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.

NOVEL

The Changeling, Sean Williams
Daughters of Moab, Kim Westwood
Earth Ascendant, Sean Williams
Economy of Light, Jack Dann
Finnikin of the Rock, Melina Marchetta
How To Ditch Your Fairy, Justine Larbalestier
Incandescence, Greg Egan
Lamplighter: Monster Blood Tattoo Book Two, David Cornish
The Seance, John Harwood
Tender Morsels, Margo Lanagan
Two Pearls of Wisdom, Alison Goodman

NOVELLA / SHORT STORY

“An Honest Day’s Work”, Margo Lanagan
“Ass-Hat Magic Spider”, Scott Westerfeld
“As We Know It”, Lyn Battersby
“Beyond the Sea Gates of the Scholar Pirates of Sarskoe”, Garth Nix
“Creeping in Reptile Flesh”, Robert Hood
“Crystal Nights”, Greg Egan
“Delivery”, Trent Jamieson
“Down to the Silver Spirits”, Kaaron Warren
“Dresses, Three”, Angela Slatter
“Ghost Jail”, Kaaron Warren
“The Goosle”, Margo Lanagan
“Infestation”, Garth Nix
“Lost Continent”, Greg Egan
“Machine Maid”, Margo Lanagan
“The Miner’s Tale”, Lara E. Goodin
“Night of the Firstlings”, Margo Lanagan
“Oh, Russia”, Simon Brown
“Painlessness”, Kirstyn McDermott
“Pale Dark Soldier”, Deb Biancotti
“Sammarynda Deep”, Cat Sparks
“Skinsongs”, Martin Livings
“This Is My Blood”, Chris Lynch and Ben Francisco
“Truth Window: A Tale of the Bedlam Rose”, Terry Dowling
“Watertight Lies”, Deb Biancotti

COLLECTED WORK

2012, ed. Alisa Krasnostein and Ben Payne
The Best Science Fiction and Fantasy of the Year: Volume 2, ed. Jonathan Strahan
Canterbury 2100, ed. Dirk Flinthart
Creeping in Reptile Flesh, Robert Hood
Dark Integers and Other Stories, Greg Egan
Dreaming Again, ed. Jack Dann
Eclipse 2: New Science Fiction and Fantasy, ed. Jonathan Strahan
Magic Dirt: The Best of Sean Williams, ed. Russell B. Farr
Midnight Echo, ed. Kirstyn McDermott and Ian Mond
The New Space Opera, ed. Gardner Dozois and Jonathan Strahan
The Starry Rift: Tales of New Tomorrows, ed. Jonathan Strahan 
Tales of Outer Suburbia, Shaun Tan
The Year’s Best Australian SF & Fantasy, vol. 4, ed. Bill Congreve and Michelle Marquardt

ATHELING

“Bad Film Diaries – Sometimes the Brand Burns: Tim Burton and the Planet of the Apes”, Grant Watson
“Popular genres and the Australian literary community: the case of fantasy fiction”, Kim Wilkins 
Science Fiction entry in Books and Beyond: The Greenwood Encyclopedia of New American Reading, Russell Blackford
“Three Views of Mount Solaris”, Chris Lawson

BEST ARTWORK

COSMOS: “A Place To Call Home”, Jamie Tuffrey
Creeping in Reptile Flesh cover, Cat Sparks
Dragonscarpe cover, Michael Dutkiewicz
Groom Lake #1, Ben Templesmith
COSMOS: “The Noise Machine”, Justin Randall
Tales of Outer Suburbia, Shaun Tan
Wormwood: Gentleman Corpse #3, Ben Templesmith

BEST FAN PUBLICATION IN ANY MEDIUM

The Scary Food Cookbook, a compendium of gastronomic atrocity, ed. Cat Sparks
Undead Backbrain, Rob Hood
 
BEST FAN WRITER

Rob Hood
Robin Pen

BEST ACHIEVEMENT

Angela Challis for Brimstone Press and for Black: Australian Dark Culture Magazine
Robin Pen for Planet Blog
Wilson da Silva, Alan Finkel, Kylie Ahern and Damien Broderick for COSMOS Magazine