Abstract
What should we tell women about the best ways to screen for breast cancer in order to ensure that every breast cancer possible is detected and treated at the earliest possible stage? In the past, women were encouraged to use a three-pronged approach to screening that included (1) performing monthly breast self-examinations (BSE), (2) getting yearly clinical breast examinations (CBE) from their doctors, and (3) having mammograms once every year or two beginning at age 50, or 40, or 35. It was the mammography message that changed over time, but the other messages remained constant. Now women are frequently advised to “Get a yearly mammogram” and little else. Mammography is important. Indeed, it is hugely important in thinking about early detection of breast cancer in the United States and in countries around the world that have breast screening programs. There is good evidence that mammography can detect small breast cancers and find cancers at earlier stages, when treatment is most likely to be effective.
Although the debate continues about the real impact of mammography on breast cancer death rates, the debate also rages about the effectiveness of mammography for women in their 40s and for those at high risk. However, mammography remains the constant in current efforts to combat breast cancer through early detection. It is the method we know a great deal about, the one with all the data. Even if debate about the role of mammography continues because we believe there is more that we as a society need to know about the benefits and possible harms of mammography and of other screening tests that have great promise and less data, we do know mammography can detect breast cancer. We even have a healthy body of research describing how best to promote mammography use. What is lost in the public debate and often in the public service messages that advise women about reducing their risk of breast cancer is any discussion of the other methods of breast cancer detection and of a woman's active role in the detection of her own breast cancers. Rather, mammography is the only breast cancer detection method promoted in many of these efforts.
This focus on mammography continues in spite of the fact that most experts appear to agree that CBEs have their place and that women should report suspicious symptoms, particularly breast lumps and discharge, to their doctors. The role of the CBE, the importance of women's self-reports of changes in their breasts, and the need for women to bring changes, signs, and symptoms to their doctor's attention and to have these checked out have frequently been eclipsed in the public debate by discussion about breast cancer screening using mammography and magnetic resonance imaging (MRI).
The article by Roth et al. 1 in this issue of the Journal supports the importance of other methods of breast cancer detection. Roth et al. report on an analysis of data from the National Health Interview Study (NHIS) describing the method of detection reported by a nationally representative sample of 361 women with breast cancer. They report that when asked How was your breast cancer found? most cancer patients and survivors in the survey reported some method of detection other than mammography; 25% reported finding their cancer during a BSE, 18% found their cancer themselves by accident, and the rest were found by doctors during a CBE. These percentages vary, of course, by a woman's age at the time of her diagnosis and among different diagnostic cohorts. Women under the age of 50 and, even moreso, those diagnosed under the age of 40 are more likely to report finding their cancers themselves and are less likely to report having their cancers detected through mammography than are women over 50. Also, a greater percentage of cancers were found by mammography in the later years of the dataset (1995–2003) than earlier in the dataset (1980–1994), which would be expected because the use of mammography has increased since the 1980s. Even in the most recent data, however, including only data for those women over the age of 50, there still appears to be a significant percentage of breast cancers (almost 40%) that are found by women themselves either by accident or through the practice of BSE.
In discussing their findings, Roth et al. note first that although this topic has not received much attention, the NHIS is not the only dataset in which this finding has been made. Even where rates of use of mammography are high, only a minority of breast cancers are found by mammography, and self-detection remains important. 2 They also note that this finding raises important issues about physician training and public health initiatives.
That is the issue, of course. There is still a need to create initiatives to improve the quality of screening mammography and to encourage women who are not using mammography to access this technology. However, at the same time, we should not forget about the role of women themselves and of their doctors in the detection of breast cancer. What is not clear is what advice to offer women and their doctors about methods of detecting breast cancer other than through mammography alone. There have been two large randomized controlled trials of BSE, one in China and one in Russia, and they found no evidence that teaching women BSE and asking them to do self-examinations reduced breast cancer-related mortality. 3,4 These studies remain the best available evidence regarding the effectiveness of teaching women BSE. Based on the results of these and other studies, the weight of evidence falls against teaching women BSE. 5 We cannot say that teaching women BSE saves lives, but with women seeking ways to be involved in their own health and to improve their odds that often include untested interventions, including supplements, changes in their diets, and others, BSE, or as it is sometimes called “breast self-awareness,” 6 may be getting too little attention in physician's offices, physician's training, and public awareness efforts. Of course, women who do not want to do BSE should not do it in the absence of evidence it works. For those who do not find it bothersome and want to be involved after being fully informed, however, the known risks are quite modest, and as this article points out, a woman's awareness of her breasts and self-report of abnormalities, signs of change, and symptoms of breast cancer appears to remain a significant pathway by which breast cancer is detected in the United States. There is a large body of research on mammography promotion, and this literature continues to grow. Research and education efforts to assure that other methods of detection are also as effective and efficient as a possible path to appropriate treatment may be needed. Even CBEs by physicians, although recommended annually for women over the age of 40 by the American Cancer Society (ACS), 7 is often not described prominently in the easily available literature on breast cancer prevention and screening. Thus, it is very likely that not all women receive these examinations as often as they are recommended.
