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New findings add to muddled message for effective breast cancer detection Self-awareness is the new catchword,
a change from years of advice to rigorously practice monthly self-exams.
Washington -- Women may feel they are caught between a rock and a hard place when it comes to identifying an adequate technique to detect breast cancer early, and their physicians may need to help extricate them. The value of mammography came under heightened scrutiny a year ago, and now the benefit of breast self-exams is being questioned. While the message is still conveyed in handouts and public service announcements urging women to perform monthly breast exams, there has been a low-key shift in medical opinion away from the worth of self-exams in cutting breast cancer deaths. The suggestion that women learn an admittedly difficult procedure and carry it out faithfully at the same time each month has been supplanted, say many experts, by a more general recommendation that women should become well-acquainted with their bodies and report any change in their breasts to their physicians. The final word, at least for now, on breast self-exams was carried in a study published Oct. 2 in the Journal of the National Cancer Institute. The study, done in China by researchers from the Fred Hutchinson Cancer Research Center in Seattle, found that "programs to encourage [breast self-exams] in the absence of mammography would be unlikely to reduce mortality from breast cancer." Medicine has lowered its opinion of the value of breast self-exams. Half of the 266,000 women in the study were provided with intensive instruction on properly conducting a self-exam, while the other half served as a control group. During the 12-year study, there were 135 breast cancer deaths in the group that received instruction and 131 in the control group. The study's publication coincided with the start of Breast Cancer Awareness Month, subjecting women to conflicting statements on breast self-exams. While handouts and public service announcements were continuing to urge women to conduct monthly self-exams, news stories were citing the study's findings that self-exams were not effective. What should women be doing to improve their chances of surviving breast cancer? That depends on whom you ask. Changing tactics Most groups do not share the coalition's negative view of mammography but have reached a similar conclusion about breast self-exams. "I'd say that over the last five or more years, most major organizations have taken some steps back from breast self-exams," said Debbie Saslow, PhD, director of breast and gynecologic cancer at the American Cancer Society. Women older than 50 are still advised to have a yearly mammogram. "While only a couple of organizations have said, 'Don't bother doing it,' most have moved their emphasis to self-awareness, rather than an actual breast self-exam done every month and done a certain way," she said. Rachel Ballard-Barbash, MD, MPH, associate director of the applied research program at the National Cancer Institute, would agree. "We've never had any studies that indicate that breast self-exams in and of themselves reduce mortality from breast cancer," she said. But self-exams may still be a useful tool, she added. "We do know that some breast cancers are picked up through breast self-exam, so there may be some benefit to doing it." The view that there may be some value to self-exams keeps them among the American Cancer Society's three early detection recommendations, along with mammography and a clinical breast exam, Dr. Saslow said. And the study doesn't mean that women shouldn't pay attention to lumps or be interested in changes in their breasts, noted Eric Winer, MD, director of the breast oncology center at the Dana Farber Cancer Institute. "What it does say is that a very routine monthly approach to making sure one does a self-exam may not be a lot better than just being aware of changes that occur in your body." "My fear is that women will interpret the study as 'Oh, it doesn't matter if I let my doctor know if I have a lump,' " Dr. Winer said. "That's certainly not good sense at all." Changes are under way on the Dana Farber Web site, Dr. Winer said, to emphasize the need for women to monitor any changes and to report them to their physicians. Questions about the worth of self-exams are not nearly as painful as those raised by the mammography controversy, Dr. Winer said. There are much more data on mammography, he said, and the data are less straightforward. "Mammography is also so entrenched in our culture," he said. "Yet it remains unclear just how beneficial it is." For now at least, Dana Farber continues to follow general recommendations for women older than 50 to receive an annual mammogram and for those 40 to 50 to discuss their individual situations with their physicians. Though uncertainty seems rampant in the world of breast cancer early detection, that's not what troubles Cynthia Pearson, executive director of the consumer group the National Women's Health Network. She believes that women can sort through incomplete or inconclusive data. "It's a different era," she said. "Women can handle a much more mixed or complicated body of information." What worries her is that when women finish sorting the available information, "there is nothing clear to see," she said. "The [China] study showed that teaching women to do exams, reinforcing it and checking to make sure they were doing it didn't save any lives," she said. And the debate over mammograms pointed out that "whether mammography helps or not, it doesn't help a whole heck of a lot," she added. A shift in focus from early detection to more targeted treatment may be the way to go, Pearson said. Now, it almost doesn't matter whether the cancer found is aggressive or not because the treatment for most women is the same: surgery, radiation and even drugs, she said. "In the advocacy world, we are coming closer to an understanding that early detection in and of itself is not the Holy Grail. It's early detection with the ability to tell which cancers are dangerous," Pearson said. --------------------------------------------------------------------------------
Source: Journal of the National Cancer
Institute, Oct. 2 |