IS BREAST TEST FAILING? SELF-EXAMS DON'T SAVE LIVES, STUDIES SAY, BUT OTHERS THINK THEY STILL BELONG IN EVERY WOMAN'S ANTI-CANCER ARSENAL.

Byline: Mariko Thompson Staff Writer

For years, advocating that women do monthly breast self-examinations, or BSE, to detect suspicious changes seemed like a logical course of action. If early detection of breast cancer improved the odds of survival, then women performing the self-exam should improve their odds of early detection.

But science doesn't always uphold what appears logical. Recently, research has demoted BSE from its place in the early detection trinity, which also includes annual mammography screenings starting at age 40 and annual breast exams performed by a doctor.

``There's no data to support BSE the way it's been described and pushed heavily through the years, which is you do it so frequently that you know all the intricacies of your breast,'' said Dr. Christy Russell, a spokeswoman for the American Cancer Society and co-director of the Lee Breast Center at the USC-Norris Comprehensive Cancer Center.

In October, researchers from the Fred Hutchinson Cancer Research Center in Seattle released results from a long-term, large-scale study that found teaching BSE did not reduce deaths from breast cancer. It wasn't the only study to cast doubt on the usefulness of BSE, but its size and scope gave it heft. In May, the American Cancer Society revised its breast cancer screening guidelines. Where women over 20 were once told to do BSE monthly, the American Cancer Society now says the self-exam is optional.

In other words, BSE doesn't hurt. But don't count on it to help.

Looking forward

Most studies of BSE have been done retrospectively, asking breast cancer patients whether they had performed self-exams. The Fred Hutchinson Cancer Research Center study, funded by a grant from the National Cancer Institute, looked forward, following more than 260,000 women in Shanghai, China, for 12 years. Because screening mammography isn't available there, researchers wanted to see if teaching BSE to women would reduce the breast cancer mortality rate.

Participants were divided evenly into a control group and a group that was trained in BSE. The women in the BSE group did the exam four to five times a year under medical supervision and also received monthly reminders to do so at home. After 10 to 11 years, the death rates in both groups remained the same, said Dr. David Thomas, the lead investigator.

The BSE group did find more lumps that had to be biopsied. This raised the number of benign breast disease cases - but not the number of cancers, Thomas said.

``If fewer women (in the BSE group) had died of breast cancer, you could say it was worth it,'' Thomas said. ``But since there was no benefit, these biopsies we would say were unnecessary.''

Thomas said the findings show that developing countries are better off placing their limited resources into creating medical infrastructure and ensuring that women have access to care rather than teaching BSE. In the U.S., where mammography is widespread, BSE still has a role to play, he said. Women, particularly those considered high-risk for breast cancer, may want to supplement their annual mammograms with self-exams.

``If a woman is highly motivated, go ahead and practice it,'' Thomas said. ``Remember, you have to do a better job and be conscientious. You may end up having a biopsy that's not going to be cancer.''

An estimated 40,000 American women die of breast cancer each year. The risk of breast cancer increases with age. For a 30-year-old woman, the odds of developing breast cancer over the next 10 years is 1 in 249. For a 70-year-old woman, the risk increases to 1 in 24, according to the American Cancer Society.

Both the National Cancer Institute and the American Cancer Society recommend regular mammograms for women over the age of 40. According to the National Cancer Institute, about 20 percent of mammograms that come up negative have missed cancers.

Santa Clarita resident Mary Petersen is concerned that making BSE optional will mean missed cancers. Petersen, 39, inadvertently found a lump in her breast while showering five years ago. Because her mother had breast cancer, Petersen had relied on regular mammograms. Her last one had come up negative.

The lump turned out to be a malignant tumor. Petersen underwent two surgeries and radiation treatment. Today she is cancer free. Still, she wonders if she might have caught the tumor earlier had she performed a monthly self-exam.

``You want to use any tool available,'' Petersen said. ``That's the way to beat it, through early detection.''

The American Cancer Society recommendation stresses that women should be familiar with the terrain of their breasts, even if they opt not to do the self-exam. Cheryl Kidd, the Susan G. Komen Breast Cancer Foundation's director of education, says the best way for a woman to have that knowledge is by doing BSE every month.

``We know BSE does not improve mortality,'' Kidd said. ``There's another side of the story. It can help a woman empower herself. It helps a woman learn her body and communicate with her doctors.''

