Breast Self-Exam Leads To Unnecessary Breast Biopsies
Posted by medconsumers on November 5, 2001
As of last year, several cancer organizations, once the biggest promoters of breast self-examination (BSE), decided to tone down the recommendation. After decades of telling women that this monthly ritual will save their lives, the National Cancer Institute, for example, acknowledged that no study has been able to verify this widespread assertion (News Section, Journal of the National Cancer Institute, 7/19/00). Last month, a Canadian policy-setting organization went one step further. After reviewing all the BSE studies, the group advised against teaching this practice because it causes harm.
The Canadian Task Force on Preventive Health Care identified eight studies in which healthy women who performed BSE were compared with those who did not. The two best-designed clinical trials were conduced in Russia and China, where women have no access to mammography and, therefore, could not “cloud” the results. Both trials had randomly assigned women to either a BSE training group or a control group (no BSE). The BSE group in each trial had exactly the same breast cancer death rate as the control group. Worse, both trials showed higher rates of benign biopsy in the BSE groups than in the control groups.
Promoters of BSE have been criticized over the years for creating an unhealthy disease-focus, particularly in young women whose odds of getting breast cancer are extremely low. The American Cancer Society used to recommend that every woman practice BSE from the time her breasts develop, though acknowledging that breast cancer is rare in teenagers. The “earlier in life the BSE habit is established, the more likely it will be used monthly–and knowledgeably–for life,” wrote ACS spokesman Arthur I. Holleb, MD, in a 1977 book, he co-authored called You Can Fight Cancer and Win.
Surveys show that most women are aware of BSE, but most do not examine their breasts. Still, the practice is seen by many as empowering, a way of taking control in the face of a widely feared disease. But there is a cost beyond the anxiety and pain of undergoing an unnecessary biopsy; scar tissue from the biopsies can obscure detection of a future cancer. Furthermore, an enormous amount of funding has been directed to the promotion of BSE that could have been spent more productively on finding the causes of breast cancer.
BSE promotion may have outlived its usefulness for other reasons. The idea of teaching women BSE was spawned in the mid-20th century, an era when women were still showing up at the doctor’s office with tumors far larger than those found today. It was also a time when women were raised to avoid touching their breasts. Today, women have been educated to see a doctor more promptly, and they tend to be more comfortable with their bodies. Most non-mammography-detected breast tumors are found by women themselves in the course of normal everyday practices, showering, dressing, making love, and so forth.
The new recommendation from the Canadian Task Force is an update of its 1994 recommendation which concluded that there was insufficient evidence to recommend for or against BSE. The update should be acknowledged for what it is: a public policy recommendation. Women are not being advised to stop performing BSE. The Task Force is addressing doctors and nurses, advising them to stop teaching BSE as part of the usual health examination for women “…because there is fair evidence of no benefit, and good evidence of harm.” Noting that some women will ask to be taught BSE, the Task Force advised they be instructed to perform BSE in a proficient manner and informed of the rate of unnecessary biopsies associated with the practice. The recommendations were published in last month’s issue of the Canadian Medical Association Journal.
American Cancer Society reaction to the new Canadian recommendation was swift and negative. ACS spokespeople were quoted in the media, saying that BSE was too useful to drop. None cited evidence to support the contention. The ACS people seem to have missed the fact that the Canadian Task Force did not say that the practice should be stopped. It advised professionals to stop teaching BSE and to warn women of the risk, if they insist upon being taught. In other words, stop selling women the idea that BSE is an entirely safe, lifesaving practice until you can come up with some good, trustworthy evidence that the claim is true.
Maryann Napoli, Center for Medical Consumers(c)