Young Survival Coalition Position on Breast Self Exam and Early Detection

November 15, 2002

Young Survival Coalition Position on Breast Self Exam and Early Detection

New York, NY - (November 15, 2002)

Overview:
In response to inquiries from YSC members regarding Breast Self Examination (BSE) and early detection and in light of recent studies on BSE, the YSC has developed this position paper. The goal of the paper is to educate YSC membership and young women on BSE and early detection so they can make informed healthcare decisions.

Position:
The Young Survival Coalition urges the scientific community to find an accurate method for early detection of breast cancer in young women. Until that time, we recommend that young women consider their risks and benefits in deciding whether to perform monthly breast self-exams and have annual exams by a clinician beginning at age 20.

By the time a woman feels a lump in her breast it could have been there for nearly 8-10 years. Early detection is defined as the ability to identify abnormal cells before they become cancer. Society needs a method of distinguishing between breast cancers that need to be treated and those that might never pose a threat to a woman's life. In addition, if we can define better screening options and guidelines for young women at high risk for breast cancer (ie: family history etc.), then these options will benefit all women.

Despite the prevailing opinion that young women don't get breast cancer, the reality is that they can and they do. In fact, breast cancer is the leading cause of cancer death in women ages 15-54,5 and one in every 258 women between the ages of 30 and 40 will be diagnosed with breast cancer within the next 10 years.

Breast cancer in younger women can be more aggressive and their diagnosis tends to be delayed as a result of the lack of appropriate screening and diagnostic tools, and insufficient education about the disease among young women and the medical community.

Currently, women under 40 have no other existing methodology for detecting breast cancer other than monthly breast self-examination and annual clinical examination. These methods have not been proven to save lives, however a woman should be educated about how to be her own best health advocate and make a very personal choice about whether or not to perform BSE. Other methods of detecting breast cancer include:

  • Mammography: Mammography is only recommended as a screening tool in cases where young women have a first degree relative risk, and is virtually ineffective in penetrating the denser breast tissue which is more prevalent in a pre-menopausal woman.
  • Ultrasound: The benefit of screening ultrasound shows great promise for pre-menopausal women with dense breasts. Currently, the most cost effective use of this technology is to diagnose a suspicious area of a woman's breast either detected through palpation or mammography. Using ultrasound screening alone is not a widely used practice. 3
  • MRI: Recently published studies show great promise for breast MRI for young women, however cost considerations will likely prevent it from becoming the gold standard for screening. In addition, one might be concerned about the high false positive rate detected with the use of MRI's. 4


Background:

In the June 26, 2001 issue of the Canadian Medical Association Journal, the Canadian Task Force on Preventive Health Care published its findings and recommendations regarding the effectiveness of Breast Self Examinations as a screening tool for the diagnosis of breast cancer in various age groups. The final recommendations published by the Task Force and picked up in the media accounts of the research, was that after review of existing literature regarding BSE, there was "fair evidence of no benefit" and "good evidence of harm" in women ages 40-69. It was further recommended that routine teaching of BSE be excluded from health examinations. 1

According to the Task Force, the risk of "net harm" in the younger population is even more likely. "Net harm" in the context of the BSE study is defined as an increase in physician visits and increase in benign breast biopsy procedures. Perhaps, young breast cancer patients would happily trade their advanced stage diagnoses for a handful of benign breast biopsy procedures. However, young women should be cautioned that scar tissue resulting from surgical excision biopsies could compromise the ability of future mammogram and sonogram screenings in detecting cancers that might grow near that scar tissue. 4

As is typically the case, women under 40 were grossly under-represented in the research, and as such, the recommendations provided for the older population were generalized by the media and cycled into the mainstream as the standard recommendation for all.

In the October 2, 2002 issue of the JNCI, Thomas et. al., reported that BSE did not decrease mortality in a study involving 266,000 female factory workers in Shanghai aged 30-63. Forty percent of these women were 30 - 40 years old. The study divided the women into two separate groups. One group was instructed on how to perform BSE while the control group was given lower back pain instruction. The study revealed that there was no benefit to teaching women BSE in a controlled environment because a similar number of cancers were detected in both the control and instruction groups and survival time from diagnosis and staging of disease were similar in both groups. The study found that women in the BSE instruction group had a more enhanced level of awareness and ability to find lumps in their breasts, however they found more benign breast lesions than women in the control group. 2

The study authors went on to say: It is possible that highly motivated women could be taught to detect cancers that develop between regular screenings, and that the diligent practice of BSE would enhance the benefit of a screening program. Until such a trial is conducted, there is no reason to discourage women who choose to practice BSE from doing so. However, it should be emphasized to such women that they must practice BSE regularly and with a high degree of proficiency. They should also be informed that if they do this, they have an increased chance of having a breast biopsy that does not reveal a cancer and that it is not known whether practicing BSE to detect interval cancers that develop between mammographic screenings will reduce a woman's chance of dying from breast cancer.

Because breast cancer in young women is a relatively rare disease, it is highly unlikely that screening methodologies will be developed as a public health intervention for all young women, and only young women considered at 'high risk' will benefit from public screening programs.

While we would agree that breast self examination is not the most effective method for breast cancer detection and potentially diverts resources from other preventive strategies, it currently exists as the ONLY method available to younger women but ONLY IF we are educated enough to know how and when to do it, as is actually suggested in the Shanghai study. This was a trial of the teaching of BSE, not the practice of BSE. It should not be inferred from the results of this study that there would be no reduction in risk of dying from breast cancer if women practiced BSE competently and frequently.

The YSC will continue to strongly advocate for the scientific and medical communities to develop an accurate and effective methodology for breast cancer screening in women 40 and under. Until that time, we recommend that young women consider their risks and benefits in deciding whether to perform monthly breast self-exams and have annual exams by a clinician beginning at age 20.

About the Young Survival Coalition:
The Young Survival Coalition is the only international non-profit dedicated to the critical concerns and issues unique to young women and breast cancer. Through action, advocacy and awareness, the YSC seeks to educate and influence the medical, research, breast cancer and legislative communities to address breast cancer in women 40 and under, and to serve as a point of contact for young women living with breast cancer.


References:

1. Baxter, Nancy, Preventive health care 2001 update: Should women be routinely taught breast self-examination to screen for breast cancer, CMAJ 2001;164: 1837-46.
2. Thomas, David B. et al., Randomized trial of breast self-examination in Shanghai: Final results, JNCI, Vol 94-19:1445-57
3. Institute of Medicine. Mammography And Beyond: Developing Technologies For The Early Detection Of Breast Cancer, Committee on the Early Detection of Breast Cancer; Sharyl J. Nass, I. Craig Henderson and Joyce C. Lashoff, editors, Washington, DC, National Academy Press, 2001: 225
4. Institute of Medicine. Mammography And Beyond: Developing Technologies For The Early Detection Of Breast Cancer, Committee on the Early Detection of Breast Cancer; Sharyl J. Nass, I. Craig Henderson and Joyce C. Lashoff, editors. Washington, DC, National Academy Press, 2001: 39
5. NCI, Fact Book, 2001