ASBS 2009: Breast Self-Exam as Accurate as Mammography, MRI in High-Risk Women

Nick Mulcahy

April 24, 2009

April 24, 2009 — Breast self-examination (BSE) is as accurate as mammography and magnetic resonance imaging (MRI) at detecting new breast cancers in high-risk women, according to the authors of a study presented at the American Society of Breast Surgeons 10th Annual Meeting, held in San Diego, California.

The surprising results raise questions about the value of BSE and how and in whom clinicians should recommend its use, said breast cancer experts attending the meeting who were interviewed by Medscape Oncology.

"Breast self-examination remains an important contributor to early detection in women at high risk for the development of breast cancer," said lead study author Lee Gravatt Wilke, MD, assistant professor of surgery at Duke University Health System, in Durham, North Carolina, at a press conference held before the meeting. "Breast self-exam should be emphasized and well taught to high-risk women," she said.

Breast self-exam should be emphasized and well taught to high-risk women.

In addition to high-risk women, BSE plays a role in screening young women, suggested Barbara Smith, MD, PhD, associate professor of surgery at Harvard Medical School, in Boston, Massachusetts, who also spoke at the press conference.

"Only certain groups of women have a critical need for self-exam," Dr. Smith told Medscape Oncology, noting that they include high-risk and young women. BSE becomes important if such women are not receiving mammograms/MRI, genetic testing, or clinical breast exams — which are the preferred screening tools, she emphasized.

Based on a number of clinical-trial results, monthly BSE is no longer a recommendation for breast cancer screening in the population at large, noted Dr. Wilke. The recommendation was dropped in recent years after several large clinical trials indicated that BSE did not improve breast cancer mortality rates, as reported by Medscape Oncology .

Discussion With Patient Is Key

The way in which breast awareness is discussed with women is key to its being a help or a hindrance, suggested meeting attendee William H Goodson, MD, senior clinical research scientist at the California Pacific Medical Center Research Institute, in San Francisco, and founder of the 2 Minute Breast Exam Web site, which encourages physician use of the clinical breast exam.

"There's a difference between encouraging women to be familiar with their bodies and issuing a strong directive to self-exam via public programs," he told Medscape Oncology.

There's a difference between encouraging women to be familiar with their bodies and issuing a strong directive to self-exam via public programs.

Formal BSE education programs that place a lot of responsibility for detecting masses on the patient — be it a woman who is young, at high risk, or in the general population — are highly problematic, he added. "For example, such programs can cause women who end up with breast cancer to blame themselves for not detecting it immediately, and can generate a sense of failure."

He also reiterated the well-known point that major clinical trials of BSE have not been shown to improve mortality. "There are only 2 things that randomized clinical trials of breast self-exam have ever shown — the exams cause women to find more abnormalities in their breasts and to undergo more biopsies," he said.

Furthermore, Dr. Goodson said that history is not on the side of BSE being a successful public-health tool. "Physicians have been trying to get patients to perform self-exams for more than 50 years. It's a very difficult thing to do. Some patients are very capable, some are freaked out. I can sympathize. I have attempted to do a testicular exam myself and it is not easy."

BSE vs MRI and Mammography

The new results reported by Dr. Wilke at the meeting come from an ongoing study of 147 women at Duke University who were at high risk by virtue of a 5-year Gail risk calculation of 1.7% or more; a previous biopsy with atypical hyperplasia, lobular, or ductal carcinoma in situ or contralateral invasive breast cancer; a BRCA1/2 mutation; or mantel radiation. The women received mammography and MRI screening and BSE training at study entry, and every 12 months thereafter. They performed BSE every 6 months.

At 3-year follow-up, there have been 14 cancers detected. The different modalities all detected cancers (as opposed to false positives) at a rate of 1 out of 4.

"Of the 24 masses that study participants found using SBE, 6 turned out to be cancer," explained Dr. Wilke. "Of the 8 abnormal mammograms, 2 turned out to be cancer, and of the 23 abnormal MRIs, 6 were cancer. The proportions were about the same across the board."

Dr. Goodson suggested that he was not surprised at the results for the BSE. "A test in a high-risk population always works better than it will in a general population," he said.

Nevertheless, Dr. Wilke defended BSE, even its use in general populations. Commenting on the fact that 3 trials have not shown an impact on mortality with routine BSE, she pointed out that 2 of the 3 studies — conducted in China and Russia, respectively — had low compliance.

Young Women With Breast Cancer Are Frequently at High Risk

Another study presented at the meeting, by Dr. Smith of Harvard, looked retrospectively at 628 women with breast cancer under the age of 40. The investigators found that 71% of the breast cancers were initially detected by BSE.

However, in those same women, 98% of the cancers were subsequently detectable by MRI/mammography. Furthermore, 50% of the 628 women in the study had a family history of breast cancer. In other words, many of those women should have received genetic counseling and related mammography/MRI.

So, while not disparaging the importance of BSE, Dr. Smith emphasized that there need to be better ways to get screenings in women with a family history of breast cancer.

"Underutilization of genetic testing and breast imaging potentially delays the diagnosis of breast cancer in women aged 40 and under," she concluded.

The researchers have disclosed no relevant financial relationships.

American Society of Breast Surgeons 10th Annual Meeting: Abstracts 9 and 20. Presented April 24, 2009.

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