New Task Force Questions Value of Breast Self-Exams
The effectiveness of breast self-examination, urged for decades as a way to detect breast cancer in women, gets poor marks from a new government task force that 1/8 warns there is “no evidence” that the technique works.
Moreover, reliance on breast self-examination may draw women’s attention away from two proven, far more reliable ways to detect breast cancer--examinations by doctors skilled at finding breast lumps and mammographies.
According to the U.S. Preventive Services Task Force, part of the Office of Disease Prevention and Health Promotion of the U.S. Department of Health and Human Services, grassroot programs that emphasize teaching self-examination would better accomplish their objectives if they persuaded more women to undergo periodical professional checkups rather than to rely on do-it-yourself methods.
The task force, which has begun a process of issuing grades to a variety of preventive health practices, says breast self-examination gets just a “C” while a combination of mammography and examination by a health worker for many women gets an “A.”
“The problem with breast self-examination is not evidence of a lack of effect, but lack of evidence (that it works),” the U.S. Preventive Services Task Force concluded. “With strong evidence already available for two other . . . methods, efforts to get older women (at least) screened for breast cancer should be focused on these.”
But even before it was released Thursday, the report sparked criticism from both the government’s National Cancer Institute and the American Cancer Society, both of which emphatically recommend self-examination and continue to believe the technique has a role in cancer detection for women. If nothing else, top officials of both institutions said, self-examination is harmless and non-invasive and stands at least some chance of leading to discovering a tumor.
Both organizations criticized the new report because the task force urges a well-designed study to scientifically determine the limitations and effectiveness of breast self-examination. Both the NCI and the American Cancer Society complained that such a study would be virtually impossible to set up--because it would entail dividing women to be studied in two groups, one of which might have to be directed to avoid touching their own breasts for a period of several years.
The National Cancer Institute is under the overall authority of the National Institutes of Health. The task force reports to a different part of the overall Department of Health and Human Services.
Breast cancer is the most common form of cancer in women, with an estimated 123,000 new cases annually.
The new dispute also underscored longstanding disagreements between the cancer society and the cancer institute over when mammography is appropriate--with the society insisting that mammograms should be far more widely available.
In a related development, the National Cancer Institute said it is reevaluating its own data on mammography and plans to change its recommendations which currently discourage most routine mammograms.
Meanwhile, the cancer society complained that the controversy over breast self-examination broke just as cancer prevention experts are trying to focus new attention on early detection.
By various estimates, 15% to 40% of all women examine their own breasts and only 15% have ever undergone mammograms. Reluctance over mammography is thought to be related to cost of the procedure and concern about radiation exposure. Experts are unanimous that while previous generations of mammography equipment gave off unacceptably high X-ray doses, current lower dose equipment is safe.
Compounding these problems, said USC breast cancer expert Dr. Peter Rosen, is the unsettling reality that many physicians aren’t competent enough at breast examination to detect tumors while they are still small. He said mammography also has severe limitations--especially when it is used in younger women and women whose breasts contain large amounts of fibrous tissue that may conceal malignancies in X-ray images.
The Preventive Services Task Force is a recently formed group that will issue occasional recommendations and reports in a wide range of preventive health areas. The recommendations and two reports focusing on breast cancer screening appear in today’s issue of the Journal of the American Medical Assn.
The task force concluded that:
- For women 50 and older, a combination of annual mammography and annual examination by a physician offers the best chance of detecting breast cancer.
- For women 40 to 49, no study has demonstrated that screening programs decrease breast cancer mortality. Nevertheless, women 40 to 49 should have annual physician examinations. However, the report said existing evidence cannot justify routine mammography in most women in the age bracket.
- For women judged to be at high risk of contracting breast cancer--including those with a family history of the disease diagnosed before menopause in close relatives--doctors may recommend annual mammography and professional examination starting as young as age 35.
- Because the cost of mammography--$100 to $150 in large cities--constitutes an insurmountable barrier for some women, price reduction should be given a “high priority” by medical professional groups, some of which have already begun programs to try to bring prices down to the $40 to $50 range. In California, a bill under consideration in the Assembly would extend Medi-Cal payments to mammography examinations for the poor.
- Breast self-examination remains such an unproven technique that “no recommendation” can be made including basic self-examination techniques. But, concluded the task force, “as currently practiced, breast self-examination’s accuracy appears to be considerably inferior to that of the combination of (examination by a physician or skilled health worker) and mammography.”
Current recommendations by the National Cancer Institute make no mention of obtaining an initial mammogram--often called a “baseline” test because it establishes an image of the breasts with which later X-rays can be compared. The NCI currently says mammography should only be considered in high-risk women, starting with those who have already had breast cancer by the time they are 35. The American Cancer Society, on the other hand, suggests mammography once a year for some women along with physical checkups.
The society suggests regular self-examination by all women, beginning when they are high school age. The NCI recommends monthly breast self-examination but urges examination by a doctor depending on the physician’s individual recommendation and concludes that some women should have checkups every year while others may not need them as frequently.
The task force questions most long-standing assumptions about self-examination, arguing that a woman’s fingertips exploring her own breasts are only 26% effective in finding cancerous growths, compared to the 75% recorded for the combination of mammography and physician examination conducted by skilled practitioners. Many studies show, moreover, that tumors women find themselves average about the size of a quarter--far larger than what can be detected by X-ray imaging, which can identify lesions the size of the tip of a ballpoint pen.
The task force report, which was written by two University of North Carolina experts, characterized itself as a “critical review” of self-examination, concluding that even the argument that self-examination is cheap may be suspect. Instead, argued Michael O’Malley and Dr. Suzanne Fletcher, a woman who finds no lump in her breast may erroneously conclude she does not have cancer and discovery of her tumor may be delayed for months or even years--bringing with it far greater risk to her life and costs when treatment is initiated.
In a telephone interview from Washington, Fletcher--who said she herself does not engage in breast self-examination--insisted the conclusion about self-examination was not intended to discourage attempts to find cancer. Instead, she said, “the evidence isn’t strong, at all, that this screening technique saves lives.
“Women ought to know that. The task force didn’t come out against (self-examination), it just said there isn’t strong evidence that it works. The irony of this is that women are not getting screened by the techniques which have such good evidence of success.
“It’s highly important for women to understand that there is more scientific evidence in support of screening (by mammography and professional checkup) for breast cancer than for any other cancer. Yet it’s not being done. That’s the irony.
Despite the new findings, Dr. Arthur Holleb, the cancer society’s senior vice president for medical affairs, said the society continues to believe that self-examination is a valuable supplement to physician checkups and mammography. Self-examination, he said, remains “a good health habit which can start as early as high school. Our feeling is that every woman is at risk. This is a disease of great magnitude and you should do everything you possibly can to detect it.”
At the NCI, Dr. Charles Smart, head of the institute’s early detection program agreed, conceding his agency and the cancer society have disagreed on mammography recommendations, but contending in a telephone interview that self-examination, at the very least, prompts women to see their physicians where they can obtain more competent, thorough examinations.
Many estimate between 70% to 90% of women with breast cancer discover the disease themselves, Smart said, either through formal self-examination or as is more often the case, inadvertently or accidentally. “So if you don’t encourage women to examine themselves, you’re going to find a whole lot (more advanced) disease,” he said.
