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SELF BREAST EXAMINATION -WORTHLESS FOR EARLY CANCER DETECTION OR AN UNFAIRLY NEGATIVE JUDGEMENT?

(December 2001)

The headlines all made the same point: women should not do self breast examination in an attempt to detect breast cancer early enough to make a difference in either severity of the illness or likelihood of death from breast cancer. The headlines resulted from an article in the Canadian Medical Association Journal from the well-respected Canadian Task Force on Preventive Care.

Based on a review of three randomized trials and five other studies of different design, called cohort or case control studies, the author concluded that self breast examination did not change death rates and caused harm because of work up of lumps found by the women that turn out not to be cancer. The review argues that women should not be taught self breast examination and gives self breast examination a negative D rating. The US Preventive Services Task Force gives self breast examination a C rating - meaning not enough evidence to make any recommendation for (A or B) or against (D or E).

Healthful Life has maintained that about one-half the studies show benefit from self breast examination (SBE), one-half do not. We have included SBE in our Program because we believe women should do SBE as part of taking charge of their own health. We believe that, if the SBE is done properly, there can be benefit in earlier detection that could result in a lesser need for chemotherapy or surgery, or in a lowered death rate.

What about the Canadian very critical review? In our judgement, the reviewer shows a clear negative bias. She says the three randomized trials show no benefit. One trial was in China where breast cancer is infrequent. Additionally, there was a very short follow-up period and a very small number of breast cancer cases. The second was a flawed study in Russia. The third was in the United Kingdom where two centers did SBE as part of a larger study. Allegedly, when the results from the two centers were combined, no benefit was found, but a review of that study leads to a very different conclusion. One of the two centers showed a very significant 21 percent drop in deaths. The other study showed no overall benefit, but an analysis of the women enrolled showed that those who were assigned to SBE and came for instruction on self examination showed a very impressive 34 percent drop in deaths.

So, in point of fact, both United Kingdom centers showed benefit.

The other studies reviewed had less ideal design; two showed benefit, especially for well carried out SBE; results were mixed in one and no benefit was found in two.

So, all in all, this review actually shows reduced deaths in about one-half the studies, no benefit in the other half, and there is also a strong suggestion that benefit will be increased if women are taught to do the examination properly.

As noted in an accompanying commentary, others find the issue of false positives much less of a problem.

There are two further issues that should be considered.

• Does SBE result in detection at earlier stages (more localized) for some women that allows them to have less extensive surgery or less extensive chemotherapy? That would be a huge advantage. One of the studies mentioned, but treated dismissively, shows exactly that. Certainly before making any negative judgement, the potential for SBE to result in less surgery and less chemotherapy for some women should be considered just as carefully as death rates.

• There is a reasonable possibility that women who do SBE starting at age 30 or earlier are more likely at age 40 to undergo annual mammographies than women who do not do SBE. Mammography is the best approach we have for early detection that can result in very high cure rates. That is not easy to evaluate because women who do SBE may be more health conscious and, therefore, more likely to follow mammogram recommendations even if they are persuaded not to bother with SBE. Nevertheless, this possibility has to be carefully considered.

The Canadian Task Force, as well as the US Preventive Services Task Force, are not enthusiastic about SBE, but do advocate an annual clinical breast examination for all women ages 50 to 69 by a health care provider (doctor, nurse). Yet, annual clinical examination has never been adequately evaluated as an independent technique. Its use is as unsettled as SBE. It is difficult to understand the enthusiasm for the inadequately documented clinical examination. If they are unenthusiastic about SBE, they should be equally unenthusiastic about the annual clinical examination.

Bottom line: Healthful Life has sees no reason to change our recommendation. We continue to believe women should do SBE starting at age 30 and have annual mammograms (not every other year) starting at age 40 and continuing throughout their lives.