The studies reviewed here found that a breast self-exam (BSE) can be an important way to find cancer in young women, especially young woman with a higher-than-average risk of developing breast cancer. The results offer another point of view in the ongoing discussion about the role of BSE in breast cancer screening.
For years monthly BSE was part of an overall breast cancer screening plan for women of all ages. A suspicious area found by BSE led to many breast cancer diagnoses and successful treatments. BSE, along with regular exams by your doctor and an annual mammogram starting at age 40, can help make sure that any breast cancer is diagnosed early, when it's most treatable. Still, screening tests aren't perfect. Both BSE and mammograms can result in what's called a false positive. A false positive is a suspicious result that looks like cancer but really isn't. Besides the fear of a breast cancer diagnosis, a false positive usually means more tests (including biopsies) and follow-up doctor visits. The process can be very stressful and upsetting.
Some doctors started questioning the usefulness of BSE after research showed that regular BSE doesn't reduce the number of women who die from breast cancer. Because it costs money to promote BSE, many public health professionals thought that the money could be better spent on something else that would have more of an impact on breast cancer's affect on society. These concerns caused the American Cancer Society (ACS) to change its BSE guidelines several years ago. The ACS now views BSE as an optional -- not a recommended -- screening technique. Still, if you or someone you know was diagnosed and treated for breast cancer because of something found during BSE, you probably think BSE is very valuable. Any woman who wants to do everything she can to monitor her breast health should do BSE.
In one study reviewed here, 147 young women at high risk for developing breast cancer took part in a program that offered BSE training and a physical breast exam by a doctor two to three times per year. The women also had a breast MRI each year. MRI is often used instead of or in addition to mammograms to screen for breast cancer in young, high-risk women. Some of the women also had mammograms.
During 3 years of follow-up:
BSE was clearly an important screening technique for these young high-risk women. Over 3 years, six of the 14 high-risk young women (43%) diagnosed with breast cancer were diagnosed because of something found during BSE.
In the other study reviewed here, researchers looked at the records of 628 women 40 or younger who had been diagnosed with breast cancer. Most of the young women weren't considered high-risk before their diagnoses, so they didn't have an intensive screening plan. And because mammograms aren't recommended for women younger than 40, most of these women hadn't had a mammogram before they were diagnosed.
The researchers looked at how the women were diagnosed with breast cancer:
Because these women weren't getting regular mammograms yet, BSE was the most likely way for breast cancer to be diagnosed.
All healthcare decisions, including BSE, are personal choices based on the information available and each person's unique situation. A woman can choose to make regular BSE part of her breast health monitoring and cancer screening plan. In many cases, official recommendations and guidelines can affect whether insurance companies cover a screening technique. But this isn't true for BSE, which requires only your time and commitment.
No matter how old you are, ask your doctor about the pros and cons of BSE and whether BSE should be part of your breast cancer screening plan. Together you can decide what makes the most sense for you. If you're younger than 40, this research suggests that doing BSE regularly is a good idea, no matter what your breast cancer risk is. If you're older than 40, it's important to have a mammogram every year, whether or not you choose to do BSE.
Visit the Breastcancer.org Breast Self-Exam page to learn how to do BSE.
SAN FRANCISCO, April 23 (MedPage Today) -- Breast self-examination still has a role for high-risk women despite being controversial for the population at-large, researchers affirmed.
Breast self-exam remains the top method of breast cancer detection among young and high-risk women, according to two single-center studies reported at the American Society of Breast Surgeons meeting in San Diego, Calif.
"It is something that should be emphasized and well-taught to those at high risk, i.e. a selected patient population," said Lee G. Wilke, M.D., of Duke University in Durham, N.C., based on her group's findings.
Breast self-exam fell out of favor after two large longitudinal studies from China and Britain revealed no mortality advantage.
A recent Cochrane Review also showed no reduction in breast cancer mortality rates with self-examination but almost a doubling in negative breast biopsies. (See: Breast Self-Exam Gets Thumbs Down in Systematic Review)
The American Cancer Society and National Cancer Institute have eliminated breast self-exam from recommendations for screening in the general population. And although the ACS still calls it optional, the goal of the exam is now to make women familiar with their "breast landscape" so they know what's normal for them.
Both organizations, however, still encourage self-exams for women at high risk of breast cancer, usually defined by presence of BRCA1 and 2 mutations.
Dr. Wilke's group examined detection methods at their High-Risk Screening Clinic, which serves women with a Gail Model risk of more than 1.7%, ductal or lobular carcinoma in situ, contralateral cancer, breast cancer in multiple first degree relatives, or BRCA1 or 2 mutation.
Women in the program get a yearly breast MRI, training in breast self-examination two or three times a year, and clinical breast examination two to three times annually.
Among 147 participants who entered the program from 2004 and 2007 with three-year follow-up, the most common method of detecting masses was breast self-examination, followed closely by MRI.
The findings were:
With advances in technology that might be expected to improve detection in younger women -- such as digital mammography's better detection in dense breasts -- Barbara L. Smith, M.D., Ph.D., of Massachusetts General Hospital and Harvard, and colleagues looked at characteristics of detection in this group.
They studied 628 women 40 and younger (median 37) who were treated at Massachusetts General Hospital from 1996 through 2008.
Over time, the researchers saw a trend for increasing tumor size at diagnosis with an average T size detected by MRI of 7.5 mm.
Breast self-exam was the means of tumor detection for 71% of these young women whereas 24% were found with mammography and only 3% were detected by clinical breast exam.
It's not that mammography isn't effective, Dr. Smith said. For the 95% of women who had a mammogram at or after diagnosis, it correctly identified 86% as abnormal.
Rather, most young women simply hadn't had a mammogram yet. In the study, the mammogram around the time of diagnosis was their first.
As expected from prior studies, MRI gave an even higher rate of detection. Among the 214 women who had MRI at or after diagnosis, 96% correctly picked up abnormalities. In 12%, MRI revealed additional cancer foci.
Overall, fewer than 2% of the breast cancers were not detectable by either method.
Likewise, genetic testing was done only after diagnosis in 99% of those checked for BRCA mutations.
"Underutilization of genetic testing and breast imaging potentially delays diagnosis of breast cancer in women 40 and under," Dr. Smith concluded.
She emphasized the need for not only better identification of BRCA carriers -- including more testing of family members -- for high-risk screening but also better strategies for finding high-risk young women without family history.
One of the key things in early detection screening for young women is cost, Dr. Smith noted.
Self-examination has the potential to be fairly cost effective, she said, but education on this detection method still needs to be targeted to the right women. "Finding the women where there's some inkling of risk you get better results."
Dr. Wilke agreed that targeting these instructions may be best, although she cautioned about the limitations of single center studies.
"Certainly, we think breast self-examination, as evidenced in the young women, is still an important component to this early detection of breast cancer," she concluded.
Dr. Wilke's study was funded in part by the Susan G. Komen Foundation and the North Carolina Triangle Affiliate.
The researchers provided no information on conflicts of interest.
Primary source: American Society of Breast Surgeons Source reference: Wilke L, et al "Breast Self-Examination: Defining a Cohort Still in Need" ASBS 2009. Additional source: American Society of Breast SurgeonsSource reference: Samphao S, et al "Diagnosis of Breast Cancer in Women Age 40 and Younger: Delays in Diagnosis Are Common Due to Underutilization of Genetic Testing and Breast Imaging" ASBS 2009.
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