Aug 11, 2010

The Breast Self Examination Controversy: What Providers and Patients Should Know

Breast cancer is the second leading cause of cancer-related deaths in women. The efficacy of breast self-examination in decreasing cancer mortality is being questioned because of some recent evidence. This finding has led to various and controversial recommendations by key health organizations. This article explores this controversy and provides resources that nurse practitioners can use for discussions with patients and to help patients make informed decisions about the role of breast self-examination in their health care.

Breast cancer is a concern for many women in America. It is the second leading cause of cancer-related deaths in women, second only to lung cancer. Genetics, obstetric and gynecologic history, and environmental factors are probable contributors to the development and progression of breast cancer. Early detection, aided by screening, greatly decreases the mortality associated with this cancer and allows for more treatment choices if breast cancer is found.

Over the years, a variety of methods including mammography, breast ultrasound, magnetic resonance imaging (MRI), clinical breast examinations by a health professional, and breast self-examinations (BSE) have been used to screen for breast cancer. However, none of these screening tests is 100% sensitive in detecting breast cancer. Therefore, it is often recommended that a combination of these techniques be used in the screening process. Opinions vary as to which combinations of screening techniques are the most effective for identifying breast cancer.

The BSE is the only procedure that medical clinicians teach their patients (who are often nonmedically trained individuals) to perform. Recently, the effectiveness of BSE in detecting breast cancer has been questioned; however, most providers cannot even entertain the idea that BSE may be unnecessary.

In the past 20 years, there has been a great deal of controversy about the necessity of teaching and performing BSE. The literature identifies both positive and negative outcomes of BSE, which poses a dilemma in creating clinical guidelines. Both novice and expert healthcare professionals, such as nurse practitioners, should base their practice on the best clinical evidence. The lack of a consensus regarding a standard recommendation for BSE is problematic and confusing, especially for patients.

A variety of screening methods are used to detect breast abnormalities and potential malignancies (e.g., mammography, ultrasonography, MRI, clinical breast examination, and BSE). However, the sensitivity and specificity of each test can vary. The sensitivity of a screening technique describes the rate at which the test can identify the presence of a disease. In other words, it predicts the probability of obtaining a positive test in those patients who actually have the disease. Problems with sensitivity produce false-negative results, leading to a missed diagnosis. The specificity of a test identifies the rate at which the absence of a disease can be detected or the probability of a negative result in patients who really do not have the disease. Problems with specificity produce false-positive results, leading to unnecessary workups.

Method 1: Mammography

The USPSTF and NCI encourage the use of mammography as a screening tool for breast cancer every 1 to 2 years starting at age 40. The Susan G. Komen for the Cure Foundation (a leader in the fight against breast cancer) and ACS recommend mammography yearly starting at age 40. Mammography sensitivity ranges from 56 to 95% depending on the quality of the test performed and the age of the person being screened. Women younger than 40 tend to have denser breast tissue, which makes detecting tumors with mammography more difficult.[20] While mammograms have a relatively high sensitivity, the specificity of the examination may be inadequate, causing increased use of ultrasonography and biopsies.

Method 2: Ultrasonography

Ultrasonography is not a first-line screening technique for breast cancer. It has a low detection rate for microcalcifications, which can be associated with breast cancer. Ultrasonography can be used to differentiate between fluid-filled cysts and solid tumors and can help with visualization for fine-needle aspiration procedures of the breast that can aid in diagnosis. It is often used in conjunction with mammography when lumps are detected that are difficult to evaluate with mammography alone. Several studies support the use of ultrasonography for breast cancer screening as an adjunct to mammography for high-risk women or women with dense breasts. One study showed that sensitivity was approximately 83.3% and specificity was 65.5% for breast ultrasonography.

Method 3: MRI

MRI is similar to ultrasonography in that it is not currently a first-line screening technique for breast cancer. MRI is used as an adjunct to mammography primarily in women who are at high risk for breast cancer. It can also be used to help with diagnosing lumps that remain after breast surgery or radiation therapy. MRI is also used to examine breast masses that were detected with manual palpation but were not located with mammography or ultrasonography. Studies are ongoing regarding MRI as a screening tool for breast cancer, but current evidence does not support the routine use of breast MRI as a screening procedure in average-risk women. One study found that MRI had a sensitivity of 79.5% and a specificity of 89.8%. The NCI stated that false-positive results were not uncommon with MRI. More studies supporting its cost benefits, effectiveness, and efficiency are needed before MRI is considered a routine screening method for breast cancer.

