Breast self-examination: Is it useless, or best cancer detection method?

Study says women — not providers — find most cancerous lumps

The spate of recent challenges to breast cancer detection techniques is enough to make even the most professional women’s health center managers tear their hair out. Now a study published in the Journal of the National Cancer Institute may cause more confusion : Study investigators failed to find differences in mortality between women who did practice breast self-examination and those who did not.1

Women’s health professionals say news of the study may discourage women from performing self-exams, even though anecdotal clinical evidence in the United States shows that breast self-exams are effective in preventing cancer.

The controversial study, conducted in Shanghai, China, from 1989 through 1991, randomly placed 267,040 women in two groups. One was trained to do breast self-exam, while the control group received instruction in alleviating low back pain. The women’s ages ranged from 31 to 64. Neither group experienced a drop in breast cancer deaths. Further, the trained group detected malignant tumors no earlier than the control group.

Though the study’s authors call the findings preliminary, noting that breast tumors take several years to grow large enough to feel by hand, the report raises concerns among women’s health providers. They fear it could stymie the hard-won gains of breast cancer education campaigns. Also, the cultural differences between Chinese and American women raise doubts about the applicability of such a study to health practices in the United States.

"It’s tough for people to know what to trust and believe in," asserts Cindy Dreher, MPH, MAT, director of women’s programs for Baptist Medical Center in Columbia, SC. "These studies make our jobs a lot tougher. We’ll be telling our women to be careful about taking [this] one study and thinking it’s the gospel."

The curious paradox between the Chinese study and the daily experiences of women’s health providers raises a troubling point. Because women find most cancerous tumors themselves, a massive amount of teaching goes on in women’s health facilities to empower them to follow the changes in their breasts.

"That could change if women no longer take breast self-exams seriously," says Alice MacMahon, RN, MPH, director of the Florida Hospital Women’s Center in Orlando. With each of the 20,000 mammograms performed at the hospital’s 50 sites each year, women receive step-by-step instruction or at least a review of self-exams.

MacMahon’s facility is in step with the others represented by the providers who spoke with Women’s Health Center Management, including Pippa Nicholson-Kuenn, BSN, MS, director of cancer services and women’s services at Sacred Heart Health Systems’ Ann Baroco Center for Women’s Health in Pensacola, FL. In fact, Nicholson-Kuenn recently made a successful budgetary proposal to keep one nurse on staff to teach self-exams. She regards the teaching as early detection insurance because, "We just find 10% of the cancers through clinical breast exams. Our patients or their partners find the majority of the lumps." Nicholson-Kuenn adds that even clinical breast exams pick up tumors earlier than mammography.

Not wanting to diminish the benefits of mammography, Dreher still argues that it does miss 15% of malignant tumors. That’s where breast self-exam is critical.

"Eighty percent of lumps are found by women themselves, and some of them are under the arm where mammograms can’t take images," Dreher says. "In our one-to-one teaching, we show women how to examine the tissue under their arms for lumps."

Everyone in women’s health wants the search for a foolproof detection or prevention tool to proceed until we triumph by eliminating breast cancer. The providers with whom WHCM spoke concede that the search will involve puzzling studies such as the Chinese trials. They further agree that the path to the ultimate goal will be strewn with new studies as unsettling as this one. With that in mind, most of them are taking a watch-and-wait stance, and they’ll encourage their patients to follow suit.

"Everyone’s looking for the magic potion," Dreher explains, "but the best thing we have at this time are the preventive habits that we’ve used for years."

Knowing that definitive answers to breast cancer might be a long time coming, women’s health providers apply the available tools as wisely as they know how.

"I’m not sold that breast self-exam is our best early detection method," says Brenda Monroe, MSN, clinical nurse specialist at St. John’s Breast Center in Springfield, MO. "I think mammography is better. But breast self-exam should not be ditched at this time. At our facility, we’ll continue the three-pronged approach of self-exam, clinical exam, and mammography."

If women interpret the study as a reason to drop breast self-exam or not to start it in the first place, they won’t find reinforcement even among the investigators. They write that their preliminary findings are insufficient evidence on which to recommend for or against breast self-exam.

Women who are afraid of what they’ll find or those who are uncomfortable in examining their own breasts might use the report to dismiss self-exam as a good health practice, suspects Monroe. "Women’s health professionals need to help their clients evaluate studies like this," she says. "I’m going to tell my patients, ‘Keep examining your breasts every month, and let’s see what happens with this in the next year, or five years.’"

Ethnic considerations

Not the least among questions this study raises is its validity across ethnic and cultural lines. Monroe believes there are too many differences between Chinese women and the women in her Midwestern community for any health-conscious woman to discard the breast self-exam practice.

"We are comparing apples to kumquats, and it’s dangerous to tell women they no longer need to practice self-exam on the basis of that study," she says. "It would need to be replicated worldwide before we could safely drop breast self-exam."

The breast self-exam habit is about more than lowering the breast cancer death rate in a five-year period. It’s a process by which women tune in to their bodies so they can be alert to changes. Nicholson-Kuenn points out that her nurses don’t teach women just to look for lumps.

"We teach them to feel the difference between rubbery lumps and solid lumps," she says.

The guideline they stress is "rubbery is all right, solid means call us." To make such distinctions, women have to be familiar with the landscapes of their own breasts.

Dropping self-exam erodes empowerment

Women’s health providers claim partial credit for gains in the quality of women’s health care in recent years, but those who commented on the Shanghai study assert that women are responsible for the rest. The gains will vanish if women fail to act as educated health care consumers. Knowing one’s body is power, Dreher explains. "We can’t ever give women enough of the power of information."

Those women who want to be in touch with their bodies, Monroe says, "are not about to drop breast self-exam any more than they’re going to stop weighing themselves or checking their skin [for suspicious changes in moles] or whatever they do to monitor their health."

Women who don’t take control of their health are most vulnerable to misconstruing the message of studies like this, Monroe says. Believing that breast self-exam is useless bolsters their tendency to assume everything’s all right until a crisis hits.

"That’s why studies like this make our jobs tough, but they keep us on our toes," constantly reminding women’s health professionals to renew educational efforts, Dreher says. "We could lose the gains we’ve made if we don’t help women interpret these findings in the light they were intended."

Reference

1. Thomas DB, Gao DL, Self SG, et al. Randomized trial of breast self-examination in Shanghai: Methodology and preliminary results. J National Cancer Institute 1997; 89: 355-365.