If you’re anxious about performing a breast self-exam (BSE) or embarrassed about skipping it for months at a time, don’t beat yourself up. Major medical organizations no longer recommend BSE as a screening tool for early detection in women who are at average risk of the disease.
But they do insist on “breast self-awareness.” Essentially, that means becoming familiar with how your breasts normally look and feel so you will be more likely to recognize anything out of the ordinary.
“I think the take-home message to women is to be alert to changes in their breasts,” says Robert Smith, PhD, an epidemiologist and vice president of cancer screening for the American Cancer Society in Atlanta.
Yet some clinicians argue the best way for women to get to know their breasts and recognize possible changes is breast self-exam.
“Telling women to be ‘aware’ of their breasts is confusing,” according to Deborah Axelrod, MD, professor of surgery and director of clinical breast programs and services at NYU Langone Health’s Perlmutter Cancer Center in New York City. It suggests that they should know they have breasts, she says, “but not what they could contain.”
BSE was once considered a crucial tool for early breast cancer detection, especially before mammography became the gold standard for breast cancer screening.
A thorough breast self-examination involves multiple steps. A woman searches each breast and surrounding tissue in a precise matrix using her fingers to feel for any unusual lumps or thickening tissue. It’s performed while lying down and standing up. The final step requires a mirror to observe any changes in the appearance of her breasts.
Naturally, doctors assumed that teaching women BSE would save lives. But evidence from two large clinical trials—one in China and another in Russia—failed to show any significant reduction in breast cancer deaths among women who were taught the technique compared with those who did not receive such instruction.
There were issues with the studies, experts acknowledge. For example, women who learned to perform BSE either failed to stick with it month after month or didn't do it correctly. Furthermore, the studies raised concern about unnecessary testing because women doing BSE had more imaging procedures and biopsies.
After weighing the risk of false alarms against the lack of evidence of potential benefit, guideline-writing groups, including the U.S. Preventive Services Task Force, American Cancer Society, and American College of Obstetricians and Gynecologists (ACOG), began to walk back their stance on BSE.
Regardless, some doctors and patient advocates continue to endorse self-examination as an important screening tool.
“For any individual, it could be what makes the difference between less aggressive treatment and potentially longer survivorship,” insists Marisa Weiss, MD, director of breast health outreach at Lankenau Medical Center in Wynnewood, Pennsylvania and chief medical officer of Breastcancer.org, a nonprofit educational outlet.
Breastcancer.org recommends that all women perform these routine self-exams and get mammograms and clinical breast exams from their doctor.
Lisa Jacobs, MD, an associate professor of surgery who specializes in breast cancer at Johns Hopkins Kimmel Cancer Center in Baltimore, says it “should be a conversation about whether it’s beneficial in an individual.”
“Frankly, mammography can miss between 10 and 20% of breast cancers,” she adds. “And so if the only screening test is mammography, … how are we going to find those cancers?”
Younger women don’t get screening mammograms, so it’s often the way they find breast cancer, adds Jessica Young, MD, assistant professor of oncology in the breast surgery division at Roswell Park Comprehensive Cancer Center in Buffalo, New York.
On the other hand, some women don’t want to do self-exams because “it gives them too much anxiety,” and that’s fine, Dr. Young says, as long as they see a doctor regularly and get prescribed breast cancer screenings.
Trouble is most women are unaware of the updated breast screening guidelines, and many lack access to consistent health care, Dr. Axelrod notes.
What it means to be breast self-aware
Mark Pearlman, MD, professor in the department of obstetrics and gynecology at the University of Michigan Hospital and Health Systems in Ann Arbor, was involved in writing ACOG’s breast cancer screening guidelines, which reflect the risk of harm from false-positive test results and lack of evidence of benefit.
Still, Dr. Pearlman notes that half of women over age 50 and 70% of women younger than 50 find their own breast cancers. “So we can’t really say, OK, just ignore your breasts.” That gave rise to the concept of breast self-awareness, he says.
What does it mean, exactly, to be breast self-aware? Actually, there’s no standard definition. Critics like Dr. Weiss say that’s a problem because “women are left with little useful direction.”
ACOG describes self-awareness as knowing what is normal for your own breasts and paying attention to changes you might feel.
Susan G. Komen, the national breast cancer research and patient advocacy group, defines it very broadly. Women need to know their breast cancer risk, including any family history of the disease, it says. They should have regular mammograms and clinical breast exams. They need to make healthy lifestyle choices, and they ought to know what’s normal for them.
“It’s important to know the warning signs of breast cancer,” adds Susan Brown, RN, managing director of Komen’s health and mission program education. Look for a lump, hard knot, or thickening in the breast; a change in shape or size of your breast; or signs like swelling, redness, or nipple discharge, for example.
Dr. Pearlman advises average risk patients to be aware of anything that feels odd while putting on a bra, washing in the shower, or being intimate with a partner. “If anything feels different, call your provider, he says. “It’s a relatively simple message.”
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