July 22, 2008 -- A report last week by a panel of experts evaluating the pros and cons of breast self-examination and clinical breast examination by a trained practitioner stirred up a lot of controversy.
Wonderfully angry responses by women (and their men for that matter) fueled the controversy, arguing that it is absurd to tell women not to examine their breasts. Many of these women found their breast cancers as a result of their own breast exams.
So what is the fuss? A group of experts convened to assess the evidence for the pros and cons of both breast self-exam and clinical breast examination by a trained practitioner. After reviewing two large randomized controlled studies from China and Russia, they concluded that women assigned to do regular breast self-examinations were almost twice as likely to undergo a biopsy of the breast than women in the control group. They found no difference in the number of cancers diagnosed overall.
The researchers found only one large population-based clinical trial evaluating the effectiveness of a clinical breast examination by trained practitioners. This study was ended early, and there were no conclusions because of poor compliance with followup. I am curious to know more about this study and how much better (or worse, according to this panel of experts) doctors perform than women in finding subtle but potentially serious breast changes.
It is interesting to me that no one picked up on this part of the study. I doubt anyone would suggest that clinical breast examination by a practitioner may also be harmful and could lead to more unnecessary biopsies.
Think about this for a minute. Women in the self-exam group knew they were part of a study that was "testing" or "grading" their ability to find possible breast cancers early. It stands to reason that these women would have been extra vigilant as a result and may have reported findings or concerns that they would not have otherwise mentioned to a physician had they not been enrolled in a study.
On the other hand, women in the study were presumably only advised to have breast biopsies after they were first evaluated by a clinician who agreed to proceed with a biopsy based on the expert's clinical judgment. Or is this a problem with the study? Perhaps women underwent biopsy in the self-examination group primarily because of the women's findings, regardless of clinician input?
This is hardly how things usually work in the real world. Rarely do doctors perform breast biopsies solely because of a woman's complaint without a clinician evaluation and recommendation.
Women in the control group likely also examined their breasts, too. Most women are aware of their bodies and fear breast cancer. These control women, however, were not being graded on their breast exam findings, and it is likely they only volunteered concerns that they felt were of importance. Perhaps they didn't report every subtle change and therefore underwent fewer "unnecessary" biopsies.
I find it ironic that more often than not when it comes to the diagnosis of breast cancer, doctors are criticized (and often sued for malpractice) because they don't take a woman's complaint seriously enough to proceed to biopsy.
In this study, did doctors go overboard and recommend too many biopsies without using their clinical judgment because the women were part of a study testing the accuracy of breast self-exam? Women want to be partners with their doctors -- not sole participants -- in decisions about their care.
A problem with a study evaluating the self-breast examination as a screening test is that a woman's breast examination is a highly subjective, variable, personal and emotionally charged. It should not have been judged as a screening test in the first place. What other screening test recommended today relies on the subjective assessment of the patient?
We recommend that young men examine their testicles for cancer, but this has reasonably never been subjected to the same scrutiny as breast self-exam in women. Fortunately for men, testicular cancer is much less common than breast cancer, yet it is considered good advice to teach a young man to examine his testicles and report any changes or concerns.
A man's testicles are much easier to examine than a woman's breasts. Our breasts undergo continuous change each month with fluctuations in our hormones, medications, diet, and body weight. Who knows our own breasts better including all the cyclic changes that go with it than a woman (or her partner)?
Women see their practitioners on a regular basis to screen for cervical cancer with one of the best screening tests we have -- the Pap test. The Pap test however also leads to many false positive and false negative results and follow-up procedures, but it has helped reduce the risk of cervical cancer death in this country by 75 percent. With the addition of the HPV test for women ages 30 and over, a negative result of both the Pap test and HPV test can now give you much greater peace of mind.
At the same time they undergo the Pap test (and HPV test if 30 and over), women also have a clinical breast exam with their practitioners. I suspect that this yearly exam of the breast is not nearly as important as a woman's vigilance in knowing her breasts and reporting any changes, but no one would suggest doctors stop performing this annual part of the exam because it may lead to more biopsies.
I fear the study conclusions will send the wrong message to women. My understanding is that many, if not most, women today who are ultimately diagnosed with breast cancer first found their lumps or changes before a clinical breast exam with their doctors. Often women find cancers that are rapidly growing and that didn't show up on their last mammogram. These women may truly have saved their own lives through breast examination and having the confidence to speak up.
The study also didn't evaluate whether some cancers were detected earlier by breast self-exam than others. For example, lobular cancers, which are on the rise, often cause few if any calcifications or other changes on mammogram. Some of these women can feel subtle changes in their breasts long before the cancer is diagnosed by mammogram.
I remember a number of my female patients waiting for me to complete my breast exam before concurring that they too found the "lump" that I discovered on exam; they were just hoping and praying that I didn't find it. It was almost as if they believed that if the doctor didn't find it, then it wasn't serious or important enough to report.
I can only be thankful that my patients were comfortable enough with me to share their concerns in the end. As physicians, we want to continue to urge our patients to be fully involved partners in their care. We must never minimize or trivialize a woman's concerns about her breasts.
It is simply absurd and outrageous to suggest women should not examine their breasts because it will do more harm than good. After reading this report, some may conclude it is better that women remain in the dark about their bodies and rely on only technology and clinicians to take care of them. Ridiculous! I also fear women will now report fewer breast complaints to their doctors, fearing they will be a squeaky wheel or appear to be "crying wolf." Some women may fear unnecessary biopsy and simply rely on their physician to find their problems.
How did you react to the news about breast exams? Are you afraid to examine your breasts? Have you found your own breast cancer before your physician? Did a mammogram miss your breast cancer? What do you think women should be advised about self-breast exams?
As always, I welcome your questions and comments.