Intended for healthcare professionals

Letters

Breast self examination

BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7391.710/b (Published 29 March 2003) Cite this as: BMJ 2003;326:710

Breast self examination provides entry strategy

  1. Richard J Epstein (repstein{at}hku.hk), professor
  1. Division of Haematology and Oncology, Department of Medicine, University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong Special Administrative Region, China
  2. Breast Cancer Action Group, PO Box 381, Fairfield, Victoria 3078, Australia

    EDITOR—Given what is now known about the long subclinical growth phase of human breast cancers, the finding of a recent study from Shanghai, that teaching breast self examination did not detectably improve survival, is not surprising.1 None the less, Austoker's related editorial, proclaiming the death of breast self examination, should not go unchallenged.2

    Many studies have reported a reduction in primary tumour size dependent on breast self examination, which may in turn enable more conservative surgery.3 The editorial's implication that all such end points are rendered illusory by the Shanghai study is overstated; as if to acknowledge this, Austoker 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—so different from what most people understand by breast self examination?

    False positive and false negative “costs” are attached to breast self examination and to any preventive diagnostic interventions. However, an individual who is informed of both the negative randomised data and of the inverse association of tumour stage with survival might still reasonably opt for the potential costs of a biopsy dependent on breast self examination, rather than for the implied comfort of ignorance or uncertainty.

    In Asia, where high rates of late presentation persist owing to cultural and economic factors,4 there seems little reason to be cheered by the debunking of breast self examination. As one facet of an expanding spectrum of patient empowering initiatives, breast self examination at least provides an entry strategy towards the gradual improvement of cancer awareness and outcomes.

    Kline has proposed that the rhetoric of breast self examination should be modified so that healthcare consumers are accurately informed and thus empowered, rather than misled or inadvertently coerced.5 Surely this is the insight that public health in the 21st century should be striving to attain.

    References

    1. 1.
    2. 2.
    3. 3.
    4. 4.
    5. 5.

    Editorial misses central point

    1. Rosetta Manasciewicz (rmanasz{at}optushome.com.au), steering committee member
    1. Division of Haematology and Oncology, Department of Medicine, University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong Special Administrative Region, China
    2. Breast Cancer Action Group, PO Box 381, Fairfield, Victoria 3078, Australia

      EDITOR—Instead of clarifying the “confusion of the past decade,” Austoker fuels a debate that misses the central point.1 No single screening procedure is foolproof. Self examination can miss tumours, as can other methods. The issue is not whether breast self examination alone can save lives, but how many lives it can save in conjunction with other screening procedures. Women need to know that screening is multifaceted—that if they are concerned they should not rely on simply one test. Only then can they be assured of detecting breast cancer earlier or eliminating the possibility of having the disease.

      Furthermore, Austoker's cited Thomas et al study was a trial of the teaching of breast self examination, not the practice of it.2 The possible impact of cultural values in the adherence to breast self examination and hence on results is overlooked. 3 4 Instead, Austoker posits that since there is no single agreed method, or it engenders anxiety, breast self examination fails to be effective. Breast cancer survivors can assure women that a positive diagnosis is far more distressing than the trepidation experienced through self examination.

      The message is clear. Breast cancer can, and does, induce anxiety in women. However, to discount breast self examination as a detection tool because it results in more biopsies or creates temporary stress, or because guidelines are inconsistent, is unconscionable. Women have been “taught” that early detection of smaller tumours is their best chance for survival. For many women in the trial reported by Thomas et al, breast self examination resulted in the identification of smaller tumours; more in situ cases and 81.9% of tumours were discovered directly through self examination.2 These figures alone speak volumes about the efficacy and effectiveness of breast self examination as part of an overall, multipronged approach to detecting breast cancer.

      References

      1. 1.
      2. 2.
      3. 3.
      4. 4.
      View Abstract