Breast Self-Exams: The Controversy and the Evidence
Goldstein, MK, Ph.D., Mehn, MA, Ph.D., Pennypacker, HS, Ph.D.
MammaCare Foundation

A U.S. government agency, The United States Preventive Services Task Force (USPSTF), recommends that women should not be taught, or learn, how to examine their breasts.*  Without explanation, this agency periodically recycles their "official" position, followed uncritically by press coverage, ignoring a considerable body of contradictory scientific evidence.
 
This "official" position against teaching women was based on a review of trials conducted in the 1980s and '90s in Russia and China.  Although challenged by contemporary evidence that breast self-exams (BSE) discover a large proportion of breast cancers, most current press reports continue to simply reiterate or paraphrase the position of the agency.  

One chilling result affecting millions of women is the notable reversal by numerous private and public agencies whose mission is to advise women on best practices.  Despite contrary evidence these prominent organizations dropped their support for BSE in deference to USPSTF's periodic press releases repeating their opposition to teaching women to examine their breasts.

While there are valid concerns over breast exams performed without skill, it is troubling that the agency failed to report that women find a significant proportion of breast cancers. Moreover, even within the studies on which their recommendation to avoid teaching women BSE is based, the agency ignored significant, positive, contradictory findings.

Pronouncements by the USPTF receive wide national coverage as they should, when accurate. But such sweeping recommendations require, at least, critical analysis of; the supporting evidence, the contradictory evidence and the current evidence. In this critical matter affecting women, the agency's recommendations fail to comply with these elementary criteria.    

For example, in the Russian study, one of two primary studies used by USPSTF to support their conclusions, was never completed. Additionally, both the Shanghai and Russian reports contained positive breast cancer detection results. Also the USPSTF did not disclose, and the public is was not made aware, that the “Russian” study found that more breast cancers were detected in the group that performed breast self-exams than in the group that did not perform self-exams:

More troubling is the agency's failure to report findings that a scientifically validated method exists for women and clinicians to learn to perform proficient breast exams. Using tactually accurate breast models and self-exam training procedures developed with the support NCI and published by a biomedical research team at the University of Florida, the Shanghai study authors reported significant improvement in Chinese factory workers detection skills and reduced false positive detections:

 The authors stated that immediately after training, “women consistently found a higher proportion of simulated cancers including those that were more difficult to feel (hidden, 3mm, soft, and deeply placed)” (p. 1450).  They also observed that women who received the breast model training were significantly less likely to falsely report finding one or more lumps that were not there (p< .001). 6

The Shanghai protocol revealed another important but unexpected finding, also unreported by USPSTF.  One of the critical training procedures employed by the researchers diminished the women’s ability to perform the most effective breast examinations.  Women were taught a search pattern known to be substantially less effective.  The Shanghai researchers taught women to examine in a circular pattern, a method reported in published research studies to be significantly inferior to the “vertical strip” pattern of examination in detecting all small lesions. 7

It should be noted that a report on breast self-examination by Dr. Suzanne Fletcher and her colleagues found that women who were provided with continuous access to practice with tactually accurate breast models containing normal breast nodularity and small simulated cancers retained superior detection skills after a year. The Shanghai study group initially adopted this procedure but apparently discontinued it after its introductory success as the project lacked funds to provide the practice models to the women. 8

It is also scientifically inadvisable to assume that self-reports of unobserved events such as the private performance of breast self- examination conducted over a 5 or 10-year period represents a valid analysis of the effect. The practice of breast self-examination is an  undocumented, private matter. The authors of the Shanghai study could not have known or confirmed what was performed outside of their limited contact with the subjects. To draw accurate conclusions about the effect of any practice on mortality requires confirmation that the practice or treatment was performed and done so in the manner proscribed. Evidence of compliance can be readily accomplished when administering a pharmaceutical or surgical intervention, but is not dependable from self-reports. The USPSTF should have known and should have reported that the practices they assumed affected mortality must be viewed with greater scientific and clinical caution than could have been exercised in this protocol. 

It is also doubtful that the Russian and Shanghai data represent the case for women in the West. The contemporary medical infrastructure available to Western women who detect a suspicious lesion in their breast is considerably advanced over that in China and in Russia, two to three decades ago.  Further, advances in and availability of numerous adjuvant treatments and re-treatments have a substantial positive effect on mortality from self-detected breast cancers, and these interventions were not available to Chinese and Russian women decades ago.

