Breast Self-Exam

Jamie DePolo: Hello, and thanks for listening. Our guest is Brian Wojciechowski, MD, who practices medical oncology in Delaware County, Pennsylvania, at Riddle, Taylor, and Crozer Hospitals, and also serves as Breastcancer.org's medical adviser. A native of South Philadelphia, he trained at Temple University School of Medicine and Lankenau Medical Center. Dr. Wojciechowski is a sought-after speaker on the topics of medical ethics and the biology of cancer.

Medical and oncology organizations disagree on the value of breast self-exam. The American Cancer Society, for example, doesn't recommend breast self-exam, while Breastcancer.org believes they are part of a comprehensive screening plan. Dr. Wojciechowski joins us to talk about the role of breast self-exam in screening, and why it's controversial.

Dr. Wojo, welcome to the podcast.

Dr. Brian Wojciechowski: Thank you, Jamie. Nice to be with you again.

Jamie DePolo: So, to start. Just in case anybody isn't clear, can you explain what a breast self-exam is? Just so everybody knows what we're talking about.

Dr. Brian Wojciechowski: Well, a breast self-exam is basically an inspection of the breast that a patient does on her own. She would use her eyes, both to look at any changes that she noticed in the breast or the nipple, and the hands, in order to determine if there's any lumps or changes that way. And just generally to understand the look and feel of the breast so that she can be more aware if there's a change.

Jamie DePolo: Okay. Thank you. So, now, I know we're going to get into the why breast self-exam is controversial, but to you, what is the value of doing a breast self-exam?

Dr. Brian Wojciechowski: I think it's important to be familiar with the breasts, for patients to be familiar with their own breasts. Just so that they understand what's normal and what's abnormal, and in that sense, you can go to your healthcare provider quickly when you sense that something is wrong. You know, breast self-exam may also pick up masses in the breasts, say, in between your mammograms. So, there's the potential value of early detection.

Jamie DePolo: Okay. Now, to get into the controversy. Breast self-exam was recommended for a long time by a number of professional organizations, including the American Cancer Society. Then, in about 2008, a number of organizations stopped recommending breast self-exam. So, could you tell us a little bit about why that happened?

Dr. Brian Wojciechowski: Well, breast self-exam has been recommended for probably 70 or 80 years, and it was always felt, intuitively, to be a good idea before we really had any evidence for it — that is, scientific evidence, Jamie. So, the turning point really came in 2008 when a very large, very well-conducted study in China of 250,000 women showed that if women were trained to do breast self-exams, they were followed for 10 years, and it really didn't show that any lives were saved.

So, they took half of the women and trained them really well to do breast exams, and the other half had no training. A certain number of the women in each group developed breast cancer, and a certain number died from breast cancer, and there was really no difference in the group that had been doing breast exams and had not been doing breast exams. So, I think that's where really the turning point was, and a lot of the professional societies — the groups of doctors that make guidelines — started to abandon the idea of doing breast self-exams.

Jamie DePolo: Okay. Let me ask you this. I know with the mammogram controversy, people who say that mammograms should start either later, like after age 40, or should be done every 2 years instead of every year, the idea is that the mammograms are finding things that wouldn't necessarily need to be treated. Is that a concern with a breast self-exam? I guess that's a long way of asking, are there any risks or downsides to doing breast self-exams?

Dr. Brian Wojciechowski: Well, there are a few potential downsides, and as you mentioned, as with mammograms, whenever you're doing screening in any disease, you're going to end up having false positives. That is, where you find something that doesn't end up being cancerous. So, just like with mammograms, you do have that cost. You pay the price of an increased number of false positives and all the increased anxiety and extra testing that goes along with that.

Now, it should be said, however, that the studies for mammograms and breast self-exam, they tend to focus on whether or not lives were saved. And in terms of mammograms, the studies definitely show that lives are saved with mammograms, where you didn't have that with breast self-exam. But the reason for that is, is that sometimes even though we catch the cancer earlier, we are still really good at curing breast cancer, whether it's stage l or stage ll or stage lll. So, that's why, maybe, we're not seeing the difference in terms of lives saved, because most women are cured anyway.