Method 4: Clinical Breast Examination

Recommendations for clinical breast examination (CBE) vary depending on the organization. The ACS and Susan G. Komen for the Cure Foundation recommend CBE be performed at least every 3 years starting between ages 20 and 39 and annually starting at age 40. The ACOG, ACR, and AMA recommend starting CBE at age 40 and annually thereafter. The USPSTF states there is a lack of evidence to support CBE. The American Academy of Family Physicians (AAFP) tends to follow the recommendations of the USPSTF, indicating that there is insufficient evidence to support CBE. The sensitivity for CBE ranges from 40 to 70%, and specificity ranges from 86 to 99%.

Method 5: BSE

The sensitivity and specificity values of the BSE are difficult to determine. However, there are a number of advantages to performing a BSE, such as allowing women to gain a sense of control over their health and to become comfortable with their own breasts. Additionally, it is a simple, noninvasive procedure that can be performed by nonmedically trained individuals.[31] According to the National Breast Cancer Foundation, up to 70% of breast cancers are found by women performing their own BSE. The ACOG recommends the use of BSE as a tool for breast cancer screening, stating that palpable lesions can be detected through BSE. The ACS also states that BSE can also help women recognize normal versus abnormal breast tissue.

Although there are organizations that still recommend the practice of BSE, the use of this technique has come under scrutiny since newer screening technologies have been developed. Disadvantages of BSE include increased number of healthcare visits and twice the number of benign biopsy results, leading to increased healthcare costs. Another disadvantage is that increased biopsies lead to a higher risk of breast cancer. According to the ACS, 4 of every 5 breast biopsy specimens are benign. With BSE, women detect changes in their breasts more often and are more likely to seek professional help and more definitive testing to rule out cancer, which increases healthcare costs. Additionally, when women discover abnormalities in their breasts, their feelings of anxiety and depression are likely to increase concerning what could possibly be a benign condition. This disease-specific anxiety could increase adherence to BSE in women; however, it could also lead to high levels of anxiety that require counseling or treatment.

Researchers have examined the efficacy of BSE in reducing breast cancer mortality. A study of 266,064 women in China, who were randomized to either receive instructions or not receive instructions in BSE, examined whether this instruction had any effect on the mortality of breast cancer. Thomas and colleagues concluded “intensive instruction in BSE did not reduce mortality from breast cancer…Programs to encourage BSE in the absence of mammography would be unlikely to reduce mortality from breast cancer. Women who choose to practice BSE should be informed that its efficacy is unproven and that it may increase their chances of having a benign breast biopsy.”

The Canadian Taskforce on Preventive Health Care no longer recommends the use of BSE for breast cancer screening due to a lack of evidence supporting its benefits (i.e., detecting breast cancer at an earlier stage) and strong evidence of harm, such as unnecessary biopsies. The ACS does not currently recommend performing BSE, as it did in the past. Instead, ACS recommends that women of all ages should be told about benefits and harms associated with BSE. Possible benefits of BSE, according to ACS, are increased awareness of breast changes leading to rapid evaluation and response to these changes. Possible harm is false-positive results.

The National Comprehensive Cancer Network (NCCN) recommends that women should be familiar with their breasts and promptly report any change to their healthcare provider. NCCN uses the term “breast awareness” to describe a woman’s familiarity with her breasts and suggests that periodic consistent BSE may facilitate this breast awareness. Furthermore, they point out that this does not need to be done in any specific formalized education program and base this on the results of the Shanghai study.

Other organizations take a neutral stance on the use of BSE. For example, the USPSTF states “that the evidence is insufficient to recommend for or against teaching or performing routine breast self-examination.” As shown in Table 2, there is no consensus among organizations related to BSE. This poses a problem for healthcare professionals such as nurse practitioners who attempt to follow evidence-based guidelines in their practices. Lack of consensus also creates confusion for patients as they hear various recommendations from clinicians and the media.

Clinical resources can be helpful when there is conflicting information regarding a screening tool. Therefore, we developed several resources based on the review of literature regarding BSE. A reference guide was developed indicating various organizations” websites and their positions on BSE so that patients and clinicians can review them. Talking points (Fig. 1) were also developed that summarize the benefits and risks of performing BSE as well as risk factors associated with breast cancer based on current evidence. Thus, healthcare professionals and their patients will have information readily available to aid them in making informed decisions about whether or not BSE is a good option for them. The “red flags” guide (Fig. 2) includes information about abnormal findings that may be of concern on a BSE. Finally, the URL for the American Cancer Society’s instructional guide for performing a BSE is included in the resources.

In summary, good clinical decision making involves consideration of best clinical evidence, the patient’s clinical and emotional state, the clinical setting, and other circumstance specific to the patient’s conditions. Resources presented here are intended to guide discussions on the use of BSE with patients. This will enable healthcare professionals and patients to review current guidelines, risks and benefits, and information on how to perform the BSE, if the woman chooses to do so. The ultimate goal is to empower women with the information they need to make educated decisions about their health.

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