Western Regional Blog – BC, YK, AB, NWT and Nunavut
By RONI CARYN RABIN
Scientists produced dismal news last week about mammograms. After tracking 90,000 women for 25 years, researchers in Canada found that those who received regular mammograms did not experience fewer deaths from breast cancer or from all causes, compared with those who did not.
But buried in the news was a nugget of hope: The women who did not receive regular mammograms were instead monitored with physical breast exams that proved effective. All of the participants were taught to examine their own breasts once a month, and specially trained nurses examined women who were in their 50s. This low-tech approach, the researchers found, appeared to be as good as or better than regular mammograms at locating the serious cancers that needed treatment.
The study authors are hesitant to draw any firm conclusions, because they did not set out to study manual breast exams per se. But as the data came in, “I began to feel that what the trial was showing was that clinical breast exam was effective and could substitute for mammography, if it was performed well and was accompanied by the teaching of breast self-exam,” said Dr. Anthony B. Miller of the University of Toronto, the study’s lead author.
That is a very different message from what women have been hearing.
“Before this report came out, I would have said the best role for clinical breast exams is in places where there isn’t good access to mammography, because it’s a reliable way to catch some cancers early, but it’s not as sensitive as mammography,” said Dr. Mary Barton, a vice president at the National Committee for Quality Assurance, a private health care nonprofit, who has studied the performance of clinical breast exams.
Now, she said, “the question is: Is mammography too sensitive?”
In the Canadian study of women ages 40 to 59, mammography identified more cancers, but overdiagnosis led to unnecessary treatment like chemotherapy.
Medical organizations like the American Congress of Obstetricians and Gynecologists do recommend regular clinical breast exams, performed by doctors or trained nurses, for women beginning at age 20. But self-exams have fallen out of favor. The American Cancer Society offers instructions and suggests women ask their doctors about them, but the United States Preventive Services Task Force in 2009 gave self-exams a “D” grade, saying it was a waste of a time to teach women to do them.
Data in support of self-exams have been “really murky,” said Dr. Elizabeth Steiner, director of the breast health education program at Oregon Health and Science University’s Knight Cancer Institute. Still, she believes there are good reasons to encourage women to do self-exams.
“Who’s going to know your breasts better?” she said. “Your doctor, who does an exam once a year, or you, who does it every month?”
There is not a lot of research to support clinical breast exams, either, but Dr. Steiner said, “I personally do think more health care providers need to be trained to do high-quality clinical breast exams.”
Given the debate over mammography, you would think that scientists would be taking a harder look at alternatives. But a randomized clinical trial comparing clinical breast exams with no care is unlikely, said Dr. Cornelia J. Baines, an author of the Canadian mammography study.
“Everyone’s looking for a technological fix, not what fingers can do,” she said.
If you are looking for a clinical breast exam, find a provider who has received training in the so-called vertical-strip, three-pressure method, which calls for moving the fingers up and down along the chest area, rather than in circular motions around the breast, and palpating lightly, then a little more firmly and then deeply in each spot.
Done properly, it is time-consuming, taking at least three minutes for each breast. One study found that the exams were more reliable when they were not performed during a patient visit that included other demanding tasks, like Pap smears.
The clinician should examine the entire chest area, not just the breast — all the way up to the neck or collarbone, into the armpit, over the center of the chest, and under the breast into the rib cage.
The exam should also include a visual inspection of the breasts while the patient is asked to stand in different poses. This can make some patients, and physicians, uncomfortable.
Detailed instructions for a self-exam are available on many breast cancer websites. You may want to ask a health provider for guidance as well.
The optimal time for a self-exam is just after your period. Start by standing in front of a mirror and examining your breasts for any unusual dimpling or asymmetry, changes or discharges from the nipple, redness or rashes.
To examine your breast, lie on your back and raise an arm above your head. Use your other hand to examine the breast beneath the raised arm; rely on the pads of your fingers, not the tips. Use three levels of pressure: light, then medium and then firm to feel near the ribs.
Physical breast exams can miss tumors, or lead to overdiagnosis and treatment of lumps that turn out to be harmless.
Still, Dr. Steiner said, “High-quality clinical breast exams are less likely to give you a false positive and might, in skilled hands, be less likely to give you a false negative.”