New findings add to muddled message for effective breast cancer
detection
Self-awareness is the new catchword, a change from years of advice to
rigorously practice monthly self-exams.
By
Susan J. Landers, AMNews staff. Oct. 28, 2002.
Additional information
Washington -- Women may feel they are caught between a rock and a hard
place when it comes to identifying an adequate technique to detect breast
cancer early, and their physicians may need to help extricate them.
The value of mammography came under heightened scrutiny a year ago, and
now the benefit of breast self-exams is being questioned.
While the message is still conveyed in handouts and public service
announcements urging women to perform monthly breast exams, there has been
a low-key shift in medical opinion away from the worth of self-exams in
cutting breast cancer deaths.
The suggestion that women learn an admittedly difficult procedure and
carry it out faithfully at the same time each month has been supplanted,
say many experts, by a more general recommendation that women should
become well-acquainted with their bodies and report any change in their
breasts to their physicians.
The final word, at least for now, on breast self-exams was carried in a
study published Oct. 2 in the Journal of the National Cancer Institute.
The study, done in China by researchers from the Fred Hutchinson Cancer
Research Center in Seattle, found that "programs to encourage [breast
self-exams] in the absence of mammography would be unlikely to reduce
mortality from breast cancer."
Medicine has lowered its opinion of the value of breast self-exams.
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Half of the 266,000 women in the study were provided with intensive
instruction on properly conducting a self-exam, while the other half
served as a control group. During the 12-year study, there were 135 breast
cancer deaths in the group that received instruction and 131 in the
control group.
The study's publication coincided with the start of Breast Cancer
Awareness Month, subjecting women to conflicting statements on breast
self-exams. While handouts and public service announcements were
continuing to urge women to conduct monthly self-exams, news stories were
citing the study's findings that self-exams were not effective.
What should women be doing to improve their chances of surviving breast
cancer? That depends on whom you ask.
Changing tactics
The National Breast Cancer Coalition has concluded that there is no
adequate breast cancer screening option. The group believes that the
evidence for mammography screening is unclear, and there is no evidence
that breast self-exams save lives.
Most groups do not share the coalition's negative view of mammography
but have reached a similar conclusion about breast self-exams.
"I'd say that over the last five or more years, most major
organizations have taken some steps back from breast self-exams," said
Debbie Saslow, PhD, director of breast and gynecologic cancer at the
American Cancer Society.
Women older than 50 are still advised to have a yearly mammogram.
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"While only a couple of organizations have said, 'Don't bother doing
it,' most have moved their emphasis to self-awareness, rather than an
actual breast self-exam done every month and done a certain way," she
said.
Rachel Ballard-Barbash, MD, MPH, associate director of the applied
research program at the National Cancer Institute, would agree.
"We've never had any studies that indicate that breast self-exams in
and of themselves reduce mortality from breast cancer," she said.
But self-exams may still be a useful tool, she added. "We do know that
some breast cancers are picked up through breast self-exam, so there may
be some benefit to doing it."
The view that there may be some value to self-exams keeps them among
the American Cancer Society's three early detection recommendations, along
with mammography and a clinical breast exam, Dr. Saslow said.
And the study doesn't mean that women shouldn't pay attention to lumps
or be interested in changes in their breasts, noted Eric Winer, MD,
director of the breast oncology center at the Dana Farber Cancer
Institute. "What it does say is that a very routine monthly approach to
making sure one does a self-exam may not be a lot better than just being
aware of changes that occur in your body."
"My fear is that women will interpret the study as 'Oh, it doesn't
matter if I let my doctor know if I have a lump,' " Dr. Winer said.
"That's certainly not good sense at all."
Changes are under way on the Dana Farber Web site, Dr. Winer said, to
emphasize the need for women to monitor any changes and to report them to
their physicians.
Questions about the worth of self-exams are not nearly as painful as
those raised by the mammography controversy, Dr. Winer said. There are
much more data on mammography, he said, and the data are less
straightforward. "Mammography is also so entrenched in our culture," he
said. "Yet it remains unclear just how beneficial it is."
For now at least, Dana Farber continues to follow general
recommendations for women older than 50 to receive an annual mammogram and
for those 40 to 50 to discuss their individual situations with their
physicians.
Though uncertainty seems rampant in the world of breast cancer early
detection, that's not what troubles Cynthia Pearson, executive director of
the consumer group the National Women's Health Network. She believes that
women can sort through incomplete or inconclusive data.
"It's a different era," she said. "Women can handle a much more mixed
or complicated body of information." What worries her is that when women
finish sorting the available information, "there is nothing clear to see,"
she said.
"The [China] study showed that teaching women to do exams, reinforcing
it and checking to make sure they were doing it didn't save any lives,"
she said.
And the debate over mammograms pointed out that "whether mammography
helps or not, it doesn't help a whole heck of a lot," she added.
A shift in focus from early detection to more targeted treatment may be
the way to go, Pearson said. Now, it almost doesn't matter whether the
cancer found is aggressive or not because the treatment for most women is
the same: surgery, radiation and even drugs, she said.
"In the advocacy world, we are coming closer to an understanding that
early detection in and of itself is not the Holy Grail. It's early
detection with the ability to tell which cancers are dangerous," Pearson
said.
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ADDITIONAL INFORMATION:
Usefulness of breast self-exams
A trial conducted in Shanghai, China, during a 12-year period attempted
to determine whether a program of self-exams without screening mammography
would reduce women's death rate from breast cancer. Among the findings:
- Women who received instruction and conducted monthly self-exams had
no fewer deaths from breast cancer than women who did nothing.
- Costly public health campaigns to teach women the proper technique
for self-exam in countries where there is no program of screening
mammography is a waste of resources.
- Women who conducted self-exams found many more benign lumps, thus
adding the cost of the biopsies to the country's health expenses.
- Though not effective in developing countries, breast self-exams may
still be a helpful tool for women at high risk of breast cancer in
countries where there is also a program of screening mammography.
Source: Journal of the National Cancer Institute, Oct. 2
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Copyright 2002 American Medical Association. All
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