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

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Publication Date: 
Tue, 2012-07-17

Whatever the method of discovery, women are discovering breast cancer symptoms earlier (or visiting doctors sooner) than in the past when some combination of fear, shyness and shame likely prevented them from seeking medical attention, notes Canadian physician and epidemiologist Dr. Cornelia Baines.

Dr. Steven Narod, a leading Canadian breast cancer researcher, says that at Women’s College Hospital (WCH) in Toronto where he works, the average size of a cancerous lump felt by women (or their physicians) has gone down from 2.5 cm to about 2 cm over the last 20 years.

And that change—the identification of a “palpable” breast cancer when it is smaller—has had a large impact on mortality rates, he says. Put simply, women come to see doctors much sooner than they used to, allowing for treatment at an earlier stage. In contrast, the size of breast cancer lumps identified by a mammogram at Women’s College Hospital hasn’t changed since 1986, Narod says.

Reasons some former BSE boosters have changed their minds
Doctors and women’s health advocates who used to champion BSE cite a variety of reasons for changing their minds.  
Baines was a co-investigator of the Canadian National Breast Screening Study, which published its first results in 1990 and she has subsequently published a number of related studies. One study she co-authored in 1997 indicated that the practice of BSE may improve early detection of breast cancer and Baines publicly took exception to the 2001 Task Force recommendation against BSE.

Since then, she has changed her mind. Her reasoning?  “The only way you get BSE to be really useful is if you have really highly qualified trainers, repeatedly training highly motivated women. Is that realistic? No,” she said in an interview.

Instead she says that women should notice change—especially if their breasts become asymmetrical or if, when lying on their side, their breast feels thicker. “We notice change in other parts of our anatomy without doing regular exams. If ever asymmetry or change knocks on your door, go to the doctor,” Baines advises.  

The medical director of the Women’s Health Clinic in Winnipeg has also changed her thinking about BSE, but for different reasons.

“Most things that women find when they’re young and doing BSE are nothing, not important,” Dr. Carol Scurfield said in an interview. “But once someone has found something they are concerned about it’s really hard for them, and for you as a health care practitioner, to say, ‘let’s just ignore it.’”

That means “the practitioner feels obligated to do something, and then you get mammography and radiation [from the mammogram] and then you get a biopsy for nothing.” Scurfield also pointed out that after a woman has had a biopsy, it might be more difficult to read a subsequent mammogram.

She adds that in her experience, BSE did not prove that useful in detecting breast cancer. “Even when we were preaching BSE, the vast majority of women that actually showed up with issues did so because they found it in the shower accidently or happened to glance in the mirror and notice a change.”

Scurfield says it’s “important to teach women about their breasts and to tell them about the kinds of things they might notice that they should have checked out. We have to teach them that. We just don’t need to teach them this [BSE] is the law.”

Dr. Susan Love, author of Dr. Susan Love’s Breast Book, also stresses that women should become familiar with their breasts so they can notice any change and follow up with their doctor, but her reasons for not promoting BSE raise yet other issues.  

Love argues in her book that BSE “alienates women from their breasts instead of making them more comfortable with them.” With BSE “you’re hunting for something . . . [It] has been set up as a way to monitor your breasts for cancer,” she wrote.  

In the end, it was the evidence from scientific studies that convinced the authors of Our Bodies Ourselves to drop their longstanding endorsement of BSE. Those studies “have not found that women who perform BSEs are any less likely to die of breast cancer than women who don’t perform them” states the 2011 edition. It continues:  “However, exploring your breasts is a good way to get to know your body and become familiar with what is normal for you.”

The science behind the recommendation
The Task Force recommendations against teaching BSE—in 2001 and 2011—are based primarily on two large randomized controlled trials (RCTs) from Russia and Shanghai that were published in 1987 and 1997. RCTs are considered the ‘gold standard’ of trials for evidence-based medicine.  

The trials demonstrated no reduction in breast cancer mortality associated with BSE. They also concluded there was evidence of harm in the form of an increased rate of unnecessary (benign) breast biopsies because of the practice.

While many breast cancer researchers and specialists, including Drs. Baines and Love, have come to the same ultimate conclusion—not to teach women BSE—their reasons are not necessarily based on evidence from the randomized controlled trials. In fact, Baines and Love argue that the trials were flawed or the results misconstrued.

The most commonly cited clinical trial is the Shanghai trial, in which women factory workers were taught formal BSE. Baines argues that its results were contaminated because, over the two-year trial period, women were increasingly transferred from one factory to another—between the BSE and control groups. Love also takes issue with the Shanghai trial, pointing out in her book that, in the control group, some women found their own cancer. This supports the idea that women should be familiar with their breasts, she wrote.