s health recommendations into the early 21st century.
The pace and complexity of research into the effectiveness of BSE peaked in the early 2000s, and several studies that showed BSE did not improve a woman’s breast cancer survival rates called into question the previous 70 years of advice women had received to conduct BSEs monthly. Then, in 2009, both the American Cancer Society and the U.S. Preventive Service Task Force — two organizations that issue guidelines for breast cancer screening protocols in the United States — dropped their blanket recommendations that women conduct monthly BSEs.
The evidence just wasn’t there to continue supporting the recommendation, says Otis Brawley, chief medical officer of the ACS. “There have been at least two randomized trials that have shown that clinically, breast self-examination does not decrease mortality.” Anecdotally, many women say they found a lump while inspecting their breasts, but from a 30,000-foot view, the evidence doesn’t support making a recommendation of conducting a monthly self-exam to all women.
Part of the problem, Brawley says, lies in the true definition of a breast self-exam. “When you say ‘breast self-exam,’ you have to define it, and it has a specific definition. Conducting a breast self-exam means examining each breast for 30 to 45 minutes once a month by oneself. This is what we do not recommend,” Brawley says, because the expectation of a woman spending an hour to an hour-and-a-half per month examining her breasts is too onerous. Additionally, many women don’t execute the exam correctly.
Some women may end up feeling guilty if they realize they’re not conducting their breast self-exam correctly or not spending enough time on it, which can inflict a certain level of psychological harm. Wanting to remove some of this burden, the ACS stopped recommending women conduct the rigidly defined “breast self-exam” monthly and began promoting a less burdensome “breast self-awareness.” “We do recommend that women be aware of their breasts, and if they find a mass or notice something abnormal, they go get it checked out by the doctor,” Brawley says.
[See: A Tour of Mammographic Screenings During Your Life.]
Leaders of the USPSTF took a similar approach when they revised their recommendations in 2009 and again in 2016. Dr. Kirsten Bibbins-Domingo, chair of the USPSTF, says the lack of clear evidence to support the potentially arduous task of breast self-exams caused changing the screening tool’s status to an “I recommendation,” which the USPSTF defines as meaning, “the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality or conflicting, and the balance of benefits and harms cannot be determined.”
Bibbins-Domingo adds that an I recommendation “is a call for more research. The task force’s procedures don’t let us substitute our clinical judgment. Our procedures are to stick to the evidence” that’s available at the time the recommendations are drafted, which is every five years.
However, the age of this data, the focus of the studies it comes from, and where the studies were conducted that are being used to create these recommendations are all concerns, says Dr. Marisa C. Weiss, chief medical officer and founder of Breastcancer.org, a breast cancer education nonprofit that has a detailed, illustrated description of how to conduct a BSE online. Weiss is an outspoken critic of the recommendation to not conduct a monthly BSE, and she says that the various bodies issuing these recommendations are confusing and disempower women, potentially putting them at risk.
Weiss points out that for the 20 percent of women whose cancers do not show up on a mammogram and are only found by physical exam, not conducting monthly self-exams could result in later detection of the cancer and more difficult treatment. She worries these recommendations are based on studies that are either looking at the wrong metrics or just too old to take into account recent advances in screening and treatment technologies. Several of the studies used to draft guidelines were also conducted outside the U.S., meaning there could be underlying differences in the health of the population being surveyed.
“The studies being used to make these recommendations only look at survival benefit,” she says. “They didn’t get into other measures of value; but survival is just one report card.” She says early detection and empowering women to take part in their own care are critical to reducing the incidence of breast cancer.
Regarding Weiss’s concern about the age of the data, Bibbins-Domingo says staying current in changes in the field is exactly why the USPSTF revisits its guidelines every five years. “Breast cancer is an area of active research. I would hope that we’ll see new studies coming out on new technologies.” But for the time being, the peer-reviewed studies the task force has used to create its guidelines are the best evidence-base they can work from, she says.
But what about the concern of false positives that can turn up during a breast self-exam and lead to much consternation for the women who experience them? “Doing a breast self-exam on a monthly basis doesn’t seem to pick up cancer earlier and can result in a lot of false positives,” says Dr. Sara Hurvitz, associate professor in the division of hematology-oncology at the David Geffen School of Medicine at University of California–Los Angeles. The Susan G. Komen foundation reports that “women who did BSE had more false positive results (which led to nearly twice as many biopsies with negative [no cancer found] results).”
Weiss speaks directly to these concerns. “I’m prepared to handle the potential harms if the benefit is that it’ll save my life,” she says, insisting that the standard of care has improved for women undergoing additional screening such as biopsies. “A scar today is tiny compared to the old ‘zipper.’ In addition to that, there are now other, better tests that help us limit overtreatment that help us decide who needs chemo and who doesn’t.”
Still, the question remains whether being more aggressive in screening for breast cancer makes a difference overall. Brawley says that most of the improvements in the breast cancer survival rate in the U.S. are not actually the result of better screening, but better treatment. “Most people think mammography is the number one reason why cancer survival rates have improved, but it’s actually number three. There’s been a 40 percent decline in breast cancer death rates, and more than half of that decline has been due to our ability to treat the disease.” CNN.com reported in 2016 that breast cancer mortality rates declined 36 percent since their peak in 1989. “The number two reason [rates have declined] is women finding something, asking what is that and feeling empowered to go to the doctor and ask that question.”
[See: Breast Pain: Stop Worrying About Cancer.]
Despite the variations in screening guidelines published in the U.S. and the debate over whether women should continue to conduct breast self-exams, it seems all parties completely agree that women need to be cognizant of their breasts and any changes that occur. Hurvitz says that, as with most aspects of breast cancer prevention and treatment, a tailored collaboration between a woman and her doctor is the best approach.
In addition to paying attention to your own breasts, Hurvitz recommends that all women get to know their family medical history and establish an open dialog with their doctors about what’s best for them. “It’s important to talk to your primary care physician about when you should begin screening. We’re not necessarily recommending that women do breast self-exams, but that women be aware of their breasts and how they look and feel. And ask your doctor for a clinical exam.”
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What’s the Deal With Breast Self-Exams? originally appeared on usnews.com