There are more recent reports from China and elsewhere  finding that a majority or large proportion of breast cancers are first detected by women themselves. The USPSTF also omitted several landmark U.S. and Western European studies that found self-exams account for a substantial proportion of breast cancers detected and that self-examinaion is associated with survival:  Breast self-examination results from 89,000 women .;Breast self-examination and survival from breast cancer  ;Breast self-examination practices and survival 1-5

Insurance organizations report that women who detect and present with a palpable solid lesion are often not evaluated further because the clinician could not palpate the mass and/or advised against further evaluation.  Reports from The Doctors Company and the Physicians Insurers Association of America (PIAA), confirm that cancers, palpated and reported by women are too often disregarded with the result that the largest number of successful lawsuits in medicine are related to such events. 9

It should be noted that the National Cancer Institute began to address the scientific issues surrounding breast self-examination in the early 1980s by inaugurating and funding a series of research studies documenting the detection thresholds and performance skills required to  distect small breast cancers. This led to a well-published and replicated body of evidence describing the optimal methods to achieve breast examination proficiency. The resulting quality-standards are readily learned for performing proficient clinical and self-breast examinations. 10

It is well established that a large proportion of women accidentally detect their own breast cancers, and that the resulting cancers are often larger, 3cm on average, than can be found after training, <.5cm. The series of investigations mentioned above demonstrate that palpation can reliably detect small breast lesions. This knowledge can assist American women by reducing anxiety and the sense of inadequacy that accompanies inadequate or inaccurate information about the utiliy of well performed self-exams and clinical exams.

To summarize, the cumulative and current biomedical evidence suggests that women should not avoid learning how to perform proficient breast self-examinations despite contrary advice from the USPSTF. Evidence confirms that a large proportion of breast cancers are palpable, that a substantial proportion are self-detected, that many breast cancers are mammographically invisible particularly in younger women and women with dense breast tissue, that the components of effective breast self-examination are known and well validated, that the skill can be learned and that women who learn and practice proficient breast examination possess an advantage in protecting their health and their lives. 11

References

1. Kösters JP, Gøtzsche PC. (2003). Regular self-examination or clinical examination for early detection of breast cancer. Cochrane Database of Systematic Reviews (2).
2. Lam, W.W., Chan, C.P., Chan, C.F., Mak, C.C., Chong, K.W. & Leung, M.H. (2008). Factors affecting the palpability of breast lesion by self-examination. Singapore Medical Journal, 49(3), 228-32.  Retrieved from  http://www.biowizard.com/pmabstract.php?pmid=18363005
3. Locker, A.P., Caseldine, J., Mitchell, A.K., Blamey, R.W., Roebuck, E.J., Elston, C.W. (1989). Results from a seven-year programme of breast self-examination in 89,010 women. British Journal of Cancer, 60(3), 401-5. Retrieved from www.ncbi.nlm.nih.gov/pubmed/2789950?dopt=Abstract
4. Huguley, C.M. Jr, Brown, R.L., Greenberg, R.S., Clark, W.S. (1988). Breast self-examination and survival from breast cancer. Cancer, 62(7), 1389-96. Retrieved from www.ncbi.nlm.nih.gov/pubmed/3416278?dopt=Abstract
5. Foster, R.S. Jr, Costanza, M.C. (1984). Breast self-examination practices and breast cancer survival. Cancer, 53(4), 999-1005. Retrieved from www.ncbi.nlm.nih.gov/pubmed/6692297?dopt=Abstract
6. Thomas, D.B., Gao, D.L., Ray, R.M., Wang, W.W., Allison, C.J., Chen, F.L. (2002). Randomized trial of breast self-examination in Shanghai: final results. Journal of the National Cancer Institute, 94(19), 1445-57.  Retrieved from http://jnci.oxfordjournals.org/cgi/reprint/94/19/1445
7. Saunders, K.J., Pilgrim, C.A., Pennypacker, H.S. (1986). Increased proficiency of search in breast self-examination. Cancer, 58(11), 2531-7. Retrieved from www.ncbi.nlm.nih.gov/pubmed/3768844?ordinalpos=8&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
8. Fletcher, S.W., O'Malley, M.S., Earp, J.L., Morgan, T.M., Lin, S., Degnan, D. (1990). How best to teach women breast self-examination. A randomized controlled trial. Annals of Internal Medicine, 112(10), 772-9. Retrieved from www.ncbi.nlm.nih.gov/pubmed/2184711?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
9. Anderson, R.E. (2001). Getting Sued for Breast Cancer. The Doctor’s Advocate. Retrieved from http://www.thedoctors.com/KnowledgeCenter/PatientSafety/articles/CON_ID_001568
10. MammaCare. (n.d.). In Google Scholar.  Retrieved from http://scholar.google.com/scholar?q=mammacare&hl=en&btnG=Search&as_sdt=40001&as_sdtp=on
11. A significant number of women present with palpable breast cancer even with a normal mammogram within 1 year.  Am J Surg. 2010 Dec;200(6):712-7; discussion 717-8
    Haakinson DJ, Stucky CC, Dueck AC, Gray RJ, Wasif N, Apsey HA, Pockaj B.

