Backing off breast exams

Evidence doesn't support regular breast exams, either self-exams by patients or clinical ones by physicians.

At her Thursday-morning session “Gynecology for the Internist,” Christine Isaacs, MD, estimated that the tally of breast exams she's performed over her 20-year career stands at approximately 20,000.

“That's a lot of breast exams,” said Dr. Isaacs, who is an associate professor in the department of obstetrics and gynecology at Virginia Commonwealth University Medical Center in Richmond. “Surely I did that with great value and great purpose. I didn't just feel a lot of breasts because my chief resident told me to do this and some attending said ‘Yep, that's what we do.’”

During her talk, Dr. Isaacs discussed the practice of regular breast exams, both by clinicians and by patients, and whether the evidence supports them. For decades, she said, clinicians have encouraged women to do regular breast self-exams. “We've all seen versions of this and counseled women on breast exams and sent them off with the charge of ‘Thou shalt do a breast exam every month on the day of your birthday.’ This is what I've explained to women throughout the years. But was that the right thing to do?”

Recent evidence suggests that for average-risk women, it wasn't, Dr. Isaacs said. For such women, expert groups now recommend against self-breast exams, due to “some pretty good research,” she noted. She pointed to two large studies, the Shanghai Trial and the Russian WHO Trial, that found higher rates of biopsy in women who were randomly assigned to breast self-exam instructions or education versus those who were not. Over 10 and 15 years of follow-up, respectively, no significant difference in cancer mortality was seen between groups.

Dr. Isaacs pointed out that women who perform breast self-exams will inevitably feel the natural characteristics of the breast, most of which are normal. “When we charged women with this task and we tagged the message of ‘If you feel anything, it could be cancer,’ we parlayed that up into a lot of overdiagnosis and a lot of interventions,” she said. “But at the finish line, they didn't come out any better or with any better outcomes than the women who were not told to do them. So unfortunately, we actually harmed them.”

Physicians might expect better results from, and evidence for, the clinical breast exam, in part assuming that the problems with the self-exam might stem from patients' inexperience or anxiety, but that's not the case, Dr. Isaacs said. She described the typical scenario for a clinical breast exam.

“A patient comes in. I, as a skilled person, examine their breasts—mind you, once a year, not 12 times a year, so I have absolutely no comparison. I'm just going to start feeling around and see; use the Force,” she said.

The bottom line, she noted, is that the evidence doesn't support regular clinical breast exams, either. The American Cancer Society and the Canadian Task Force on Preventive Health Care have both advised against them, while the U.S. Preventive Services Task Force has said there is insufficient evidence to assess additional benefits beyond mammography, Dr. Isaacs noted.

The American Congress of Obstetricians and Gynecologists' recommendations, from 2011, advise a clinical breast exam every one to three years from ages 20 through 39 and annually thereafter, but those guidelines are currently being revised, Dr. Isaacs said. “Out there right now, ACOG still stands behind a clinical exam, but I have a strong suspicion and belief that is going to change,” she noted.

Dr. Isaacs cautioned that patients may balk when physicians explain the new thinking about breast exams and may require additional information and reassurance. “We did such a good job teaching women, and on this emotional campaign, that to undo it takes a lot of work,” she said. “It was well-intended advice that we gave women, but it was never based on any science.”

She recommends directing uncertain patients to the American Cancer Society website so they can read more about the evidence, or lack thereof, themselves. She also explains to patients that women are not Barbie dolls, she said.

“Our breasts are not perfectly smooth. They change. They change as we age, as our weight changes, as our hormones change. So it's natural and normal. We are supposed to feel the natural and normal physiology of the breast,” she said. “We're just not supposed to panic and think those things that we feel mean cancer.”