Breast self-examination
=======================

* Ellen Warner

It is unfortunate that *CMAJ* readers are more likely to have read the conclusions of the report by the Canadian Task Force on Preventive Health Care on breast self-examination1 than the much more balanced commentary2 and will now erroneously believe that the risks of breast self-examination have been proven to outweigh its benefits. 

Breast self-examination can never be evaluated using standard clinical trials methodology. Short of following study subjects for several years with round-the-clock video camera surveillance, it would be impossible to document either the compliance of the intervention group or the lack of contamination of an informed control group (who would be instructed to not perform breast self-examination so that the investigators could determine with proper scientific rigour whether or not the procedure saves lives). 

The more fundamental issue is whether early detection of an already palpable breast cancer improves outcome. If it does, then it is ludicrous to believe that it is better for a woman 50 years or older to wait for a physician or nurse to perhaps find the cancer during an annual clinical breast examination than to find the cancer herself months earlier. Women under 50 years of age, for whom there is no Canadian recommendation for breast screening, can only hope that some illness will befall them that might bring them to a physician who just might examine their breasts. The argument that most women find their cancers between formal self-examinations is also flawed by the fact that women who are familiar with their breasts from practising breast self-examination are much more likely to notice early changes that could be signs of cancer.

I would also take issue with the purported harms of breast self-examination. Almost invariably a core biopsy that leaves no scar can be performed instead of an excisional biopsy. Although breast self-examination produces anxiety for some women, it can be extremely reassuring to other women, particularly those who are not yet candidates for mammography or those who know its limitations.

## References

1.  1. Baxter N, with the Canadian Task Force on Preventive Health Care. Preventive health care, 2001 update: Should women be routinely taught breast self-examination to screen for breast cancer? CMAJ 2001;164(13):1837-46.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMToiMTY0LzEzLzE4MzciO3M6NDoiYXRvbSI7czoyMjoiL2NtYWovMTY2LzIvMTYzLjIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

2.  2. Nekhlyudov L, Fletcher SW. Is it time to stop teaching breast self-examination? [editorial]. CMAJ 2001; 164 (13):1851-2. 
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMToiMTY0LzEzLzE4NTEiO3M6NDoiYXRvbSI7czoyMjoiL2NtYWovMTY2LzIvMTYzLjIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9)