Cancer Society Downplays Self-Exam

Women who are concerned about their breast health are scratching their heads about a startling change in breast cancer screening guidelines.

The American Cancer Society (ACS) amended its breast-cancer screening map for women and their doctors. Mammograms, although not perfect, are still the best things you can do to screen for the disease.

But those monthly self-exams that women have been urged for generations to do may not be as necessary as you think.

"With self-exams, there is very little evidence that there is any sort of advantage above and beyond self-awareness and mammograms," says Debbie Saslow, Ph.D., director of breast and gynecologic cancers for ACS.

The ACS is not saying women should skip self-exams, which are part of knowing your own body. Just don't think of self-exams as being just as good or better than seeing your doctor, knowing your body's landscape and getting routine mammograms. These exams have not proven to save a woman's life. However, many women do find breast lumps that are cancer.

"We want to downgrade both the sense of importance of BSE and the reliance on self exams. We encourage self-awareness and regular mammograms," Saslow says. "We certainly do not want to discourage women from doing self-exams if they choose to, but we don't want women to see this as a life-saving screening. Women who don't do BSE shouldn't feel badly."

Not a substitute

Saslow explains these changes were done because not enough strong data showed that BSE helped with early detection. Also, some women might be relying too heavily on self-exams to pick up on possible cancers, even substituting such exams for mammograms and doctor visits. However, mammograms, which are more sensitive, can detect tumors years before a lump can be felt.

The ACS and other organizations such as the United States Prevention Services Task Force conclude getting regular mammograms and clinical exams by their doctors are the most important screenings for early detection.

"The woman should know what her breast feels like. You can become self aware through bathing and dressing, and by looking at yourself in the mirror when you step out of the shower every day," she says.

At the core of ACS' recommendations is a major study in China about the effectiveness of self-exams. Researchers trained 133,000 women to do self-exams. Another 133,000 got routine medical care without self-exam instructions. No one had access to mammograms.

The intensive instruction for breast self-exams did not reduce death rates from breast cancer, according to the study. Although the women who were trained were much better at doing the exams, the study did not show these women lived longer or died less often.

Breast cancer deaths in the United States and Europe have declined 20 percent in the past 10 years. But it is not exactly clear why, and the answer involves progress in early detection, treatment and self-awareness. Have we gotten better in our treatments and procedures? Or have we improved in our catching the disease early? And what is the role of self-exams?

"Mixed message"

"The guidelines send a mixed message," says Michael Torosian, M.D., clinical director of Breast Surgery Research at Fox Chase Cancer Center in Philadelphia. A physician is urged to tell a woman starting at age 20 about doing monthly exams, the limitations of breast self exams and to report any changes to her doctor immediately. But a woman is also told it's acceptable not to do them at all or do them occasionally.

"In practices like mine, we see many patients who pick up their own cancers," he says, noting that the Chinese study is not enough evidence.

Saslow says the message is not at all mixed. "Women need to be informed about what we know but also what we don't know. Today the scientific evidence is not strong enough to say that monthly BSE offers an advantage over simply having a heightened sense of awareness. Yes, a significant percentage of women find their own breast cancers, but the evidence suggests that most are not found while doing BSE. Furthermore, while mammography will miss a small percentage of breast cancers, many women who find their own cancers also haven't been getting regular mammograms."

Another study, considered one of the largest and most rigorous to examine the benefits of routine mammograms, found women getting routine mammograms reduced their risk of dying by 44 percent. The study in the British medical journal, The Lancet, focused on 210,000 Swedish women ages 20 to 69.

Mammograms improving

Mammogram technology has improved in the past 20 years, picking up much smaller tumors, says Robert Smith, Ph.D., director of cancer screening for ACS and co-author of the Swedish study. Such small tumors are rarely found through self-exams.

"Catching them early is the name of the game," he says. "Any surgeon or oncologist will tell you that they would prefer to treat breast cancer early."

Victor G. Vogel, M.D., director of the Magee/University of Pittsburgh Cancer Institute Comprehensive Breast Program, discounts self-exams entirely.

He says self-exams are more likely to lead to unnecessary biopsies and procedures, creating an emotional storm and a financial burden to the health care system and women. Women often cannot feel the difference between benign and malignant tumors. Such physical exams should be performed annually by a trained health care provider, he says.

"Should you do something that is of no proven benefit?" Vogel says. "We don't ride horses anymore because they are slow and inefficient. So why keep doing something that doesn't work? Mammograms are really what we need to be stressing instead."

Only one-quarter of all biopsies are cancerous. Mammograms find 80 percent of cancers, according to the National Cancer Institute. But X-rays, too, are flawed. In a majority of cases in which something is detected, biopsies show the growth is benign.

Still a benefit

Vladimir Lange, M.D., president of the breast cancer education company Lange Productions and a board member of the Women's Information Network Against Breast Cancer organization, says while self exams may not actually extend lives any better than mammography, these exams still offer a benefit as an adjunct screening.

He found a lump in his wife's breast when she was 42. The cancerous lump was missed several times by mammograms. However, younger women have denser breast tissue. The guidelines still urge women to start annual mammograms at age 40.

Every woman's body is different, and every tumor is different, he says. In rare cases, tumors can be extremely fast growing.

"If I had a 25 percent chance of finding a cancer, I would want to have that biopsy. That's a high number," he says. "Nobody will complain about a benign tumor being biopsied if it gives a woman some relief in knowing what it is."

Although the Susan G. Komen Breast Cancer Foundation agrees with the recommendations on screening issued by ACS, it does not support the de-emphasis on self-exams.

"Some women are yelling at the top of their lungs about this," says Cheryl Kidd, director of education. "We have always advised women to be aware of the look and feel of their breasts. We want women to take control of their lives and feel empowered by knowing their own body and reporting any changes to the doctor."

Breast cancer is the second most common cancer in American women and the second leading cause of cancer deaths. The ACS estimates more than 214,600 women will get breast cancer this year, and nearly 41,430 will die from it. The ACS recommends women 40 and older get an annual mammogram and clinical breast exam to help detect tumors in the early stage, when they are easier to treat.

Related Articles Many Women Skipping Breast Exams The Importance of Screening

External Sources Thomas DB, Li Gao D, Ray RM, et al. Randomized Trial of Breast Self-Examination in Shanghai: Final Results. The Journal of the National Cancer Institute: 94:19:1445-1457, October 2, 2002. Tabar L, Yen M, Bedrich V, et al. Mammography Service Screening and Mortality in Breast Cancer Patients: 20-Year Follow-up before and After Introduction of Screening, The Lancet: 361:1405-1410, April 26, 2003. National Cancer Institute. Smith RA, Saslow D, Sawyer KA, et al. American Cancer Society Guidelines for Breast Cancer Screening: Update 2003. CA Cancer J Clin. 2003; 53:141-169. Fox Chase Cancer Center. Susan G. Komen Breast Cancer Foundation. Women's Information Network Against Breast Cancer. Dollinger M, Rosenbaum, EH, Tempero M., et al. Everyone's Guide to Cancer Therapy, Fourth Edition, Kansas City, Missouri: Andrews McMeel Publishing, 2002.

This article was reviewed and updated June 2007.

Search