Additional Recent References (underlining added)

Self-Detection Remains a Key Method of Breast Cancer Detection for U.S. Women. Roth MY, Elmore JG, Yi-Frazier JP, Reisch LM, Oster NV, Miglioretti DL. J Womens Health (Larchmt). 2011 Jun 15. [Epub ahead of print] Department of Internal Medicine, University of Washington School of Medicine , Seattle, Washington.

Abstract Purpose: The method by which breast cancer is detected becomes a factor for long-term survival and should be considered in treatment plans. This report describes patient characteristics and time trends for various methods of breast cancer detection in the United States. Methods: The 2003 National Health Interview Survey (NHIS), a nationally representative self-report health survey, included 361 women survivors diagnosed with breast cancer between 1980 and 2003. Responses to the question, How was your breast cancer found? were categorized as accident, self-examination, physician during routine breast examination, mammogram, and other. We examined responses by income, race, age, and year of diagnosis. Results: Most women survivors (57%) reported a detection method other than mammographic examination. Women often detected breast cancers themselves, either by self-examination (25%) or by accident (18%). Conclusions: Despite increased use of screening mammography, a large percentage of breast cancers are detected by the patients themselves. Patient-noted breast abnormalities should be carefully evaluated.

A significant number of women present with palpable breast cancer even with a normal mammogram within 1 year.  Am J. Surg 2010 Dec;200(6):712-7. Haakinson DJ, Stucky CC, Dueck AC, Gray RJ, Wasif N, Apsey HA, Pockaj B  Conclusion: A significant number of women present with palpable breast cancer within 1 year of a normal mammogram, many with an aggressive cancer. Therefore, we continue to advocate SBE and CBE for breast cancer screening. http://www.ncbi.nlm.nih.gov/pubmed/21146009

Diagnosis of breast cancer in women age 40 and younger: delays in diagnosis result from underuse of genetic testing and breast imaging.  Am J Surg. 2009 Oct;198(4):538-43. Samphao S., Wheeler AJ, Rafferty E, Michaelson JS, Sprecht MC, Gadd MA,, Hughes KS, Smith BL 

  BACKGROUND: The impact of newer breast imaging technologies and genetic testing on the detection of breast cancer in women age 40 and younger remains unknown. METHODS: A records review identified 628 women age 40 and younger diagnosed with breast cancer from 1996 to 2008. Patient and tumor characteristics, means of diagnosis, imaging results, and genetic testing were examined. RESULTS: Tumors were first detected by self-examination in 71%, with a median invasive tumor size of 2.0 cm. Imaging performed at or after diagnosis visualized most tumors; mammography visualized 86%, magnetic resonance imaging (MRI) visualized 96%, and mammography plus MRI visualized more than 98% of tumors. For 81% of patients, the mammogram at diagnosis was their first mammogram. Although 50% had a family history of breast or ovarian cancer, few underwent genetic testing before their cancer diagnosis; 61 of 247 (25%) ultimately tested had a BRCA mutation. CONCLUSIONS: Better use of genetic testing, mammography, and MRI could improve breast cancer detection in young women.  

Method of detection of new contralateral primary breast cancer in younger versus older women. Robinson, A. Speers, C, Olivotto, I, Chia, S. Clin Breast Cancer. 2007 Aug;7(9):705-9.