Dr. Ken Murray, who runs a family practice in North Hollywood, said he continues to train female patients on how to perform BSE.

``I have an uneasiness with abandoning the practice altogether,'' he said. ``All of us as physicians have the experience of patients who discovered lumps that turned out to be cancer.''

Keep in touch

The majority of women with negative mammograms who find their own tumors typically do so in the same manner that Petersen did - not through a trained self-exam, but by touching their breasts in the shower or while dressing, Russell said. That's why the American Cancer Society recommends ``self-awareness'' - that women be familiar with how their breasts normally feel and report any changes to their doctor.

The guidelines also suggest that women with a family history go to screening clinics that specialize in breast care. These women can be monitored more frequently and receive additional tests, such as a breast ultrasound or MRI, Russell said.

A second member of the early detection trinity may take a hit down the road as well. There are questions about the effectiveness of the clinical breast exam, since a doctor who performs it once a year isn't likely to notice subtle changes, Russell said.

However, the clinical exam provides other benefits. It's an opportunity for doctor and patient to discuss breast health. And it can be useful if performed just prior to the screening mammogram, she said.

``If something doesn't feel right, the mammogram will no longer be a screening mammogram but a diagnostic mammogram,'' Russell said. ``It will be evaluated in a different light, with concentration in the area that needs to be looked at a little more closely.''

For health educators and doctors, it's much easier to send a message with one-size-fits-all instructions. But in the realm of breast cancer and early detection, scientific research is now requiring that those simple messages give way to more nuanced discussions.

``BSE still has a place, but it's more restricted now,'' Thomas said. ``We know what we can and can't expect.''

Mariko Thompson, [phone]

mariko.thompson(at)dailynews.com

BREAST CANCER SCREENING

The latest guidelines

Last May, the American Cancer Society released updated breast cancer screening guidelines. The biggest change from the 1997 and 2003 guidelines came in the recommendation for breast self-examination or BSE. The practice had long been considered an integral part of early detection efforts. But a long-term, large-scale study released in October confirmed that BSE was not effective in reducing the death rate. The American Cancer Society revises its guidelines approximately every five years to account for new scientific findings. Here's how the old and new guidelines compare:

Mammography

Old recommendation: Annually starting at age 40.

New recommendation: No change.

Clinical breast exam

Old recommendation: Every three years for women age 20 to 39, annually for women age 40 and older.

New recommendation: No change.

Breast self-examination

Old recommendation: Monthly starting at age 20.

New recommendation: Beginning in their 20s, women should be told about the benefits and limitations of BSE. It is acceptable for women to choose not to do BSE or to do it occasionally. Women should report any breast change promptly to their health-care provider.

Older women and women with serious health problems

Old recommendation: More research is needed.

New recommendation: Continue annual mammography, regardless of age, as long as a woman does not have serious, chronic health problems. For women with serious health problems or short life expectancy, evaluate ongoing early detection testing.

Women known to be at high risk

Old recommendation: Women with a family history of breast cancer should discuss guidelines with their doctors.

New recommendation: Women known to be at increased risk may benefit from initiating early detection tests at a younger age and from additional tests such as breast ultrasound or MRI.

How to do a breast self-exam

Step 1: Lying down

Feel for a hard lump, thickening or any change in your breast tissue.

Lie down on your back with a pillow under your right shoulder.

Use the pads of the three middle fingers on your left hand to examine your right breast.

Press using light, medium and firm pressure; follow an up-and-down pattern.

Repeat on your left breast.

Step 2: In front of mirror

Look for changes in the shape, size or appearance of your breast. Inspect your breast in four steps:

--Holding arms at sides.

--Holding arms overhead.

--Pressing hands on hips to tighten chest muscles.

--Bending forward with hands on hips.

CAPTION(S):

photo, drawing, box

Drawing:

(cover -- color) Breast self-examination

New study questions its value in reducing cancer deaths

Jorge Irribarren/Daily News

Photo:

Mary Petersen, pictured with dog Tia. Petersen is a Santa Clarita breast cancer survivor who inadvertently found a lump while in the shower.

Charlotte Schmid-Maybach/Staff Photographer

Box:

BREAST CANCER SCREENING (see text)

Courtesy of the Susan G. Komen Breast Cancer Foundation