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Self-Exams Don't Reduce Breast-Cancer Death Risk
By SHARON BEGLEY
In another blow to the hope that early detection of breast cancer will save lives, the most-rigorous-ever study of the value of teaching women breast self-examination has found that it doesn't reduce the risk of dying from the disease.
A 10-year study of 266,064 women in Shanghai showed the death rate from breast cancer among those who became proficient at monthly self-exams after intensive instruction was no different from women who received no instruction and who didn't practice self-examination. Tumors in the exam group weren't even found at an earlier, more treatable stage.
The finding, reported in Wednesday's issue of the Journal of the National Cancer Institute and coming, ironically, as Breast Cancer Awareness Month begins, threatens to dash the hopes of women who are already reeling from the controversy over whether regular mammograms save lives. An editorial in the medical journal pulls no punches: "At least for the great majority of women whose [exam] practice is not optimal, it does not reduce the risk of dying of breast cancer," write Russell Harris and Linda Kinsinger of the University of North Carolina, Chapel Hill.
That counterintuitive result flies in the face of years of data showing a link between outcome and at what stage a breast tumor is detected.
The theoretical underpinnings of self-exam are simple: It lets you detect a tumor earlier, when it is smaller and supposedly more treatable. But breast cancer is unpredictable. "By the time a woman feels a lump, the cancer may have been growing for eight to 10 years," notes cancer surgeon Susan Love of the University of California, Los Angeles, who wasn't involved in the study. If it is very aggressive, it will already have metastasized, in which case "early" detection is still too late.
On the other hand, if the tumor is very slow-growing, whether you catch it through a methodical self-exam, casually in the shower, or during a doctor visit doesn't much matter, says Dr. Harris. Such tumors are far more treatable. It's cancers in the middle where discovering the lump now or next year "might matter," he says. "If you really know what you're doing, breast self-exam can be a great tool, but we just don't know how many tumors are of this in-between type where it might make a difference."
This year, 203,500 women in the U.S. are expected to be diagnosed with breast cancer and 39,600 are expected to die from it.
Both doubters and supporters of self-exams agree that returning to the era when women showed up at the doctor's office with a breast lump the size of a lemon is a prescription for tragedy. Even if rigorous self-exam doesn't statistically reduce mortality from breast cancer, recognizing lumps before they get large can't hurt.
Yet contrary to the messages women receive from doctors and public-health campaigns, breast self-examination has never been proved to save lives. "To believe otherwise is wishful thinking," says Dr. Love. "It feeds all our prejudices about empowering women to take their health into their own hands."
Indeed, "pretending things work gets in the way of finding things that are better," argues Dr. Love, who advocates research into blood tests or other markers of early breast cancer, akin to Pap smears for cervical cancer.
For their study, researchers led by cancer epidemiologist David B. Thomas of the Fred Hutchinson Cancer Research Center in Seattle recruited 266,064 Chinese women working at factories in Shanghai. Half received intensive instruction in self-examination; half didn't. The first group received regular reminders about exams and practiced them on themselves under the supervision of a health worker every six months. After 10 to 11 years, there was no difference in breast-cancer mortality between the two groups: one-tenth of 1% of the women in each group had died of the disease.
Reflecting the uncertainty in the value of self-examination, the position of the U.S. Preventive Health Services Task Force is that there isn't enough evidence either for or against teaching it. The American Cancer Society's advice that women perform it monthly is under review; the National Breast Cancer Coalition has long held that self-exams don't save lives.
"In my heart of hearts I believe breast self-examination makes a difference, but because the literature is so mixed I don't push it," says Leslie Montgomery, director of a program for women at high risk of breast cancer at Memorial Sloan-Kettering Cancer Center in New York.
Write to Sharon Begley at firstname.lastname@example.org
Updated October 2, 2002
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