July 17, 2008

THURSDAY, July 17, 2008 — If you think that breast self-exams are a waste of time, I'm not surprised. A recent study created a deluge of publicity after it found that women taught to do breast self-exams didn’t cut their chances of dying of breast cancer. In fact, the study concluded that self-exams might even be a burden on the medical system because they result in more biopsies and tests to check out perfectly harmless lumps and bumps.

It would be a relief and a natural reaction to think, Thank you! That’s one more thing I can cross off my to-do list!

But hold on: Some experts advise otherwise for many women.

Studies conducted in China and Russia
First of all, does the new analysis, published in The Cochrane Library, even apply to American women? Jan Peter Kosters, PhD, and a colleague merged data from two studies, conducted in 2002 and 1999, which included 388,535 women—one group from Shanghai, China, and one from Russia. In both, factory workers were trained to do breast self-exams.

Women in China were no more likely to detect a cancer, and no less likely to die of breast cancer, than women who did not receive breast self-exam training. The women in Russia were 24% more likely to find a cancer, but no less likely to die of the disease, than their untrained peers.

Now it's logical to ask if less-than-stellar medical treatment in Russia and China could explain why self-exams didn’t cut breast-cancer mortality (breast-cancer patients in the U.S. have the highest survival rate anywhere in the world). But David B. Thomas, MD, the epidemiologist at Fred Hutchinson Cancer Research Center in Seattle as well as the lead author of the 2002 Shanghai trial, tells me that the women actually had pretty good breast-cancer treatment.

No, the more important message is this: Dr. Thomas cautions women not to pull a personal lesson from a public-health study. Statistics that guide public-policy decisions are not necessarily relevant for you or me.

What it means for public health and what it means for you

You see, Dr. Thomas and colleagues set out (in the 2002 study) to determine if breast self-exams could take the place of mammograms in a group of women who didn’t have access to them.

“What we found was that trying to teach women in the general population to perform breast self-examination didn’t influence their risk of dying of breast cancer,” he tells me. Part of the reason was that they—like me and lots of women in the U.S. and around the world—weren’t motivated to do them consistently and correctly. (They did them at least every four to five months; it's not clear if they did them once a month as recommended).

When experts talk about breast self-exams, they aren’t talking about a quick once-over in the shower whenever you think of it; they're talking monthly. And they mean a detailed series of specific steps, including a diligent exam in both a standing and lying down position. A lot of women in the Shanghai trial just didn’t seem to stick with it.

The public-health implication for the general population is that teaching breast self-exams doesn’t cut breast-cancer mortality, and it’s crucial to have regular mammograms. However, for a highly motivated woman (one who does exams correctly and consistently because she’s concerned about breast cancer), the message could be quite different, according to Dr. Thomas.

“I wouldn’t ever tell a woman [of a certain age] not to practice breast self-exams,” he says. (For younger women in their teens, 20s, or even 30s, self-exams may not be worth it because the risk is so low in those without a family history, Dr. Thomas says.)

Self-exams are probably a good idea starting at around age 40 for women who are motivated to do them diligently, says Dr. Thomas. However, self-exams should be used to check for abnormalities between mammograms—not take the place of them.

If you do breast exams, you may undergo unnecessary tests
There is a risk here. If you conduct detailed examinations of your breasts, you will likely find lumps—and those lumps are likely to be benign. But a lump often leads to medical tests, including biopsies or expensive magnetic resonance imaging (MRI) tests.

This is a risk many women are willing to take, says Marisa Weiss, MD, the founder and president of

"The reality is that in today's world most women are willing to have a biopsy to prove that something is OK or find that it's malignant, if in case it is," says Dr. Weiss. "Individually, we women are willing to take a risk and so if you ask a woman, she’s not going to see that it's harmful."

Dr. Weiss was slightly exasperated by the new study’s conclusion that breast self-exams couldn’t be recommended but that “breast self-awareness” was important (self-awareness would include properly conducted self-exams, you'd think.)

"What in fact is breast awareness? What does that mean? How do I as a doctor advise my patient?" she asks. "Are we to say, 'Oh great, don’t examine your breasts but be aware of them, and call me if your breast falls off?'”

The bottom line
The reality is that 15% to 20% of all breast cancers are picked up by a physical exam, either at a doctor's office or by a woman herself, says. Dr. Weiss.

"Among these huge population studies, [breast self-examination] didn’t make a survivorship difference, but I can tell you that have I patients—plenty of them—who were the ones to find their breast cancer and it was found early and they are living and doing well," she says. "You can say that’s individual and anecdotal, but it’s real."

We've featured some of those women in stories about the self-exam issue. It’s impossible to know what percentage of women find cancer as a result of by-the-book breast self-examinations versus random "I-picked-it-up-in-the-shower" type of exams.

But it stands to reason that the more you know about your breasts and how to examine them, the more likely you are to detect changes, healthy or unhealthy. There are plenty of good online videos about proper self-exam techniques.

"I would say, don’t sit on your hands—use them," says Dr. Weiss. "They’re convenient, they’re free; use them on a regular basis as one of the tools that could potentially detect breast cancer early—or possibly even save your life."


By Theresa Tamkins

Related Links:
A Young Athlete With Breast Cancer Asks, Why Me?
Video: Ellen Had a Fine-Needle Biopsy at Age 36
Breast Cancer's Emotional Roller-Coaster
Breast Cancer: I Was Discriminated Against at Work

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