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EDITORIALS: Joan Austoker Breast self examination BMJ 2003; 326: 1-2 [Full text]

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Not all women need breast self examination.

Sergio Stagnaro   (4 January 2003)

Breast examination has clinical usefulness

Arnold Seglenieks   (4 January 2003)

What about mammography programmes?

Niall A Herity   (4 January 2003)

To BSE or not to BSE: The woman's perspective

Rosetta Manaszewicz   (6 January 2003)

Reports of BSE's death are greatly exaggerated

Richard J. Epstein   (22 January 2003)

Not all women need breast self examination. 4 January 2003
Sergio Stagnaro, Specialist in Blood, Gastrointestinal, and Metabolic Diseases. Researcher in Biophysical Semeiotics. Via Erasmo Piaggio N° 23/8 16037 Riva Trigoso (Genoa) Italy Send response to journal: Re: Not all women need breast self examination.	Sirs, in order to both prevent and early recognise breast cancer at the bed side, we have to consider, in my opinion, something really different from breast self examination. It is to say that we must reflect, firstly, on the paramount developments of physical semeiotics over the last five decades, particularly as breast cancer clinical diagnosis as well as primary prevention is concerned (1) (See my site, HONCode 233736, http://digilander.libero.it/semeioticabiofisica). In addition, all over the world doctors have to know the existence of a congenital, acidosic, functional, mitochondrial cytopathology, "conditio sine qua non" of the most frequent and dangerous human disorders, including malignancies (1, 2, 3). Unfortunately, if doctor does not know the existence and, consequently, he can not assess the seriousness as well as the precise location of Congenital Acidosic Enzyme-Metabolic Histangiopathy, “Oncological Terrain” is based on (See, above-cited site), he can not recognise women at “real” risk of breast cancer. As a matter of fact, apart from the well-known negative influence of oral contraceptive use on breast and/or ovary oncogenesis, and/or arterial disorders, we have to consider the importance of the genetic “predisposition”, now-a-days perfectly and clinically evaluated in a “quantitative” manner (See: “Biophysical-Semeiotics Constitutions” in above-cited cite), as far as the onset of a large number of disorders is concerned, including solid as well as liquid malignancies. In fact, without this remarkable functional abnormality of psycho-neuro-endocrine-immunological system, i.e., oncological terrain, oncogenesis is not possible at all: among women exclusively those involved by oncological terrain, particularly if it is localized in the breast, need breast self examination. In oncological medicine, the importance of the above-mentioned congenital, functional, mitochondrial cytopatology should not be overlooked, particularly when we assess a "possible" risk factor or we carry out cancer screening programme. 1) Stagnaro-Neri M., Stagnaro S., Cancro della mammella: prevenzione primaria e diagnosi precoce con la percussione ascoltata. Gazz. Med. It. – Arch. Sc. Med. 152, 447 2) Stagnaro S., Istangiopatia Congenita Acidosica Enzimo-Metabolica condizione necessaria non sufficiente della oncogenesi. XI Congr. Naz. Soc. It. di Microangiologia e Microcircolaz. Abstracts, pg 38, 28 Settembre-1 Ottobre, 1983, Bellagio. 3) Stagnaro S., Istangiopatia Congenita Acidosica Enzimo-Metabolica. Una Patologia Mitocondriale Ignorata. Gazz Med. It. – Arch. Sci. Med. 144, 423, 1985 (Infotrieve). Competing interests:   None declared
Breast examination has clinical usefulness 4 January 2003
Arnold Seglenieks, General Surgeon Riverland Regional Hospital, Maddern Street, Berri, South Australia 5343 Send response to journal: Re: Breast examination has clinical usefulness	As a practising clinician dealing with benign and malignant breast disease, I will continue to recommend regular breast self-examination to my female patients and the general female population, if only for the simple reason that patient awareness of the duration of symptoms, as well as stability or progression, are of assistance in the clinical diagnosis and management of breast symptoms. I work on the presumption that there is no evidence that negates the value of standard techniques in clinical evaluation. Competing interests:   None declared
What about mammography programmes? 4 January 2003
Niall A Herity, Consultant cardiologist Belfast City Hospital BT9 7AB Send response to journal: Re: What about mammography programmes?	That breast self-examination does not prevent death from breast cancer is an obvious stimulus to a frank and honest debate about breast cancer screening programmes generally. Regrettably this has not been possible to date given the public's fear of cancer, the well-meaning but blinkered cancer lobby and the unwillingness of health care organisers to consider whether the billions spent on mammography programmes to date have been wasted. Recent analyses indicate that breast cancer screening has no effect on all -cause mortality and probably no effect even on breast cancer mortality (1,2). Until these findings are refuted, scarce financial resources should be diverted towards effective medical interventions. 1. Gotzsche PC, Olsen O. Is screening for breast cancer with mammography justifiable? Lancet 2000;355:129-34 2. Olsen O, Gotzsche PC. Screening for breast cancer with mammography. Cochrane Database Syst Rev 2001;4:CD001877 Competing interests:   None declared