But the difference is, if you get diagnosed at stage lll, where the tumor may be bigger or the tumor may be involved in lymph nodes, you have to go through much more in terms of surgery and chemotherapy and different treatments to get your cure. So, that's what a lot of the critics of mammograms and breast self-exams ignore. They just focus on the lives saved, and they don't focus on the benefits of early detection, which may go beyond simply, you know, did the woman have a greater chance of dying? But you really have to look at, did they go under less chemotherapy? Did they have to have less aggressive surgery? And that's what's missing from a lot of these big studies and analyses.

Jamie DePolo: Okay. So, if I'm understanding you correctly, just put it in my own words, what's not being looked at in these studies is, was the cancer found, say, at stage l versus stage lll? And maybe with the stage l cancer, somebody could get by with, say, just surgery and radiation as opposed to needing chemotherapy, which usually happens with stage lll.

Dr. Brian Wojciechowski: Yes, or even more aggressive and extensive surgery.

Jamie DePolo: Okay. Okay. That is good to know. Now, I do want to ask, too. I feel like — and maybe this is just me — but I feel like some women, especially women who are at high risk of breast cancer — say they have a strong family history or, say, they know they have a genetic mutation linked to a higher risk of breast cancer. I feel like those women might get a lot of benefits from breast self-exam. What's your take on that?

Dr. Brian Wojciechowski: I agree, Jamie. As a general rule, the higher the index of suspicion,
the more benefit for screening. So, to put that more in layman's terms, if someone has a higher risk of a certain cancer — say, lung cancer, colon cancer, breast cancer — they get a much greater benefit from screening than the person who's at average risk. So you're going to get a lot more bang for your buck if there's a BRCA mutation in the family, or you have a history of breast cancer, because your risk is higher. And the higher the risk going into a screening program, the greater benefit a person will receive.

Jamie DePolo: Okay. Okay. Good to know. Now, I know at Breastcancer.org, we talk about — as I said in the intro — we talk about breast self-exam as one part of a comprehensive screening plan. So, does that match up with how you think about it and what you tell your patients? Like, this is just one piece of several things that are going on.

Dr. Brian Wojciechowski: Yeah. The one thing we don't want to do is have a false sense of security: “Well, I did my breast exam. I didn't feel anything. So, I'm good to go.” No. The breast exam does not take the place of a doctor's breast exam, and it especially does not take the place of a mammogram, which is a much more sensitive test for breast cancer than a breast self-exam.

Jamie DePolo: Okay. So, finally, to wrap up. If one of your patients came in, say, somebody who — well, I'm not even going to say had a high risk. Just a patient, and asked you about doing breast self-exam and the value of it. How would you advise her?

Dr. Brian Wojciechowski: I would basically say that breast awareness is a very good thing. It helps your doctor determine what tests need to be done. For example, if you get a breast exam, a first-time breast exam with a doctor, and something is a little abnormal, and you say to the doctor, “Well, that's been that way for 20 years, it hasn't changed,” then that's a case where you're less likely to have a false positive. You're less likely to have unnecessary tests because you go in aware of your own anatomy, and you kind of have ownership of it.

So, I tell my patients that breast self-awareness is a very good idea. I think it's not unreasonable to say, “It's not clear that it'll save your life, but it may catch the cancer at an earlier stage and spare you more aggressive and extensive treatment.” So, I still recommend it, but in a sober way, just being aware of the caveats and the possibility that it could lead to false positives and unnecessary testing. But I think that's worth it.

Jamie DePolo: Okay. Okay. Great. Thank you so much, Dr. Wojo. It's always great to hear from you, and these insights, I think, will help a lot of people.

Dr. Brian Wojciechowski: The pleasure's all mine. Thank you, Jamie.