The Doctor Is In: Do Breast Self-Exams Matter?
Sometimes, there may be more anxiety provoked than benefit.
Q: I check myself for breast lumps every month like I’m supposed to, but all I can feel are lumps. I get nervous and run to the doctor every time I feel something, but everything is always fine. When can I stop doing my exams instead of making myself a nervous wreck every month?
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A: That’s a question many women have. Breast Self Examination (BSE) is a controversial topic among medical professionals.
BSE has been both questioned as a way of finding early breast cancers and passionately championed by doctors and their patients.
A study of Russian and Chinese women found that death rates from breast cancer were not influenced when these women were instructed in BSE. After the results were released in 2002, news media reported these findings with the suggestion that a monthly BSE wasn’t worth the frustration.
But one of the study’s authors explained that it is unknown whether the women actually performed BSE correctly or did it at all — only that they were taught to do it. The researchers sought to identify whether BSE done instead of a screening mammogram was as effective in preventing death. The issue of whether earlier, more easily-treatable cancers could be identified by BSE was not addressed in the study.
The researchers noted that the findings may be most applicable for countries with few resources for screening mammograms and breast cancer diagnosis. Screening mammography rates differ dramatically worldwide.
In the U.S., annual screening rates in 2000-03 for women over the age of 40 approached 70%, according to the National Cancer Institute.
The Canadian Institute for Health Information reported that the country’s average screening rate for women over 50 was 51.8% in 2000-2001.
This age limitation reflects the country’s differing recommendation for breast cancer screening: the Canadian Task Force on the Periodic Health Examination does not recommend screening mammography for women ages 40-49. The screening standard is every two years.
European nations also adhere to this standard, while some, including Germany, limit screening mammograms to women ages 50-69. Since 2003, France has limited mammograms to every other year for women ages 50-74. The country reports screening rates of 50%. Britain’s National Health Service allows screening mammography every three years for women ages 50-64 (for whom the International Agency for Research on Cancer reports a 76% screening rate in 2003) but none for women under 50.
Mayo Clinic data indicates that women find about 90% of all breast lumps. The vast majority of these turn out to be harmless. The risk of unnecessary biopsies and additional (often expensive and stress-inducing) testing increases with the identification of benign lumps. Though many women are glad to assume this risk for the benefit of early diagnosis, complications of both surgical and non-surgical biopsies can be serious.
In addition to benign lumps, 15-20% of all breast cancers are identified on physical exam — either by the patient or her doctor — suggesting the value of both BSE and clinical exam. More than 95% of early breast cancers are curable (author’s note: “curable” is defined disturbingly as “the woman dies of something unrelated”).
But breast exams miss the smallest cancers, as well as those seen only on mammograms. Pre-cancerous conditions are often identified as a speckling of calcium on X-ray rather than a lump.
Putting this sometimes conflicting information together may be as difficult for your doctor as for you. The best evidence exists for continuing to recommend BSE for most women as part of a three-pronged screening approach. BSE is done in addition to a yearly physical exam by a doctor and screening mammogram for most women over 40. Unlike most testing, BSE is convenient, non-invasive and free.
For some women, however, there may be more anxiety provoked than benefit generated by the performance of this monthly ritual. A conversation with a trusted doctor or nurse practitioner can go a long way toward reassurance, especially if it is accompanied by education. Look for health forums and cancer awareness events for free information. Some community educators provide synthetic breast forms containing different-sized “lumps” to help train women and their caregivers in what can be a challenging exam.
Recommendations for women deemed to be higher risk can be dramatically different, including screening at a younger age using methods like MRI or genetic testing.
A word about male breast cancer — it happens. About one in every 150 cases of breast cancer is in a man. There has even been a genetic mutation identified that increases the likelihood of cancer in both men and women, “BRCA-2.” But because the condition remains relatively rare, there have been no studies suggesting that routine BSE or mammogram in men is effective. There may be advantages for men in families identified to have the gene mutation, but their numbers are too small to make this recommendation.
Dr. Linda Halderman was a Breast Cancer Surgeon in rural central California until unsustainable Medicaid payment practices contributed to her practice's closure. She now serves as a policy advisor in the California State Senate.
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17 Comments
1. Valerie:My mom and several friends have been diagnosed with breast cancer over the last year. The best results are obtained when the cancer is picked up by a mammogram — these are much smaller, less-developed, and easier to treat. By the time a lump is big enough to feel, it’s far more serious.
Meanwhile, ovarian cancer goes undiagnosed until it kills.
We are getting close to the point where whole-body scans and radiation therapy for very tiny cell clusters is a real possibility.
Nov 16, 2008 - 4:42 am 2. Anne:Doctor, I find no mention in your article of
Nov 16, 2008 - 6:56 am 3. keith:cancers not detected by mammograms. After I found my IDC, accidently due to pain, it only appeared on an ultrasound scan. Women should be given warnings, lest they put too much faith in the highly recommended yearly mammogram.