To BSE or not to BSE: The woman's perspective 6 January 2003
Rosetta Manaszewicz, Steering Committee Member, Breast Cancer Action Group (Vic.) PO.BOX 381 Fairfield, Vic. Australia Send response to journal: Re: To BSE or not to BSE: The woman's perspective	To BSE or not to BSE: The woman’s view How many more times will women be assailed with ‘conclusive’ evidence that Breast Self Examination (BSE) does not work? That it induces unnecessary fear and anxiety, is too complicated to practice competently, and worse still, that it fails to reduce breast cancer mortality? Instead of clarifying the ‘controversy and confusion of the past decade’, Joan Austoker’s (1) editorial merely succeeds in further fuelling a debate which appears to be missing the central point. No single breast cancer screening procedure is fool proof. BSE can miss tumours, as can CBE , mammography, ultrasound, and even fine needle biopsy. The issue therefore is not whether BSE alone can save lives, but how many lives it can save in conjunction with other screening procedures. More to the point, Austoker would be doing women a far greater service if she and the medical establishment were to recommend an approach to breast cancer screening which fully embraced the triple detection path – BSE, CBE, mammogram, and if necessary, ultrasound. Women need to know that screening is multifaceted – that they should not rely on simply one test, especially if they are concerned. Only then can they be confident that they have acted in a manner which ensures their greatest chance of detecting breast cancer earlier or eliminating the possibility of having contracted the disease. It is in this context that Austoker’s editorial is worrying. By glossing over the final comments of the Thomas et. al (2) trial, Austoker fails to place the results in perspective. For instance, the study concluded that: “this was a trial of the teaching of BSE, not of the practice of BSE. It should not be inferred from the results of this study that there would be no reduction in risk of dying from breast cancer if women practiced BSE competently and frequently. 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 would enhance the benefit of a screening program.” (p.1457) So how has Austoker portrayed the study? - “the findings should bring to an end more than a decade of controversy and confusion…....concerning the efficacy and effectiveness of self examination of the breast”. (3) Is Austoker referring here to the teaching of BSE, or to its practice? Furthermore, the Thomas et al trial notes that “the frequency of practice outside the clinic setting is unknown” (p.1455). Did these women implement what they had learnt? And if not, why not? We tentatively suggest that one issue which has not been considered by either the study team or Austoker , is the impact of cultural values. There is a growing body of literature ( 4,5 ) which suggests that for the Asian woman in particular a diagnosis of cancer may be viewed far differently than her Western counterpart and, that the attendant screening strategies are also influenced by the cultural context. For instance, Sadler et.al (5)note that “a fatalistic view toward illness, can influence attitudes toward health care. Cultural modesty, the belief that “what you don’t know can’t hurt you,” and the importance of family in decision making also influence the way in which the Chinese seek and receive health information.” (p.20) Furthermore, Thomas et.al report that nearly half of all women diagnosed in both the control group and in the study arm underwent radical as opposed to partial mastectomies or breast conserving surgery. Again, the question that remains unanswered is what psychological effect such treatment may have on other women in the study? Would this engender an even greater terror in discovering a lump, and hence cause more women to refrain from practising BSE – especially when other screening avenues and information was not available? Austoker’s argument that there is no single agreed method, or that many women refuse to practice BSE because of the anxiety it engenders is both illogical and demeaning. As breast cancer survivors we can assure women that a positive diagnosis of breast cancer is far more anxiety producing then the trepidation experienced through BSE! More revealing however, is a recently published Australian paper by Davey et.al (6) which reports on screening and diagnostic testing for breast cancer and women’s attitudes to information and anxiety associated with receiving potentially threatening information. The authors’ results show that “many women recognized that being more informed about tests may provoke anxiety. These women nevertheless reported a strong desire for such information even if they expect it will trigger anxiety”. (p.339) The message is clear. Breast cancer can, and does, induce anxiety in women. However, to discount BSE as one of several detection ‘tools’ because it results in more biopsies, or creates temporary stress, or there is a lack of consistency in recommending how often it should be practiced, is unconscionable. For decades women have been ‘taught’ that early detection of smaller tumours is their best chance for survival. The Thomas trial reveals that for many women, BSE resulted in the detection of smaller tumours, more in situ cases and 81.9% of tumours were discovered in the study group directly through BSE. (p.1452) These figures alone speak volumes as to the ‘efficacy and effectiveness’ of BSE as part of an overall, multi-pronged approach to the detection of breast cancer. 