Breast Self Examination to Breast Awareness

Screening for Breast cancer involves various modalities and includes BSE, CBE, Mammography and MRI.

Recently work on Tomography and Proteomics is being carried out. However, none of these screening tests is 100% sensitive and specific in detecting breast cancer. Therefore, it is often recommended that a combination of these techniques be used in the screening process. Opinions vary as to which combinations of screening techniques are the most effective for identifying breast cancer. The BSE is the only procedure that medical clinicians teach their patients to perform. But, the effectiveness of BSE in detecting breast cancer has long been questioned; however, most providers cannot even entertain the idea that BSE may be unnecessary.

Screening for breast cancer with BSE aims at detecting breast cancer at an early, curable stage.

Also, BSE has been seen as an opportunity for women to self detect Breast masses that may develop between screening sessions. The idea of early detection started in the US in the early 20th century with educational mass campaigns where the message of 'do not delay' seeking medical help for a variety of cancer signs and symptoms was central. Although, first presented in 1933 by Adair as a tool in the early detection of Breast Cancer, and expounded on by Haagensen in 1952, studies evaluating the effectiveness of BSE were not published until late 1972. In the past 30 years, there has been a great deal of controversy about the necessity of teaching and performing BSE.

Three Clinical trials of teaching BSE have been analyzed and which have created furor are:

The nonrandomized United Kingdom Trial, The Russian Trial and The Shangai Trial . The risk of dying from breast cancer was remarkably consistent in these three trials and over the different follow up periods. The pooled RR was 1.01 with a narrow 95%CI (0.92-1.12; p=.79).The two randomized trials of mortality are unaffected by bias and both show no effect of BSE in breast cancer mortality. (RR=1.05; 95% CI=0.90-1.24; p=.54). Given that two randomized trials and one non randomized trial were based on approximately 580,000 women and 2,344 breast cancer deaths, the conclusions were considerably ROBUST: BSE is ineffective in saving lives.

Using data from the Breast Cancer Detection Demonstration Project, O’Malley and Flethcer estimated the sensitivity of BSE to be 26 % . Another estimate, assuming that all interval cases detected in the clinical trials assessed were detected by BSE (as opposed to chance detection), found an upper limit of sensitivity ranging from 12-25 % . Additionally, sensitivity has been demonstrated to be lower in older women , the group most likely to benefit from early detection of breast masses. As previously stated, BSE has been an appealing screening method because it has been considered inexpensive, self generated and generally without significant risk. Current evidence, however suggest that none of these are in fact true. The cost of performing BSE includes the cost of provider time for instruction and evaluation of false positives. An additional point to consider in the cost of teaching BSE is that the monies spent to promote BSE are potentially those that could be used for other preventive strategies of proven benefit. Further, with the limited number of caregivers and the time spent with patient is not unlimited, it is prudent to focus on those strategies in which evidence of benefit exists and in which benefit outweighs the risks. Evidence also suggests that false positive and over diagnosis are not only the issues but anxiety and fear in woman and the message it gives to the society are also of major concern. It is important to note that over the past several decades, there has been reduction in size of the lump that women identify themselves. Although, it is not clear that the practice of BSE has improved during this time but it is clear that women have greater appreciation or Awareness, now than they did before about the importance of a lump of any size.

NCCN panel experts in 1998 made BSE, an optional screening modality for all risk stratification.

In American Cancer Society breast Cancer Screening recommendations published in 2003, BSE is optional for women starting in the twenties. But Breast awareness is encouraged as women are encouraged to promptly report any new breast symptom to health care professionals. Not surprisingly, there was ardent opposition from Breast Cancer Advocacy and community organizations on this issue. Shortly, thereafter, The USPSTF updated their recommendation and took less controversial stance. It concluded that the evidence is insufficient to recommend for or against teaching or performing routine BSE. Again in its 2009 guidelines, the US Preventive Services Task Force (USPSTF) recommends against clinicians teaching women how to perform breast self-examination (BSE), stating that evidence suggests that teaching BSE does not reduce breast cancer mortality . The 2011 American College of Obstetricians and Gynecologists (ACOG) guidelines favor that all women be taught about breast self-awareness. ACOG is in favor of considering teaching high-risk women breast self-examination . In 2015, the American Cancer Society (ACS) released new guidelines for screening for women with average risk and does not favor the clinicians teaching BSE. Adding to the confusion came three studies done by Duke University (2009), Harvard (2009) and Mayo Clinic in Arizona (2012). In a recent study of Duke University, 146 high-risk women who were followed over a three year period, 47% on the cancers were first detected on BSE, and many of these cancers not even detected on screening mammograms. This study demonstrates the limitation of screening mammography in young women with dense breasts, and the value of doing regular BSE in addition to mammographic screening. A recent report from Harvard provides further support for the value of BSE in younger women. In the Harvard study, 71% of cancers detected in women 40 or younger were first detected by women doing BSE. Finally, a study published from the Mayo Clinic in Arizona review a series of 782 who were diagnosed with breast cancer. The study demonstrated that women under 50 year of age were more likely to present with a palpable breast lump than have their cancer detected on screening mammography . The study also found that in the group of women who did routine mammographic screening, two thirds of the cancers were found on the mammogram and one third first presented as breast lumps. The authors suggest that this study may have underestimated the percent of breast cancers presenting as lumps among women doing screening mammography because of the relatively small sample of young women in their study population. The authors conclude that until better imaging techniques become available BSE and clinical breast exam will continue to play an important role in breast cancer diagnosis. These 3 recent studies provide clear evidence that doing BSE in conjunction with mammographic screening provides an added layer of protection in early detection of breast cancers. The skeptics will continue to point out that there is still no scientific proof that doing BSE in conjunction with mammography reduces breast cancer mortality, and it is unlikely any study will be done in the near future that provides the proves the point one way or another.

So, literature identifies both positive and negative outcomes of BSE, which poses a dilemma in creating clinical guidelines. Breast awareness provides women with some acknowledgement of the part they can play in being empowered to fight breast disease, not in terms of statistics used for mortality but on the qualitative effects of reductions in morbidity. The lack of a consensus regarding a standard recommendation for BSE is problematic and confusing not only for patients but also for health care professionals. But in last, I would to say, that as we move forward from here, whatever changes are implemented, as scientific studies and science as such are not absolute, it is vital for women to remain involved in their own breast health as other factors like life style modifications and genetics also play role in breast cancer.