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NEWS & VIEWS |
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"There is considerable evidence suggesting a benefit to the use of BSE," says Robert Smith, PhD, director of cancer screening for the American Cancer Society (ACS).
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CMAJ Article Suggests BSE Not Useful |
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 TOP CMAJ Article Suggests BSE... Many Experts DisagreeACS Recommends Three-Part... |
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"We’re not trying to discourage women from being aware of their breasts and reporting any abnormality they find immediately to their doctors; those would be changes they find in dressing or bathing or during sexual relations," notes the study’s first author, Nancy Baxter, MD. "But what happens with BSE education is they don’t find those, they find benign lumps they wouldn’t find otherwise."
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Many Experts Disagree |
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TOPCMAJ Article Suggests BSE...Many Experts DisagreeACS Recommends Three-Part... |
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"Our view is that the recommendation [that BSE not be used or taught] is premature," says Larissa Nekhlyudov, MD, of Harvard Medical School’s department of ambulatory care and prevention. "The data they’re basing their recommendations on are still incomplete. Women should be taught how to perform BSE, and should discuss it with their doctors. However, they should also be aware of its limitations."
In their editorial, Nekhlyudov and co-author Suzanne W. Fletcher, MD, agree that clinical trials of BSE have not found that the practice influences breast cancer mortality. But they note several aspects of the trials that limit their relevance to the issue of BSE in North America:
Smith agrees that it is important to consider limitations of available data. He says, "Measuring the efficacy of BSE is extraordinarily difficult, and these challenges are magnified if you try to draw conclusions from countries with different underlying breast cancer rates, breast cancer awareness, and access to state of the art screening and treatment."
Smith asks, "Is the experimental group actually practicing BSE? Is the control group not examining their breasts? How do physicians respond to women’s report of a palpable mass? Is state-of-the-art treatment available? Most important, was the average size of diagnosed tumors in the population so large that a BSE intervention could be expected to measurably reduce tumor size through earlier detection? Finally, attempting to measure differences in the breast cancer death rate associated with BSE would likely require a study with 10 or more years of follow-up."
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ACS Recommends Three-Part Screening |
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TOPCMAJ Article Suggests BSE...Many Experts DisagreeACS Recommends Three-Part... |
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"Breast self-exam can help with early detection of the small number of breast cancers found in the under 40 age group," Smith says. "Although these women should have a clinical breast exam every three years, BSE can reasonably be expected to help detect some cancers that reach a palpable size during this interval. After 40, we should not expect much added benefit from BSE if compliance with mammography is high.
"As mammography utilization has increased during the past two decades, the percentage of breast cancers women find themselves has decreased," Smith notes. "But we do expect that BSE can provide a safety net for some women whose breast cancers weren’t picked up by their last mammogram or clinical breast exam."
The authors of the Canadian report raised the issue of harms associated with BSE, which include anxiety when doing the exam and diagnostic work-ups, including biopsies in some instances, for masses that are not cancerous. Smith admits that although false positives are a reality in any early detection program, the data are not that clear that BSE contributes to an excess of false positives.
"More to the point, research has shown that women understand that false positives are an inevitable part of a larger program to detect breast cancer early in order to save lives," Smith explains. "We should do whatever we can to reduce avoidable biopsies, but we should not presume on women’s behalf that these harms are intolerable in the context of the benefits of early detection."
"The bottom line is that early detection of breast cancer is better than later detection, and BSE most likely contributes to early detection," says Smith, "although in this day and age that contribution is likely less for women 40 and older than it was 10 or 20 years ago."
Nevertheless, "BSE is a prudent thing to do; it’s worth the time and effort to teach and to use," Smith summarizes. "There may be a better and more efficient way for providers to teach BSE and breast awareness, and perhaps, that should be revisited. At the same time, it’s important for clinicians to emphasize the limits of what can be accomplished through BSE, and the far greater importance of mammography and clinical breast examination."
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