New American recommendations on breast cancer screening have caused quite a stir by advising a reduced number of screening tests. Although controversial, the changes essentially bring the US recommendations into line with the recommendations in the rest of the world and the only real question is why has the US taken so long to follow? ¹

On the whole, this new report is a major improvement and Talking Squid wholeheartedly approves of the move to incorporate better evidence in medical policy. But…there is clearly a less than reliable process at work in one aspect of the recommendations, and that is in its resounding dismissal of breast examination. This is, admittedly, a controversial question because it would seem intuitively obvious that breast self-examination would be a helpful practice if one is trying to detect breast cancer early. Unfortunately, there is very little evidence that it works, and there is a downside: if women are taught to examine their breasts, a large number will detect lumps that are completely benign but which need to be biopsied to confirm the diagnosis. This represents a cost to the health system, a burden of worry to women, a painful procedure, and a lot of time spent by doctors, nurses, and ultrasonographers. It would be nice if we could show some benefit. But we can’t. Despite a lot of research, nobody has been able to show that routine breast self-examination makes a discernible difference to breast cancer.

So far most recommendations around the world have cautiously supported breast self-examination with strong caveats about the lack of positive evidence. If the new US recommendations had simply followed suit, there would be little disagreement. But the new recommendations go a lot further. They emphatically recommend against breast self-examination. And they actively misrepresent the evidence.

New USPTFS recommendation statement:

Surveys suggest that the CBE technique used in the United States currently lacks a standard approach and reporting standards.

Actual paper referred to (Sazlo 2004):

Conclusion: CBE [clinical breast examination] can contribute to the ability of health care professionals and women to detect some breast cancers and should lead to appropriate follow-up care.

Comment: The Sazlo paper did indeed note the lack of a standardised approach to breast examination, but then goes on to describe an approach with a view to developing a standard for clinical practice. It does not recommend abandoning breast examination altogether. Given that this paper was published 5 years ago, it is highly likely that clinical practice has changed as a result (certainly the how-to diagram from the paper was widely reprinted in medical books). Plus, it was not a survey.

New USPTFS statement:

Clinicians who are committed to spending the time on CBE would benefit their patients by considering the evidence in favor of a structured, standardized examination.

Actual paper referred to (Barton 1999):

Indirect evidence supports the effectiveness of CBE in screening for breast cancer.

Comment: Nice bit of snark there from the USPTFS. Oh yes, if you recommend breast examination, you should check the evidence. Hint, hint. But please don’t check the evidence we provide.

New USPTFS statement:

In 2009, the World Health Organization recommended mammography every 1 to 2 years for women aged 50 to 69 years, but does not recommend CBE [clinical breast examination] or BSE [breast self-examination].

Actual document referred to (WHO 2009):

There is no evidence on the effect of screening through breast self-examination (BSE). However, the practice of BSE has been seen to empower women, taking responsibility for their own health. Therefore, BSE is recommend [sic] for raising awareness among women at risk rather than as a screening method.

Comment: none needed, I believe.

It is a great shame that this statement contains such flaws because it represents a major step towards applying evidence in public health in the US. Unfortunately, it does not accurately represent all the evidence it puts forward and it completely ignores the very important difference between regular breast self-examination and the now more commonly recommended breast self-awareness. They are not the same thing.

Given that around 90% of breast cancers are detected by women or their sexual partners on home examination, it seems somewhat hubristic to take a lack of evidence and turn it into stern discouragement. Especially when the best current advice — breast self-awareness — has not been addressed.

My advice: follow the UK guidelines. Or the Australian version (which is much the same but not as clearly articulated). Or the World Health Organisation’s source guidelines.

Tags: breast cancer, guidelines, recommendations, screening, statement, USPTFS