Breast self-examination: What it means and why the thinking about it has changed

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Publication Date: 
Tue, 2012-07-17

The Canadian Task Force on Preventive Health Care released its guideline on screening for breast cancer for average-risk women (aged 40 to 79) in late 2011. The guideline updated screening recommendations made by the Task Force’s predecessor, the Canadian Task Force on the Periodic Health Examination, in 2001. The focus of the guideline is on mammography screening, but the guideline authors also recommended against clinical breast examination (by physicians) and breast self-examination by patients. The Task Force issues guidelines for primary care (family) doctors on a range of preventive care issues. In this article, journalist Ann Silversides wades through the recent controversies about the guideline, explaining the issues and summarizing the evidence and current thinking about breast self-examination. See also: Mammography screening: weighing the pros and cons for women's health.

By Ann Silversides

Many women were puzzled and even angry when the Canadian Task Force on Preventive Health Care recommended against breast self-examination as part of its 2011 guideline on breast cancer screening.

Why advise against a procedure that appears to facilitate self-care, isn’t costly, and doesn’t seem to have a downside? The advice seems to fly in the face of what we know: that many women themselves discover cancer because they notice a change in their breasts.   

Poor communication from the Task Force and in media reports explains much of the confusion about the recommendation.

The Task Force made the same recommendation against breast self-examination (BSE) back in 2001 and, in the intervening decade, several leading Canadian women’s health advocates—who used to champion BSE—ceased teaching or actively recommending it to their female patients.

Even Our Bodies Ourselves, the influential women’s health publication, revised its position on BSE—ceasing to endorse it—in the most recent 2011 edition.

What’s going on here?

For one thing, much of the reaction to the Task Force recommendation stems from different interpretations of the meaning of the term “breast self-examination.”

For many women, the term simply means checking their breasts for any changes. But to Canadian health professionals, BSE refers to a formal procedure—to be taught to women—that involves checking for breast changes in particular ways at the same time every month.

Dr. Ruth Wilson, director of health policy for the College of Family Physicians of Canada, emphasizes that it is “really important to distinguish between a woman who finds a lump in the shower and the practice of regular, monthly self-examination.”

But the Task Force didn’t spell out that distinction in its communications with women. The Task Force’s two-page FAQ for Patients features a “STOP” sign graphic (a hand with a slash through it) next to the recommendation “against routine BSE.”

Such loaded imagery leaves many with the impression that any examination of their breasts should be avoided. This was also the message that many women took away from media coverage of the issue.

Dr. Marcello Tonelli, spokesperson for the Task Force and co-author of the 2011 recommendations on breast cancer screening, stressed in an interview that the Task Force is “not telling women don’t examine your breasts, or don’t know your breasts.”

Instead, the recommendation against BSE is based on evidence showing that “devoting resources and time for doctors and programs in a structured way to teach women about BSE doesn’t seem to improve the health of women,” Tonelli said.

Notwithstanding Tonelli’s explanation, the FAQ for Patients (with its dramatic “STOP” graphic) goes on to state that studies found evidence of “increased harm” from BSE.

The FAQs do not include any suggestion that women should check with their health practitioners if they notice changes in their breasts, even though this has long been supported by advocates in the women’s health movement and by many physicians.

CBC radio host Kathleen Petty was in the shower when she looked down and spotted a change in her breast. “I had all these sort of big plans and then everything stopped. And it all stopped in the shower.”
“It’s not an unusual story,” she matter-of-factly told a CBC colleague in a televised interview in December 2011.  
Petty’s big plans involved a move from Ottawa to host the CBC’s morning radio program in Calgary.
But the abnormality that she spotted turned out to be cancer; instead of moving, she remained in Ottawa to undergo treatment. Read full story 

Most breast cancers and changes in breasts “are discovered by women themselves, frequently while bathing,” says Dr. Donna Stewart, Lillian Love Chair in Women's Health at the University Health Network and the University of Toronto.
Of course, the changes that women identify aren’t always symptoms of breast cancer. But a large proportion of women do themselves find changes that turn out to be cancer. Estimates are that between 40 and 75 per cent of breast cancers are discovered this way, and the clinical experience of many family physicians suggests the higher percentage is more accurate.