Q: I check myself for breast lumps every month like I’m supposed to, but all I can feel are lumps. I get nervous and run to the doctor every time I feel something, but everything is always fine. When can I stop doing my exams instead of making myself a nervous wreck every month?
A: That’s a question many women have. Breast Self Examination (BSE) is a controversial topic among medical professionals.
BSE has been both questioned as a way of finding early breast cancers and passionately championed by doctors and their patients.
A study of Russian and Chinese women found that death rates from breast cancer were not influenced when these women were instructed in BSE. After the results were released in 2002, news media reported these findings with the suggestion that a monthly BSE wasn’t worth the frustration.
But one of the study’s authors explained that it is unknown whether the women actually performed BSE correctly or did it at all — only that they were taught to do it. The researchers sought to identify whether BSE done instead of a screening mammogram was as effective in preventing death. The issue of whether earlier, more easily-treatable cancers could be identified by BSE was not addressed in the study.
The researchers noted that the findings may be most applicable for countries with few resources for screening mammograms and breast cancer diagnosis. Screening mammography rates differ dramatically worldwide.
In the U.S., annual screening rates in 2000-03 for women over the age of 40 approached 70%, according to the National Cancer Institute.
The Canadian Institute for Health Information reported that the country’s average screening rate for women over 50 was 51.8% in 2000-2001.
This age limitation reflects the country’s differing recommendation for breast cancer screening: the Canadian Task Force on the Periodic Health Examination does not recommend screening mammography for women ages 40-49. The screening standard is every two years.
European nations also adhere to this standard, while some, including Germany, limit screening mammograms to women ages 50-69. Since 2003, France has limited mammograms to every other year for women ages 50-74. The country reports screening rates of 50%. Britain’s National Health Service allows screening mammography every three years for women ages 50-64 (for whom the International Agency for Research on Cancer reports a 76% screening rate in 2003) but none for women under 50.
Mayo Clinic data indicates that women find about 90% of all breast lumps. The vast majority of these turn out to be harmless. The risk of unnecessary biopsies and additional (often expensive and stress-inducing) testing increases with the identification of benign lumps. Though many women are glad to assume this risk for the benefit of early diagnosis, complications of both surgical and non-surgical biopsies can be serious.
In addition to benign lumps, 15-20% of all breast cancers are identified on physical exam — either by the patient or her doctor — suggesting the value of both BSE and clinical exam. More than 95% of early breast cancers are curable (author’s note: “curable” is defined disturbingly as “the woman dies of something unrelated”).
But breast exams miss the smallest cancers, as well as those seen only on mammograms. Pre-cancerous conditions are often identified as a speckling of calcium on X-ray rather than a lump.
Putting this sometimes conflicting information together may be as difficult for your doctor as for you. The best evidence exists for continuing to recommend BSE for most women as part of a three-pronged screening approach. BSE is done in addition to a yearly physical exam by a doctor and screening mammogram for most women over 40. Unlike most testing, BSE is convenient, non-invasive and free.
For some women, however, there may be more anxiety provoked than benefit generated by the performance of this monthly ritual. A conversation with a trusted doctor or nurse practitioner can go a long way toward reassurance, especially if it is accompanied by education. Look for health forums and cancer awareness events for free information. Some community educators provide synthetic breast forms containing different-sized “lumps” to help train women and their caregivers in what can be a challenging exam.
Recommendations for women deemed to be higher risk can be dramatically different, including screening at a younger age using methods like MRI or genetic testing.
A word about male breast cancer — it happens. About one in every 150 cases of breast cancer is in a man. There has even been a genetic mutation identified that increases the likelihood of cancer in both men and women, “BRCA-2.” But because the condition remains relatively rare, there have been no studies suggesting that routine BSE or mammogram in men is effective. There may be advantages for men in families identified to have the gene mutation, but their numbers are too small to make this recommendation.