Breast cancer is the number one diagnosed cancer for women in the United States and second only to lung cancer in cancer-related deaths. There is much uncertainty surrounding the diagnosis and treatment of breast cancer: Are mammography and breast self-examination effective methods of detection? Should treatment include lumpectomy or mastectomy? Chemotherapy, radiation, or both?
A recent large-scale, long-term study on breast self-examination (BSE), published in the October 2nd Journal of the National Cancer Institute, adds more uncertainty. It followed a group of 266,064 female factory workers in Shanghai for ten to eleven years. Half were assigned to a BSE instruction group and the other half acted as the control group. The results showed that BSE did not reduce women's risk of mortality from breast cancer. There were roughly the same number of breast cancer deaths in both the instruction and control groups (135 and 131, respectively). The editorial that went along with the published findings suggested that physicians should stop "spending time routinely teaching women's fingers to do BSE...and spend a little longer on the CBE [clinical breast examination]."
However, there is negligible harm involved in continuing a practice that may do a tiny bit of good and may work for some women. In light of these most recent findings, should breast self-examination continue to be promoted as a public health practice? Should public health officials decide for women everywhere whether or not they have the right to learn this practice? The study certainly does not suggest that BSE increases women's risk of dying from breast cancer. Thus, there is no reason to discourage it as a personal health practice among women who choose to perform it.
Some organizations, such as the Canadian Task Force on Preventive Health Care, have recommended against the teaching of BSE to middle-aged women. The U.S. Preventive Services Task Force, while not taking as strong a stance, feels that there is insufficient evidence supporting the benefits of BSE to actively support or denounce the routine teaching and performing of BSE. Since BSE alone has not been shown to effectively reduce mortality rates, these groups are hesitant to say it does any good at all. The endpoint they are focusing on in determining their position is death: Does the use of BSE alone reduce the death rate? Should we be investing public health funds in something that doesn't save lives? The Shanghai study author proposed in an Associated Press article that health officials should not invest their money in teaching BSE but rather focus on programs that have large-scale benefits, such as immunizations.
While there may be higher priorities for public health spending, that concern alone does not mean BSE should be abandoned as a personal practice. Doctors can teach women how to examine their breasts during annual check-ups without devoting vast resources to the technique. Most well-respected health organizations understand this and agree that BSE is much more effective when it is not the sole tool for detecting cancer but instead is used in conjunction with mammography and clinical breast examination (CBE). The American Medical Association, the American College of Obstetricians and Gynecologists, the American Cancer Society, and the American Academy of Family Physicians all currently support teaching BSE. Dr. Rebecca Garcia, vice president of health sciences for the Susan G. Komen Breast Cancer Foundation, has said: "Breast self-examination is something all women can do to take charge of their own health. It is private, it's free, and it can be done at home. However, based on the results of this study, it is important that women understand the role of BSE as part of a three-step process and not as a stand-alone method of early detection."
The National Cancer Institute contends: "Studies so far have not shown that BSE alone reduces the number of deaths from breast cancer. Therefore, it should not be used in place of clinical breast examination and mammography."
In promoting the findings of this study or criticizing the effectiveness of BSE, we should not lose sight of the fact that if a woman does detect a lump either by accident or by BSE she should not ignore it, regardless of whether the lump is painful. Yes, BSE could lead to increased anxiety among women who find lumps, resulting in an increased chance of women having benign breast biopsies, but this should not stop women from getting any abnormalities checked out by their doctors. While they needn't panic over every abnormality, they should not live in ignorance in order to avoid anxiety, and they should not deny any warning signs their bodies may be telling them.
Breast self-examination may not reduce breast cancer mortality rates, but it does help women to detect abnormalities in their breasts and may give them some feeling of control over detection of the disease. The Breast Cancer Support Services of Ontario asserts: "The only thing worse than finding a lump is not finding one." While we await further studies to confirm the Shanghai findings, BSE may increasingly be thought of as a personal choice with debatable costs and benefits like most other health-seeking behaviors, such as diet, exercise, and medical check-ups. The individual must decide what is right for her, and a single study should not dissuade her from making those choices.
Karen L. Schneider is a research intern at the American Council on Science and Health.