For decades women were encouraged to perform monthly breast self-examinations in an effort to catch the disease at its earliest and most treatable stage. Then, based on large studies in China several years ago, recommendation of breast self-exams was eliminated from national breast cancer screening guidelines and many doctors are telling women that self-breast exams are unnecessary.
Now – further complicating the debate – researchers at Duke Breast Wellness Center (Durham, North Carolina) are suggesting that self-exam can be beneficial to certain groups of women and only with appropriate instruction.
The self-exam controversy was one of several hot topics discussed by breast cancer experts Wednesday during a press briefing webcast that kicked off the 10th annual meeting of the American Society of Breast Surgeons (ASBS; Columbia, Maryland) in San Diego.
"It should be emphasized and well-taught to those that are high risk ... it has not been abandoned," Lee Wilke, MD, an assistant professor of surgery at Duke, said during a question-answer period after she presented a small single-institution study in which breast self-exams did work in many cases, with appropriate instruction. The study enrolled 147 women at the Duke Breast Wellness Center.
"Certainly we think breast self-exam, as evidenced in the young women, is still important," Wilke said.
Wilke's presentation overlapped with a presentation from Barbara Smith, MD, PhD, co-director of the department of surgery and radiology at Massachusetts General Hospital (Boston). Smith talked about the diagnosis of breast cancer in women age 40 and younger and noted that breast cancer diagnosis in premenopausal women is increasing around the world.
In the U.S., about 5.5% of all breast cancer occur in women under the age of 40, Smith said. She added that about 11,000 new cases are diagnosed each year. Some of the problems associated with the disease in this population of women is that breast cancer is more dense, younger women are not routinely screened, their tumors probably grow more quickly and they often present in patterns that are atypical, according to Smith.
Smith presented statistics on a group of women younger than 40 who were diagnosed between 1965 and 1995. She said the vast majority of these women found their tumors on their own by self-exam.
The study showed that the size of the tumors at the time of diagnosis in these women appeared to be increasing, despite advances in imaging technology used to detect breast cancer. Smith said the researchers enlarged the cohort of women diagnosed after 1996 to the present time, of which the average age of diagnosis was 37, and a little less than half of the patients had had digital mammograms compared to those who had traditional film mammograms. Once again the researchers noticed an upward trend over time in tumor size.
The means of detection among these patients, Smith said, was mostly by self-exam, however a quarter of the women had had mammography and hardly any of the cases were detected by MRI. Once the patient was diagnosed with breast cancer, however, 95% had a mammogram but for 81% of those patients it was their first mammogram ever.
Smith said that as MRI became more available an increasing percent of patients had MRIs after their initial diagnosis and that MRI identified additional cancer foci in 12% of those women.
"We looked at risk factors within the population to see if we could have identified these women as high risk earlier and 50% had a family history of breast or ovarian cancer," Smith said.
She argued that clinicians are "really underutilizing genetic testing" as a means to determine which women should be considered high risk for developing breast cancer.
"We would like going forward to be better at identifying patients for risk gene screening," Smith said. In addition to screening women who have a family history of the disease, Smith said "we would like to ... do better at identifying risk factors in women who don't have a family history of breast cancer where we really need to do some work at determining what factors contributed [to them developing the disease]."
When asked to comment on Wilke's presentation, Smith said, "I think that certainly one of the key things in finding breast cancer in young women is going to be the cost. To do mammography and MRIs in young women is not going to be possible."
She said it's important to find a way to "really educate the right women and have them learn more about self exam."
However the data suggests, Smith said, that self-exams do not help a lot for all women but that the test may yield better results when performed by women who have "some inkling" of risk.
"You'd expect that MRI could find things sooner than self exam does just by the characteristics of self exam to feel things, but certainly in younger women anything would help," Smith said.