Performing a physical examination of the breasts (CBE or BSE) may be a difficult skill to teach, and only rarely are women trained to perform it carefully enough to improve the rates of breast cancer early detection, but there is evidence to support that CBEs performed by experts are effective. 8 Further, there is reason to believe that even if women are not specifically performing BSE, their awareness of the possibility of finding small painless lumps in their breasts appears to have led to reduction in the size of breast cancers found in the absence of mammography. Harris and Kinsinger 9 provide a nice discussion of this distinction between the value of teaching women the manual skills need for effective BSE and the awareness women need to have that appears to increase their ability and willingness to report small lumps and get prompt treatment.
Some internet sites do not mention BSE and even say, “early breast cancer does not cause symptoms,” before mentioning that lumps, changes in size, shape, and feel of breasts, or the presence of fluid discharge should be brought to the attention of a physician. Early breast cancer may not produce distinctive, reliable symptoms, and this may be particularly true of ductal carcinoma in situ (DCIS), but claims that there are no symptoms may not be helpful when there is a steady stream of women who are accurately reporting changes in their breasts that lead to successful early diagnosis.
The claim that there are no symptoms is a specific claim that should not be made without specific scientific support, and rarely is evidence provided that there are no symptoms. It is also a statement that formerly was routinely made about ovarian cancer, but recent studies of ovarian cancer have shown this statement to be false. It is not yet clear, however, if knowledge that there are symptoms that often precede a diagnosis of ovarian cancer 10 –12 can be used as a screening test or to improve early detection or prompt more efficient diagnosis, and there are no data that it could improve treatment outcomes for ovarian cancer patients. However, it is clear that the common and widespread belief that there were no symptoms of ovarian cancer served, in at least some cases, as a barrier to efficient diagnosis and treatment of this cancer in some women. Until better methods of screening for both breast and ovarian cancer are developed, and perhaps even after they are, there may continue to be a role for the patients themselves in assuring prompt cancer treatment. It may be necessary to acknowledge the role of women as the first line of surveillance for cancer. It also may be necessary to be ready to inform women about the importance of their role in reporting symptoms that might be indicative of breast cancer. How can we ensure that women are optimally supported in that role?
Just like mammography promotion, this is an appropriate topic for research. How much awareness of the potential for self-detection and of the possible signs and symptoms of breast cancer is optimal in a population? Are we overemphasizing mammography in our current public education efforts? Is CBE underused? Could the current emphasis on mammography cause women and their doctors to become complacent about CBEs and breast changes that could prompt swift assessment? How should public health messages be designed to improve women's awareness of breast cancer and all methods of detection, not just mammography? What should the public health messages contain to guarantee neither neglect of mammography nor overreliance on it and other technologic methods of screening to the exclusion of support for self-detection? How can we support physician awareness that women themselves may report signs of cancer that need to be acted on quickly and diligently? How can we assure women that most lumps are not cancer while effectively encouraging the report of all suspicious signs and symptoms?
Finding the right level of prominence to give to information about the role of women and their physicians in breast cancer detection independent of mammography, MRI, or other technologic methods of screening yet to be developed may be a challenge. Efforts to develop a message that encourages self-detection and CBE that supports and but does not undermine messages promoting mammography may require actual research. First, we need to be reminded that mammography, although a valuable tool, has not completely transformed the treatment of breast cancer; it has only improved it for a minority of patients. Other patients are diagnosed clinically, and if the needs of these patients both before and after diagnosis are not the same as those of patients detected through mammography, the needs of both groups of patients must ultimately be met.
Footnotes
Disclosure Statement
The author has no conflicts of interest to report.