Breast Self-Exam Flunks Test

<P>They Don't Cut Breast Cancer Deaths, but May Increase Unnecessary Biopsies</P>

From the WebMD Archives

Oct. 1, 2002 -- Breast self-exams can work -- but not the way most women do them. A major study shows no fewer breast-cancer deaths among women taught to check their own breasts for lumps.

Experts agree that women should know their breasts and that they should see a doctor if they notice any suspicious changes. Most U.S. doctors follow the recommendation of the American Cancer Society. They teach women to do detailed checkups -- called breasts self-exams or BSEs -- every month.

Many doctors may change their minds after seeing the new study in the Oct. 2 issue of the Journal of the National Cancer Institute. The huge trial compared large groups of women taught -- and faithfully reminded -- to do BSEs with women not taught to do BSEs. The result: both groups had the same rate of breast-cancer death. Study leader David B. Thomas, MD, DrPH, heads the epidemiology program at Seattle's Fred Hutchinson Cancer Research Center.

"It has not been proved that BSE will result in a reduction in a woman's risk of dying of breast cancer," Thomas tells WebMD. "I would also say, however, that it hasn't been definitely proved that if a woman diligently practices BSE on a monthly basis very carefully, it will not do some good. We don't know if it works."

The study signed up more than 266,000 women working in factories in Shanghai, China. When the study started, nearly 40% of the women were aged 30-39 and about 15% were age 40-49. Half the women were taught BSE and regularly reminded to check their breasts. The other half -- the control group -- got no training or reminders. None of the women in either group had access to mammograms or clinical breast exams performed by doctors. All women who found suspicious lumps or other signs of trouble got free medical care. Women who developed breast cancer got aggressive treatment including surgery, radiation therapy, and/or chemotherapy. U.S. observers rated this treatment as adequate.

After 10-11 years, there were 135 breast-cancers in the BSE group and 131 in the control group. Women taught BSE underwent more biopsies for lumps that turned out to be benign. They also detected their cancers sooner than did women who didn't do BSE, but they didn't get any survival benefit from this.

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Why? The study doesn't show that BSE doesn't work. It does show that most women have trouble doing BSE well or often enough. BSE isn't easy to do, Thomas says. Most women in the study learned to do it moderately well. But that wasn't good enough.

"If you practice BSE, you have to do a better job than they did," Thomas says. "BSE is rather a formal technique. It is not just poking your breasts when you are taking a shower, but systematically searching the breast for very small changes and lumps. You have to do an excellent job."

Breast-cancer expert Cornelia J. Baines, MD, professor emerita at the University of Toronto, has some problems with the study. She notes that many of the women were no older than 40 or 50 at the end of the study period -- ages at which relatively few women get cancer. And she says that any kind of breast-cancer screening usually takes more than 10 years to show a survival benefit.

"The most important message here is that women who don't want to do BSE shouldn't be made to feel guilty for not doing it," Baines tells WebMD. "But if women are sufficiently motivated to do BSE well and want to perform it, it probably is a very good idea. The majority of breast cancers are still found by the woman and not by her doctor. If she is doing BSE she is more likely to notice it earlier than later. BSEs are worth doing, but not worth doing badly."

Russell Harris, MD, MPH, is co-director of health promotion at the University of North Carolina, Chapel Hill. He's also the author of an editorial accompanying the Thomas study. Harris points out that the study compares BSE alone to no screening at all. BSE would be expected to have even more of an effect in this setting than in the U.S., where women get regular mammograms as well as regular clinical breast exams (CBEs) from their doctors. That the study found no effect, he says, means that most women might as well take down those shower cards illustrating BSE techniques. Thomas agrees.

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"I don't want to tell women not to examine their breasts, but it is definitely not a substitute for mammography," Thomas tells WebMD. "Women should go regularly to get mammograms and to get examined by professional personnel. Formal breast examination includes palpation in a proper way using the pads of the three middle fingers, systematic searching of the whole breast in both sitting and lying positions, and looking for asymmetry. That takes time and a real effort. That is what a woman has to learn if wants to do BSE. It is more than looking at a card in the shower."

Harris says that the time doctors spend teaching BSE could be better used in giving more thorough clinical examinations. But Baines insists that women who want to learn BSE should be encouraged to do so.

"Trained eyes see more than untrained eyes. Trained fingers feel more than untrained fingers. Women who do BSE regularly have more trained eyes and more trained fingers," Baines says. "When women find their own tumors, they are more likely to do it if they do BSE -- regardless of how they actually notice them. I approve of the concept of breast self-awareness."

Harris doesn't dispute this. "Part of what Dr. Baines is saying is right," he says. "We need trained minds to understand. But training those fingers is darn hard. It is a very hard thing to learn. What's needed is a really excellent physical examination of the breast, whether by the woman or by her doctor. A haphazard exam isn't enough. Training people to do it in the right way is really important."

There are many products on the market designed to make BSE easier. Baines thinks they are, at best, a waste of time and money.

"You have no idea of the number of entrepreneurs who have made things like revolting collapsed balloons full of wet jelly, and women are supposed to lie on their backs like fish and palpate their breasts with them," she says. "These ways to enhance BSE -- do I give them credence? No. The closer your fingers are to your breast, the better."

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