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Breast self examination no longer recommended: breast self examination is no longer recommended as an option for early detection of breast cancer. Rather, women are being encouraged to be 'breast aware.'.

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More than two thousand women each year are faced with a diagnosis of breast cancer and the impact this will have on their lives and the lives of their families. (1) As a way of trying to reduce the impact of this disease, the Cancer Society, the New Zealand Breast Cancer Foundation and the National Screening Unit have been working together to clarify/issues around breast self examination (BSE).

Late last year the three organisations released a joint position statement on breast awareness, no longer recommending regular BSE. (2) Rather, each now recommends that all women, especially those over the age of 40 years, be "breast aware" In being breast aware women should know what is normal for them; know what changes to look and feel for; report changes without delay to their family doctor; and attend mammography screening if appropriate for their age. (2)

So what has changed and why does it make a difference? What should health professionals working in women's health be teaching women about early detection of breast cancer? For many years BSE (the formal process of examining one's breasts each month to detect lumps and/or changes in the breast tissue) was taught to women to try and detect possible breast cancer early. BSE appealed as a patient-centred, non-invasive procedure that allowed women to become comfortable with their own bodies. The underlying assumption was that abnormal breast tissue detected early, with the appropriate follow up, would reduce the mortality rate.

Before 1969, this form of manual detection was the only "screening" option available. However, with the onset of mammography screening in the 1970s, women were able to access formal screening programmes as they became available worldwide. In New Zealand, a national programme was not initiated until 1995, when two-yearly mammography for all women between 50 and 64 years was provided. Now, free two-yearly mammograms are offered to women aged 45 to 69 years. Some agencies and health professionals continued to teach BSE as a way to detect early breast cancer outside the eligible screening age range and in between screening visits.

As evidence-based practice became the norm, however, questions were asked as to whether BSE really did make a difference. As early as 1987, the-validity of BSE was questioned. The United States Preventive Services Task Force published a review of BSE and concluded that "many questions require scientific examination be-fore this procedure can be advocated as a screening test for breast cancer." (3)

However, it wasn't until the late 1990s, when the results of several large randomised controlled trials started to be published, that the evidence became clearer. The Shanghai Trial showed that, despite the participants receiving regular training in BSE and reminders to do so, there was no improvement in mortality figures for breast cancer. (4) Moreover, the trials showed that those women who were randomised to the BSE group were almost twice as likely to undergo a biopsy of the breast. The conclusion was that the harms associated with BSE outweighed any possible benefits. (4)

In 2001, the Canadian Task Force on Preventive Health Care published its recommendations. For women aged 40 to 69 years there was fair evidence of no benefit and good evidence of harm, so teaching BSE should be excluded from any periodic health examinations of women. (5) Younger women were more at risk of increased harms associated with BSE. For older women, there was no evidence of benefit, despite increased rates of breast cancer.

This was then followed by the publication of the Cochrane review paper in 2003 stating that it did not find a beneficial effect of BSE in terms of improvement in breast cancer mortality. (6)

Significant changes found by chance

Research in New Zealand found that although the majority of the women in a study practised BSE, 65 percent of significant changes were not detected during BSE, but were found by chance. (5) Also, 14 percent of women referred to the South Auckland Breast Clinic had waited more than 90 days before seeing their doctor after detecting a breast symptom, and in this group there was no difference in delay between those who performed BSE and those who did not. (7)

A sound evidence base should underpin all health practitioners' practice. Those working in women's health need to acknowledge that BSE should not be routinely taught to women and should inform women what breast symptoms to took out for. These include a new lump or thickening; a change in breast size or shape; unusual pain in the breast; puckering or dimpling of the skin; any change in one nipple, eg a turned-in nipple or a discharge that occurs without squeezing; and a rash or reddening only on the skin of the breast. (2)

Women who request to be taught BSE should be made aware its efficacy is unproven and that it may increase their chances of having unnecessary false-positive biopsies performed.

Encouraging women to be aware of what is normal for their bodies, to know what a breast symptom is and to seek advice early, will reduce late diagnosis and treatment, and hopefully improve outcomes for symptomatic women, without increasing the risk of unnecessary invasive interventions.

References

(1) Ministry of Health. (2008) New Registrations and Deaths 2005. Wellington: The author.

(2) National. Screening Unit, Cancer Society New Zealand and The New Zealand Breast Cancer Foundation. (October 2008) Position Statement an Breast Awareness. http://www.healthed.govt.nz/ resources/positionstatementonbreastawareness,aspx.

(3) O'Malley, M.S. & Fletcher S.W. (1987) US Preventive Services Task Force. Screening for Breast cancer with breast self examination. A critical, review. Journal of American Medical Association; 257:16.

(4) Thomas, D.B., Gao, D.L. et art (2002) Randomised Trail of Breast Serif-examination in Shanghai: Final Results. Journal of The Notional Cancer Institute; 94:19.

(5) Baxter, N. (2001) Preventive health care, 2001 update: should women be routinely taught breast self-examination to screen for breast cancer? Canadian Medical Association Journal; 164:13.

(6) Kosters, J.P. & Gotzsche, P.C. (2003) Regular self-examination or clinical examination for early detection of breast cancer. Cochrane Database of Systematic Reviews; issue 2. Art No: CD003373. DOI:10.1002/14651858. CD003373.

(7) Meechan, G., Collins, J. & Petrie, K. (2002) Delay in seeking medical care for self-detected breast symptoms in New Zealand women. New Zealand Medical Journal; 116:1166.

Sarah Perry, RN,BN, is the adviser, screening and early detection, at the Cancer Society's national office in Wellington.
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Title Annotation:EDUCATION
Author:Perry, Sarah
Publication:Kai Tiaki: Nursing New Zealand
Geographic Code:8NEWZ
Date:Mar 1, 2009
Words:1071
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