1. Austoker, Joan (2003) “Breast self examination: Does not prevent deaths due to breast cancer, but breast awareness is still important”, British Medical Journal 326: 1-2. 2. Thomas, David B., Gao, Dao Li., Ray, Roberta M., Wang, Wen Wan, et.al (2002) “Randomized trial of breast self-examination in Shanghai: Final results”, Journal of the National Cancer Institute 94(19): 1445- 1457. 3. Austoker, Joan – op.cit. – page 1 4. Tang, T.S., Solomon, L.J., McCracken, L.M. (2000) “Cultural barriers to mammography, clinical breast exam, and breast self exam among Chinese- American women 60 and older”, Preventive Medicine, 31(5): 575-583. 5. Sadler, G.M., Wang, K.,Wang, M. Ko, M. (2000) “Chinese women: behaviors and attitudes toward breast cancer education and screening”, Women’s Health Issues 10(1):20-26. 6.Davey, H.M., Barratt, A.L., Davey, E., Butow, P.N. et.al (2002) “Medical tests: women’s reported and preferred decision-making roles and preferences for information on benefits, side-effects and false results”, Health Expectations 5: 330-340. Competing interests:   None declared
Reports of BSE's death are greatly exaggerated 22 January 2003
Richard J. Epstein, Deputy Director National Cancer Centre Send response to journal: Re: Reports of BSE's death are greatly exaggerated	EDITOR — Given what is now known about the long subclinical growth phase of human breast cancers, the finding in a recent study from Shanghai that teaching breast self-examination (BSE) did not detectably improve survival (1) is not surprising. Nonetheless, the related editorial proclaiming the long-overdue death of BSE (2) should not go unchallenged. Many studies have reported a BSE-dependent reduction in primary tumour size (3-5) which may in turn enable more conservative surgery (6). The editorial's implication that all such endpoints are rendered illusory by the Shanghai study is overstated; as if to acknowledge this, the author concedes that prompt symptomatic presentation ("breast awareness") remains important. But is the timely presentation of breast symptoms — of which palpation of a lump is the commonest (7) — so different from what most people understand by BSE? It is certainly true that there are both false-positive and false-negative "costs" attached to BSE, as there are to any preventive diagnostic intervention. However, an individual who is aware of both the negative randomised BSE data and the inverse association of disease stage with survival might still reasonably opt for the potential costs of a BSE-dependent biopsy, rather than for the implied comfort of ignorance or uncertainty. Here in Asia, where high rates of late presentation persist due to cultural and economic factors (8,9), there is little reason to feel enthused by the debunking of BSE. As one facet of an expanding spectrum of patient-empowering initiatives, BSE at least provides an entry strategy towards the incremental improvement of cancer awareness and outcomes — notwithstanding the low event rate (0.1% mortality over 10 years) of the Shanghai study, and the questions which should rightly be raised by this. Kline (10) has proposed that the rhetoric of BSE should be modified so that people are accurately informed and thus empowered , rather than misled or inadvertently coerced . Surely this is the central challenge for 21st-century public health; revelling in triumphalist sweeping statements that "…doing breast self-examination is dead" is not. 1. Thomas DB, Gao, DL, Ray RM, Wang WW, Allison CJ, Chen FL et al. Randomized trial of breast self-examination in Shanghai: final results. J Natl Cancer Inst 2002; 94: 1445-57 2. Austoker J. Breast self examination. Br Med J 2003; 326: 1-2 3. Philip J. Harris WG, Flaherty C, Joslin CA, Rustage JH, Wijesinghe DP. Breast self-examination: clinical results from a population-based prospective study. Br J Cancer 1984; 50: 7-12 4. GIVIO Italy. Reducing diagnostic delay in breast cancer. Cancer 1986; 58: 1756-61 5. Dowle CS, Mitchell A, Elston CW, Roebuck EJ, Hinton CP, Holliday H, Blamey RW. Preliminary results of the Nottingham breast self-examination education programme. Br J Surg 1987; 74: 217-9 6. Koibuchi Y, Iino Y, Takei H, Maemura M, Horiguchi J, Yokoe T, Morishita Y. The effect of mass screening by physical examination combined with regular breast self-examination on clinical stage and course of Japanese women with breast cancer. Oncol Rep 1998; 5: 151-5 7. Chow LW, Ting AC, Cheung KL, Au GK, Alagaratnam TT. Current status of breast cancer in Hong Kong. Chin Med J 1997; 110: 474-8 8. Goel AK, Seenu V, Shukla NK, Raina V. Breast cancer presentation at a regional cancer centre. Natl Med J India 1995; 8: 6-9 9. Alagaratnam T. The presentation of breast cancer in an Oriental community. Aust N Z J Surg 1995; 65: 634-6 10. Kline KN. Reading and reforming breast self-examination discourse: claiming missed opportun Competing interests:   None declared