Media Coverage About Breast Self-Exam Misleading, Say Experts

Roxanne Nelson

August 26, 2008

August 26, 2008 — For decades women have been urged to perform a monthly breast self-examination (BSE), but recently, an increasing number of organizations have backed away from recommending routine self-exams. Studies evaluating the benefit of BSE have shown decidedly mixed results and, last month, a flurry of media stories reported on a Cochrane analysis that showed that BSE does not improve breast cancer survival and might, in fact, cause harm.

However, Mark Kane Goldstein, PhD, and H.S. Pennypacker, PhD, both members of the American research team that identified and validated the standards for proficient breast examination, with the support of the National Cancer Institute (NCI), pointed out in a detailed response that the media coverage was misleading, contained a number of errors, and omitted critical information.

"The news stories seem to suggest that this is the final word on breast self-exam, and that the practice is ineffective or even harmful," said Dr. Goldstein, senior scientist and chairman of the board at MammaCare, in Gainesville, Florida. "And that's not the case at all."

MammaCare began more than 30 years ago as a research project supported by the NCI, with the goal of developing a program to teach efficient manual breast examination. Currently, MammaCare teaches and certifies healthcare professionals to perform clinical breast examination.

Drs. Goldstein and Pennypacker explained that the media stories made no mention of studies that have demonstrated the efficacy of BSE, or that major published studies have documented the fact that BSE has accounted for a substantial proportion of breast cancer detections, and that it is associated with survival. Reports in the popular media also largely ignored the contradictory evidence that was published within the 2 studies that comprised the Cochrane analysis.

In an interview with Medscape Oncology, Dr. Goldstein explained that mortality was the only end point in the Cochrane studies, and that can be difficult to validate. "It is hard to determine whether a single procedure can affect longevity, so it is difficult to come to clear conclusions about the effect of breast self-exams on survival," he said. "There are too many variables in these types of studies to isolate just 1 for an outcome such as mortality."

Confusion Over "Update"

One glaring flaw in the media stories, Drs. Goldstein and Pennypacker pointed out, was that even though the data were presented as news, the Cochrane review is actually 5 years old. Some media outlets presented the data as brand new, whereas others made reference to the fact that the original article appeared in 2003 and issued the story as an update of the initial results.

The Cochrane review, published on April 22, 2003, analyzed data from 2 large population-based studies conducted in Russia and Shanghai, China (Cochrane Database Syst Rev. 2003; 2:CD003373). Both studies compared breast self-examination with no intervention, and the authors of the Cochrane analysis concluded that the data did not suggest a beneficial effect of screening by BSE. Instead, they found that the data suggested increased harm in terms of greater numbers of benign lesions identified and an increased number of biopsies performed.

The authors of the 2003 Cochrane analysis recently revisited this analysis, and searched the Cochrane Breast Cancer Group Specialised Register, The Cochrane Library, and PubMed in October 2007 to evaluate new literature on the subject.

"The review has been updated, meaning that a new search for evidence has been conducted as stated in the updated review," Jan Peter Kösters, MD, from the Nordic Cochrane Centre at Rigshospitalet, in Copenhagen, Denmark, told Medscape Oncology. "Since this search did not find new evidence, the conclusions in the updated review remain the same."

Theoriginal Cochrane review and the updated review were both reported by Medscape when they were published.

Omissions and Applicability

David Sampson, director of medical and scientific communications at the American Cancer Society (ACS), believes that the ensuing widespread media coverage got its start from a press release that appeared on a health-related newswire. "I alerted them as soon as I found out that this was not new information or a change, and that the report inaccurately quoted ACS guidelines," he said. Unfortunately, "they did not rescind the press release, so everyone covered this as news."

Another problem with the reporting, contend Drs. Goldstein and Pennypacker, is that news articles tended to be 1 sided, focusing only on the results of the Cochrane analysis. Media outlets generally omitted any mention of results from major American and European studies that found BSE to be associated with a substantial proportion of detected breast cancers and survival. This includes findings from a study published this year (Singapore Med J. 2008;49:228-232), which confirmed the value of BSE. If support for BSE was mentioned in media reports, it tended to be anecdotal accounts, not evidence from clinical trials.

Dr. Kösters explained that, in the Cochrane analysis, "only studies that met the predefined inclusion criteria were included. These criteria are generally accepted in the clinical–scientific community."

Dr. Goldstein pointed out that although media reports repeated the finding that self-detected breast lumps might lead to an increase in unnecessary biopsies of benign tissue, they failed to mention that this is true of every method of breast cancer screening.

"All screening methods lead to false positives," he said. "About 11% of mammograms are false positive. That's about 3 million a year."

A limitation of the review itself, explained Dr. Goldstein, is that it doesn't provide information on how the conclusion might apply to populations in other countries, such as the United States. The end point in the Shanghai study was mortality rather than self-detected breast cancer or morbidity, and because medical technology and treatment options are less advanced or aggressive in China than in the United States, the outcomes of breast cancer detection are confounded and cannot be accurately compared with or transferred to American or Western women.

Dr. Kösters disagrees, and states that is just a hypothesis. "As far as I know, there is no evidence from clinical studies to support this statement," he said. "General screening of a healthy population needs to be tested in clinical trials of good quality."

Mixed Messages

Although a definitive consensus has yet to be reached, many of the major organizations and advocacy groups have stopped recommending routine BSE because of the lack of strong evidence showing a clear benefit.

The ACS stopped recommending BSE in 2003, based on the data from the original Cochrane analysis, according to Mr. Sampson. The Canadian Cancer Society also stopped recommending routine BSE. Other health organizations supporting this change include the Canadian Task Force on Preventive Health Care, the World Health Organization, the US Preventive Services Task Force, and the UK National Health Services.

Even though they still have a BSE instructional screening tool on their website, the Susan G. Komen for the Cure website no longer recommends a monthly BSE. In a statement, Eric P. Winer, MD, their chief scientific advisor, stressed that women should be familiar with how their breasts look and feel. “It is important for women to be aware of the normal look and feel of their breasts and report any changes to their doctors,” he said.

The NCI takes a more neutral approach. "We have levels of evidence," NCI press officer Aleea Farrakh told Medscape Oncology, "but we do not have any strict recommendations regarding BSE."

The American College of Obstetricians and Gynecologists has kept BSE in its most recent breast cancer screening guidelines. "Despite a lack of definitive data for or against breast self-examination, breast self-examination has the potential to detect palpable breast cancer and can be recommended," the guidelines state.

Several advocacy groups also continue to recommend BSE, including San Francisco–based Breast Cancer Action, which states that annual clinical breast exams by trained health professionals and breast self-exams are essential aspects of breast cancer screening. Our Bodies Ourselves, also known as the Boston Women’s Health Book Collective, a nonprofit public-interest women’s health education and advocacy organization, points out that BSE is rarely used as a sole screening method, is generally combined with clinical breast exam and mammography, and is the only detection method that women have control over with their own 2 hands.

Most breast cancers are palpable and are usually discovered by the women themselves, Drs. Goldstein and Pennypacker note. When the biomedical research team at the University of Florida and MammaCare were first investigating optimal palpation procedures, they found that skill training using tactually accurate breast models with small simulated lesions enabled women and healthcare practitioners to reliably detect 3 mm breast lesions, which is 10 times smaller than the average lesion found by accident.

"Published evidence documents that a large proportion of breast cancers are palpable and self-detected, that some breast cancers are mammographically invisible, that the components of effective breast self-examination are now known and validated, that the skill can be learned, and that women who learn and practice proficient breast examination possess an advantage in protecting their health and their life," they write.

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