Breast Self Exams: don't cut death rate from breast cancer

Subject: a study of 26,000 women who did breast self exams did not reduce the risk of dying of breast cancer.

A few years back when we were lobbying the Colorado State Legislature to pass a bill regulating the naturopathic medical profession we had to spend many hours meeting with representatives of the Colorado Medical Society and other medical groups defending our profession. The mantra which the medical doctors always hammered us with was the phrase, "untested and unproven therapies" to imply that naturopathic therapies which had hundreds of years of historical use could not work unless proven to do so by the modern rigorous scientific method. No matter that the vast majority of things we do prescribe have been subjected to modern examination, the phrase was a good one-liner when playing politics. Since then I have become very sensitive to stories which point out modern medical practices which not only don't have evidence supporting their use but which have clear evidence that they are ineffective.

Earlier this year a study called into question whether routine mammograms were of any benefit in reducing breast cancer deaths. Now today's Journal of the National Cancer Institute has asked the same question about breast self-examinations.

Here's the news release the National Cancer Institute put out this morning:

Press Release from the Journal of the National Cancer Institute Vol 94, No 19, October 2, 2002
Study Finds No Evidence That Teaching Breast Self-Examination Saves Lives

Linda Wang, Assistant News Editor, Katherine Arnold, News Editor jncimedia@oupjournals.org
Teaching women breast self-examination (BSE) does not appear to decrease the number of deaths from breast cancer, according to a study in the October 2 issue of the Journal of the National Cancer Institute. However, intensive teaching of BSE was found to increase the rate of benign breast biopsies, potentially adding to health care costs without benefits. Evidence from non-randomized observational studies had not been consistent. Given such evidence, the U.S. Preventive Health Services Task Force currently does not recommend for or against the teaching of BSE.
To address this issue directly, David B. Thomas, M.D., Dr.P.H., of the Fred Hutchinson Cancer Research Center in Seattle, and his colleagues randomly assigned 266,064 female factory workers in Shanghai to either a BSE instruction group or a control group. Women in the BSE group were taught how to perform BSE and participated in reinforcement sessions 1 and 3 years later. The women also received regular reminders to practice BSE monthly and practiced BSE under medical supervision every 6 months for 5 years. The control group received no information on breast cancer screening.
After 10 to 11 years, there was no difference in breast cancer mortality between the BSE and control groups. There was also little evidence that cancers were detected at an earlier stage in the BSE group. However, women taught BSE found more benign breast lesions than women in the control group did during every year of the trial.
"In developing countries, where mammographic screening is not available, it would not seem to be a good use of the limited funds available for preventive services to promote practice of BSE," the authors write. For women with access to mammographic screening, the authors say that the results make clear that BSE is not a substitute for regular screening by mammography. They also point out that the implications of these results for women who do receive regular mammograms are unclear.
They note, however, that it is possible that highly motivated women could be taught to detect cancers that develop between regular screenings, and that the diligent practice of BSE might enhance the benefit of a mammographic screening program. They suggest that future studies look into this possibility.

In an accompanying editorial, Russell Harris, M.D., and Linda S. Kinsinger, M.D., of the University of North Carolina School of Medicine, point out that while teaching BSE seems like a good idea, BSE is more expensive than it first appears, is difficult to learn to do well, and is difficult to do long-term.

They say that the new findings should lead to a change in clinical practice. Rather than spending time teaching BSE, physicians should find ways to educate women about breast cancer symptoms and spend a little longer on the clinical breast exam, they say.
"Routinely teaching BSE may be dead, but giving women information-and continuing research on the effectiveness of excellent physical examination-should live on," the editorialists write.