 BACKGROUND: Surveillance for contralateral primary breast cancer after a diagnosis of unilateral breast cancer typically consists of yearly mammography and physical examinations at 3-6 month intervals. Mammography is known to be less sensitive in younger, dense breasts. It is unknown at this time how well mammography performs in young patients to detect a new contralateral primary breast cancer.
PATIENTS AND METHODS: Patients with contralateral breast cancer diagnosed between 1980 and 2004 were identified from the British Columbia Cancer Agency's Breast Cancer Outcomes Unit database in Vancouver. Characteristics of the tumor at baseline and the contralateral tumor were recorded as well as the method of detection of the contralateral breast cancer. A subset of patients was identified based on the age at which they were diagnosed with their initial primary cancer: < 40 years (group A) and 55-59 years (group B). chi2 and independent-sample t tests were used for between-group comparisons. RESULTS: Older patients were significantly more likely to have their second primary tumor detected by routine follow-up mammography compared with the younger cohort (P < 0.001). Older patients were also more likely to have estrogen receptor-positive, lower grade second primary tumors, and there was a trend toward smaller tumors. Tumors detected by mammography were more likely to be lower grade, estrogen receptor positive, and smaller.
CONCLUSION: Older patients were more likely to have a contralateral breast cancer detected by conventional mammography, whereas younger patients tended to have cancer detected by physical examinations or by self-diagnosis. Better imaging techniques are required to detect new contralateral primary breast cancer in younger patients.

Recent trends in breast cancer among younger women in the United States. Brinton, Louise A.; Sherman, Mark E.; Carreon, J. Daniel; Anderson, William F. J Natl Cancer Inst. 2008 Nov 19;100(22):1643-8. Epub 2008 Nov 11.

Division of Cancer Epidemiology and Genetics, Hormonal and Reproductive Epidemiology Branch, National Cancer Institute, Bethesda, MD 20852-7234, USA. brinton@nih.gov

Increases in the incidence of postmenopausal breast cancers have been linked to screening and menopausal hormone use, but younger women have received less attention. Thus, we analyzed trends in breast cancer incidence (N = 387 231) using the National Cancer Institute's Surveillance, Epidemiology, and End Results Program 13-Registry database (1992-2004). Whites had higher incidence rates than blacks after age 40 years, but the reverse was true among younger women (black-white crossover). Among younger women, the rate per 100,000 woman-years was 16.8 for black vs. 15.1 for white women; the highest black-white incidence rate ratio (IRR) was seen among women younger than 30 years (IRR = 1.52, 95% confidence interval = 1.34 to 1.73). This risk pattern was not observed in other ethnic groups. The black-white crossover among younger women was largely restricted to breast cancers with favorable tumor characteristics. The annual percentage change in the incidence of invasive breast cancers decreased modestly among older women but increased among younger (<40 years) white women. Continued surveillance of trends is needed, particularly for molecular subtypes that preferentially occur among young women.

Breast self-examination training and counseling as motivation strategies for breast awareness and participation in breast cancer screening programs. Journal of Clinical Oncology (2006). Proceedings Part I. Vol 24, No. 18S (June 20 Supplement), 2006: 1027 A. Artmann, M. Heyne, M. Kiechle, N. Harbeck

 In Germany, the participation rate in gynecologic cancer and the Bavarian breast cancer-screening program is only about 30%. Therefore, the impact of counseling and raising confidence in breast self examination (BSE) by a structured BSE training on breast awareness, acceptance of screening offer, and participation rate was evaluated. For evaluation of the training quality, specified MammaCare data sheets and questionnaires were used. Method: Since 2003, 167 women (mean age 35 y; range 19-65 y; 61% >40 y) got intensive breast cancer counseling and were professionally trained in MammaCare BSE; 41% had positive breast cancer family history. In their beginner's course, trainees got general BSE information, covering breast anatomy, breast symptoms, breast cancer screening and therapy. Participants practiced BSE, after training on tactually accurate silicone breast models with simulated lumps in order to discriminate normal nodularity from lumps. After 3 months, the supervision sessions included BSE evaluation and - again - professional instruction. In a model exam false positive and negative findings were documented. In breast exams, performance technique and breast tissue coverage were assessed. At both initial sessions and after 12 months, questionnaires on BSE practice, experience, and compliance, cancer worry, acceptance and participation at cancer screening programs were evaluated. Results: Breast cancer worry, anxiety, and lack of information were the main reasons for program participation. Within 3 months after the base course, mean decrease of breast cancer worry was about 95%. Participation in gynecologic and breast cancer screening (>40 y) more than doubled (94% and 86%). Even after 12 months, these numbers remain consistent. 80% of participants practice BSE monthly and 46% reported changes in lifestyle regarding nutrition and obesity. Conclusions: Our approach emphasizes importance of self-confidence and awareness for participation in cancer screening, also in women with breast cancer family history. Counseling, BSE re-evaluation and reinforcement are correlated with decreased breast cancer worry, a main barrier against participation in breast and gynecologic cancer screening.

*USPSTF Report: 

http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm