The Current State of Breast Self Examination

By Michael L. Ormont, MD FACS

    As a surgeon who takes care of many women with breast health issues, I often hear, “I haven’t really examined my breasts myself on a regular basis and I feel terrible about it!” I tell her that her feeling is completely understandable; after having been told repeatedly to examine her breasts monthly since the age of twenty, why would she not feel guilty when she forgot? In fact, women who don’t manage to do it on a regular basis often feel some sense of inadequacy. The roots of these feelings are deeply set into the breast care culture.
    Breast self examination has been a mainstay of breast care for 70 years, however most women face some level of emotional difficulty with breast cancer screening programs. Every month, women are encouraged to perform breast self examinations and every year, women over the age of 45 are subject to the stress of scheduling, waiting for, then having a mammogram, only to have to wait a week for the results.
    They are often subject to further tests, including additional mammograms, an ultrasound and an MRI, as well as surgical procedures only to find that the mammographic finding was not a cancer. Then, they ask themselves if they will have the same experience next year. Given the anxiety associated with the annual screening studies, there is no question that women may feel nervous about checking themselves monthly for any changes in their own breasts that would, no doubt, begin a series of stressful tests and related events.
    Currently, the American Cancer Society recommends breast self examination as “optional.” Repeated studies have failed to demonstrate a significant survival benefit from performing breast self exams. It is now unclear as to whether women should perform meticulous breast self examination at exactly the same time each month, or whether women should simply ignore their breasts altogether.
    For most women, the answer lies somewhere in between. The goal of breast self exam is to detect tumors at an early stage, and improve the chance of cure. It takes a long time for a breast cancer to grow to a size where it can be felt on exam, and often other studies, such as mammograms will detect cancers before they can be found on examination. The most common first indication of a breast cancer is a lump felt by the patient.
    The real lesson from this study is that breast self examination is a test with the ability to detect some cancers in some women some of the time. Breast self examination must be used in conjunction with professional (clinical) examinations mammograms, ultrasounds, MRI, and, under some conditions, biopsies to fully evaluate breast abnormalities.
    While meticulous breast self examination certainly still has a role in the detection of cancer, the crucial issue is that women must bring lumps they find to the attention of their health care professionals. Examples would be the three women with palpable masses and negative mammograms. This situation is seen in as many as 22% of patients with breast cancers. In these cases, the breast exam contained more information than the mammogram.
    One woman came to my office complaining of breast pain. I examined her and found no worrisome abnormalities. A mammogram and an ultrasound were also unremarkable. She was still quite concerned, and I asked her to return in three months for a repeat examination. At the follow up visit, she had discovered a lump; and an office biopsy demonstrated an early stage cancer which was successfully treated.
    Another woman who was not in the habit of doing self examination of her breasts came to an office visit in January. Her exam showed no masses and her mammogram was negative. In July she returned, having found a lump in her breast in the shower. She too had an office biopsy which demonstrated cancer and was successfully treated. A third woman presented with a mass found on self examination, and the initial mammogram and ultrasound was negative. A biopsy again demonstrated an early stage cancer.
    While the presentation of these three women was unusual in my breast health practice, it underscores the importance of all modalities in evaluating the breast, and the importance of a full breast health screening program.
    I encourage all women to perform breast self examinations. These programs include the participation of the individual, professional examinations, mammograms at the age of 40 and yearly over the age of 45, and possibly other studies based on the level of risk for developing breast cancer.
    There is, however, agreement that the monthly breast self examination does have several benefits. It provides an awareness of one's own anatomy, it may provide some empowerment over one's health care, and it can help those with new changes noted on breast self exam gain early entry into a full evaluation of any abnormalities they may encounter.
    No newly discovered breast mass should be ignored, and no persistent breast symptom should be overlooked. All women should understand that they need to bring changes in their breasts to the attention of a health care professional. It is possible to imagine that, in the future, with better studies available, breast self examination may play a less important role in the evaluation of breast health.

    Michael Ormont is a surgeon at Cheshire Medical Center/Dartmouth Hitchcock Clinic Keene. He was born in New York City, and graduated from Vassar College. He attended medical school at Temple University, and Surgical Residency at Thomas Jefferson University Hospital, in Philadelphia. He lives in Keene with his wife Mary Hofreiter and their son Alden. They are expecting their second child in October.

How to Perform a Breast Self Exam