I felt a strange bb or baby pea sized bump in the upper portion of my wife’s left breast just before Christmas. By January 25, she had the diagnosis of stage I grade III poorly differentiated breast cancer and it was taken out that day. eight rounds of chemotherapy and 33 rounds of radiation later, she is now five months out and on a schedule of getting checked every three months with diagnostic mammogram every six months.
Physical examination of the breast caught a bad cancer early and gave my wife the best chance of a cancer free future. Women and their mates should get to know her breasts intimately (hee hee) so that when something out of the ordinary arises, no time is wasted in getting to a doctor to check it out.
Screening mammograms are fine and should be used, but when a woman is younger, the recommended frequency is not sufficient to catch and deal with an aggressive cancer like my wife had. She was almost exactly in the middle of the time between her annual mammograms when this lump was discovered.
Just my bit to say that women should use every tool in their arsenal (including both physical self exam and screening mammograms) against this deadly and surprisingly common disease.
Keith
Nov 16, 2008 - 2:25 pm 4. RC:Although only anecdotal, my wonderful wife is alive today because she found an unfamiliar lump about 12 years ago. Statistics and research are all very well (and constitute science vs anecdotes), but there are always people behind those numbers…something that shouldn’t be forgotten.
I can’t prove it myself but my impression is that the total package of diagnostic tools, self-exam, mammogram and ultrasound, are largely effective. Whether they are worth the cost is an analysis each person much make for themselves.
Nov 16, 2008 - 2:27 pm 5. Hendrick:["(BSE) is a controversial topic among medical professionals."]
…. all cancer screening should be controversial.
Screening tests are worthwhile if the death rate (mortality) in the screened group is lower than the rate in people who are not screened. “Survival” rates are meaningless statistics — as soon as you advance the date of diagnosis with any screening test, you will improve the apparent ‘cancer-only’ survival period.
One cannot assume every untreated cancer is ultimately fatal. Every cancer, is a mixture of types… some tumors are generally harmless — never spread & kill, and would have gone undetected were it not for the screening. But the screening of such tumors usually results in a cancer diagnosis, treatment and often-alleged cure.
Other tumors are fatal no matter when they are found & treated — finding them early only means more time with a cancer diagnosis (i.e., ’survival’ time). A person might die 5 years after symptoms appear, no matter what treatment is provided. If screening detects it 5 years before symptoms emerge, that person will survive 10 years after diagnosis … versus ’surviving’ only 5 years if the cancer is not diagnosed until after symptoms appear.
Recent American study of Lung-Cancer screening indicated it did not save lives, and exposed people to serious risks of injury/ death from needless surgery.
Nov 16, 2008 - 5:36 pm 6. Huan:self breast examination could contribute to a personal culture of breast health, of which getting routine mammogram is a result of. with or without anxiety.
And Anne is correct. upward of 10% of all breast cancer are not seen on mammogram.
Nov 16, 2008 - 7:32 pm 7. Huan:Screen only cancers we have effective therapy for
Nov 17, 2008 - 4:20 am 8. Someone75:I cannot believe this is even an issue. Self exams are a no brainer. Over the last ten years, two women in my extended family have dealt with breast cancer and, fortunately, all did routine self-examinations. This is a non-issue.
Nov 19, 2008 - 6:50 pm 9. kathy:Sorry to be off topic and conspiracy thought driven, but do you think that Obama has acromegaly? Gait and hand size?
Nov 19, 2008 - 6:56 pm 10. Someone75:Kathy,
No. But nice use of WebMD for a bizarrely misguided diagnosis.
Nov 20, 2008 - 10:41 am 11. Henry Perea:Dr.Halderman is, as usual, thorough in her analysis. Having experienced breast cancer in my family, it is imperative that women (and men) engage in preventaive strategies for the detection of cancer. Bottom line, as the doctor recommends, make the BSE part of a multiple strategy for early detection
Nov 20, 2008 - 12:36 pm 12. Abbadean:It is good that you are including men in your article. Many men are unaware of the danger.
Murph
Nov 20, 2008 - 1:55 pm 13. Amy L.:Great article by Dr. Halderman. Interesting that in the UK the standard is a mammogram every THREE years and only for women over 50. Beware socialized medicine!
Nov 20, 2008 - 2:24 pm 14. Herb Gladen, M.D.:As Dr. Halderman cogently notes, one of the disadvantages of BSE is a high false (+) rate leading to anxiety and further expensive testing (including biopsy). Failure to diagnose breast cancer is one of the most common causes of malpractice. I would value Dr. Halderman’s comment on the impact of litigation risk, here and in England, on the use and possible overuse of these diagnostic measures.
Nov 21, 2008 - 9:17 am 15. Mark:Very informative!
Nov 21, 2008 - 12:43 pm 16. Con Michas, MD.:Excellent presentation of BSE
Nov 23, 2008 - 9:20 pm 17. Mariela Resendes, M.D.:Thank you for your well written, and thoughtful article. I enjoyed it.
Nov 26, 2008 - 6:07 pmAlthough mammography is our best tool-bar none-for finding breast cancer, BSE always needs to be included in patient’s/physician’s armamentarium. I will distribute your article to my patients.