Many national health groups decided to review the largest, most significant studies on breast cancer screening, hoping to make recommendations based on solid scientific evidence.
Experts say the new guidelines on the most popular screening methods should help boost the chances of detecting disease in its earliest stages, when it's most treatable.
There's good reason to follow these guidelines. Breast cancer is the most common type of cancer among women in the US, other than skin cancer, according to the National Cancer Institute. In 2003 alone, an estimated 211,000 American women will likely be diagnosed with breast cancer. But if caught early, most breast cancers can be cured.
Mammography: Still the Gold Standard
Most cases of breast cancer in western countries are now found by mammography. The X-ray technique became the subject of much controversy after a group of Danish investigators analyzed several international studies used by leading health associations to make their recommendations on mammography. The analysis suggested that the research had a number of flaws, and that perhaps mammograms did little to detect breast cancer, and, thus, save lives.
The report, which appeared in the October 20, 2001 issue of The Lancet, spurred national organizations to reassess the literature on mammography. The re-examination, however, only strengthened earlier positions.
"Every organization that made a statement (about the benefit of mammograms) reviewed the studies again, and said, 'Absolutely, mammography does have a benefit. It decreases death from breast cancer,'" says Debbie Saslow, PhD, director of breast and gynecologic cancer at the American Cancer Society.
More than ever, leading health groups view mammograms as the gold standard in breast cancer screening. As Harold Burstein, MD, PhD, member of the breast cancer team for the Dana-Farber Cancer Institute, puts it, "In terms of the treatments that have been proven to help early detection, and therefore early survival of breast cancer, onlymammography has really been proven to be a very valuable treatment."
This recent reaffirmation of mammograms has yielded the following guidelines:
- American Cancer Society and the Dana-Farber Cancer Institute recommend that all women get a mammogram every year beginning at age 40.
- The National Cancer Institute advocates screening every one to two years for women 40 years and older. Women with higher than average risk of getting breast cancer are also encouraged to ask their doctors if they should start screening at an earlier age, and how often they should have it done.
- The US Preventive Services Task Force advises women 40 and older to get a mammogram, with or without a breast examination performed by a doctor, every one to two years.
There is an 85% chance that a mammogram will find breast cancer, says Saslow, noting the percentage is significant, even if it's not 100%. A perfect test, she remarks, is not realistic at this time.
Most medical professionals stand by mammography, even with the hazards that come with using it. The device can wrongly highlight something as malignant when it is not. And it can fail to detect a true cancer. But its success rate outweighs those drawbacks, experts say.
"There are risks to most screening methods," reminds Helen Meissner, PhD, chief of National Cancer Institute's Applied Cancer Screening Research Branch.
New Policy on Breast Self Exams
The risks to inspecting your own breasts are similar to the hazards of the mammogram, in that you can miss a true cancer, or mistakenly pinpoint something as a concern. However, doctors have still advised female patients to perform a breast self exam every month.
Leading health groups used to give a strong recommendation for such monthly tests, but after reviewing the studies on screening, they determined there isn't enough evidence to advocate or reject the method.
"The recommendation (for the breast self exam) was never based on evidence," says Saslow, because there is not enough available data on the value of the technique. "It's enough to show that any effectiveness would be extremely small."
The American Cancer Society guidelines on breast self exams only advise women to be aware of their breasts, enough to notice any physical changes. Women can achieve this awareness by occasionally looking at breasts while taking a shower, getting dressed, or looking in the mirror.
Still, a monthly self exam is a great way of becoming familiar with the texture of your own breasts, says Meissner. "There may be insufficient evidence to recommend performing a self breast exam, but it doesn't mean that women shouldn't do it."
Burstein encourages self-examination on a regular basis, preferably after a menstrual cycle, when there are fewer changes in the composition of the breast. Using the flat side of several fingers, he suggests moving your fingers around the breast in a circular motion. It's a good idea, he adds, to examine how the breast feels in a horizontal position (while lying down), and in a vertical one (while standing in the shower).
The National Cancer Institute states that women performing breast self exams should watch out for the following symptoms of breast cancer:
- A lump or thickening in or near the breast or in the underarm area
- A change in the size or shape of the breast
- Nipple discharge or tenderness, or the nipple pulled back (inverted) into the breast
- Ridges or pitting of the breast (the skin looks like the skin of an orange)
- A change in the way the skin of the breast, areola, or nipple looks or feels (for example, warm, swollen, red or scaly)
Women who notice these symptoms are urged to see their doctor for a clinical breast exam.
The Value of a Doctor's Touch
Leading health groups used to recommend that women visit a doctor's office annually for a clinical breast test, as part of their routine physical exam. Now medical associations do not push for the test, but do see it as a nice complement to mammography.
What happened? As in the breast self exam, authorities determined that there was insufficient scientific evidence to make a strong recommendation for or against the clinical breast exam.
The doctor's inspection actually has the smallest benefit for breast cancer screening, when compared to the mammogram and breast self exam, says Saslow. She says, however, that a standardized process could improve the nature of the test.
"I don't know about you, but when I go to a doctor and I get that exam, it takes about 30 seconds," she says. "You can't do a thorough clinical breast exam in 30 seconds."
Saslow suspects that more breast cancers could be found if medical professionals took more time to conduct the test. She cites a study in Canada that found a strong benefit to clinical breast exams. The Canadian doctors, however, performed 15-minute inspections of each woman's breast, which may be unrealistic under managed care in the US.
A good clinical exam should take at least a couple of minutes, says William Gradishar, MD, spokesman for the American Society for Clinical Oncology. He says the physician should check the appearance and feel of the breasts while the patient is upright, and while lying down on each side. It's also important to look at the neck, and the lymph nodes under the arms.
Three Good Screening Tools
Revised guidelines may highlight the mammogram as the most useful tool in breast cancer screening, but experts say it's a good idea to add self and clinical breast exams into the mix.
After all, says Gradishar, women are most familiar with their breasts, and it's easy to feel your breasts once a month.
Plus, your doctor could notice a lump missed by a mammogram, or could point out an area for a radiologist to examine after an X-ray, says Meissner.
The caveat with the clinical and breast self exams is that they could generate anxiety, most of the time unwarranted. A suspicious finding may turn out to be nothing to worry about at all.
So, use common sense. Check your breasts each month. When you get your annual pap smear, ask your doctor to also check your breasts. And understand that small changes in breast tissue are normal. Don't panic unnecessarily. Just remember this: these tests are part of a comprehensive screening practice, which along with the gold standard mammography, could boost your chances of detecting a potentially deadly disease.