The effect of breast self-examination on early detection and survival

Assessing breast self-examination knowledge and practices among women in Iraq: A cross-sectional study

Background and Aims

The present study aims to shed light on the knowledge, attitude, and practice of breast self-examination with breast cancer (BC) among female patients in the oncology department of Baghdad Medical City.

Methods

This cross-sectional study involved 100 female participants at the Oncology Teaching Hospital in Baghdad Medical City between June 15 and October 15, 2022. Using convenient sampling, the study targeted females aged 30-75, recently or previously diagnosed with BC, admitted for treatment and follow-ups.

Results

Regarding the assessment of knowledge, among the surveyed patients, 71 are aware of breast self-examination (BSE), primarily through social media (42 patients). The study also explores the link between BSE and education levels. While Pearson's chi-square shows no significance (0.107), the likelihood ratio suggests a significant association (0.041). Regarding the analysis of attitudes, the study assessment for the reasons for compliance showed that 19 patients cite medical reasons, and 48 patients attribute noncompliance to a lack of knowledge of how to perform BSE. Regarding the examination of practice, high statistical significance is evident in both Pearson's chi-square (0.000) and likelihood ratio (0.000) tests, emphasizing the substantial relationship between the post-diagnosis initiation timing of BSE and its correct execution. Additionally, a statistically significant association exists between performing BSE correctly and discovering BC (p = 0.000).

Conclusion

Regarding the assessment of knowledge, our study found high awareness of BSE within the population, primarily through social media and health organizations. Regarding the analysis of attitudes, a notable proportion refrained from practicing BSE, primarily due to a perceived lack of knowledge about the methods. Regarding the examination of practice, the observed significant associations between performing BSE correctly, discovering BC, and the frequency of examinations underscore the pivotal role of consistent and accurate BSE in early detection.

Breast Self-Examination - the case for a second look

PURPOSE OF REVIEW

Breast Self-Examination (BSE) remains controversial despite the 2009 United States Preventive Service Task Force (USPSTF) recommendation against teaching of BSE. The USPSTF recommendations were based on results from the Shanghai Study, high-quality randomized trial of BSE in 266,064 Chinese factory workers from 1989-1991; women instructed in BSE did not have a significant difference in mortality versus uninstructed controls. Regardless of the outcome of the Shanghai Study, the practice of BSE in the United States (U.S.) over the past 25 years has been associated with a marked reduction in the size of breast cancer identified by women.

RECENT FINDINGS

In the Shanghai study, BSE was tested in China from 1989-1991. During this time period, Chinese breast cancer screening and treatment was not consistent with standard-of-care in U.S. and Europe. Breast cancer was a rare illness in China in the 1980's. Treatment was not standardized; there was no breast imaging or margin assessment of the tumor. Tumor markers (e.g. estrogen receptor, progesterone receptor) were not reported. The Shanghai Study did not report in detail on the anti-cancer agents provided to women who enrolled in the trial.

SUMMARY

BSE needs to be rigorously re-evaluated under current standard of care.

Commentary - Evidence Against Breast Self Examination is not Conclusive: What Policymakers and Health Professionals Need to Know

Breast cancer is a serious health concern and a disease that is not well understood. Early detection remains the best way to prevent debilitation and death. Traditionally, mammography, clinical breast examination (CBE), and breast self examination (BSE) have been accepted as legitimate breast screening modalities. Over the past 5 years, academics, health professionals, and policymakers have seriously questioned the usefulness of BSE after influential organizations such as the Canadian Task Force on Preventive Health Care downgraded their BSE recommendation citing fair evidence of no benefit and good evidence of harm. We briefly review the three large BSE trials, highlighting methodological weaknesses limiting their ability to evaluate its effectiveness, as well as critique the 2001 Canadian Task Force on Preventive Health Care report on BSE. We argue that it is premature to conclude that BSE is ineffective. Given that most women find their own breast cancer, this article cautions policymakers and health professionals that a prudent approach to BSE promotion should be taken.

Increasing our understanding of breast self-examination: women talk about cancer, the health care system, and being women

The author engaged 13 women, aged 30 to 59, in a collaborative research project over several months to explore the meaning of breast self-examination (BSE) to them. Through a series of 11 group discussions, the women developed a critical consciousness of the commonality of their personal experiences in relation to BSE. Although these women valued BSE, their reluctance to perform it was influenced by their perceptions of breast cancer as a lethal disease, the perceived threat it posed to their femininity, and their ability to negotiate an increasingly medical and technological health care system. This study provides insight into the importance of the social environment and shared understandings in influencing women's individual behavioral choices for BSE. It also illustrates the particular value of collaborative health research.

Breast cancer mortality in relation to clinical breast examination and breast self-examination

Mammography is the most sensitive available means for early detection of breast cancer, but both clinical breast examination (CBE) and breast self-examination (BSE) have the potential to advance the diagnosis of breast cancer without the expense of a mammography facility. CBE detects about 60% of cancers detected by mammography, as well as some cancers not detected by mammography. There have been no randomized trials comparing breast cancer mortality between women offered and not offered CBE. However, indirect evidence comes from a Canadian study in which women were randomly assigned to CBE alone or CBE plus mammography. Women in the two groups had similar rates of nodal involvement at diagnosis and of breast cancer mortality. Thus if receipt of mammography averts some deaths from breast cancer, the results of this study suggest that CBE has the potential to do so as well. Most studies have found that breast cancers detected by BSE are smaller than those detected without screening and are more likely to be confined to the breast; furthermore, survival after a diagnosis of breast cancer tends to be longer among women who practice BSE than among women who do not. However, neither observational nor randomized studies of BSE provide evidence that this screening modality reduces breast cancer mortality. A recent randomized study in Shanghai, China, found that women assigned to extensive BSE instruction and women assigned to another health intervention had similar distributions of cancer size and stage at diagnosis and similar breast cancer mortality rates. In summary, CBE appears to be a promising means of averting some deaths from breast cancer, whereas BSE appears to have little or no impact on breast cancer mortality.

Breast self-examination and death from breast cancer: a meta-analysis

Breast self-examination (BSE) is widely recommended for breast cancer prevention. Following recent controversy over the efficacy of mammography, it may be seen as an alternative. We present a meta-analysis of the effect of regular BSE on breast cancer mortality. From a search of the medical literature, 20 observational studies and three clinical trials were identified that reported on breast cancer death rates or rates of advanced breast cancer (a marker of death) according to BSE practice. A lower risk of mortality or advanced breast cancer was only found in studies of women with breast cancer who reported practising BSE before diagnosis (mortality: pooled relative risk 0.64, 95% CI 0.56-0.73; advanced cancer, pooled relative risk 0.60, 95% CI 0.46-0.80). The results are probably due to bias and confounding. There was no difference in death rate in studies on women who detected their cancer during an examination (pooled relative risk 0.90, 95% CI 0.72-1.12). None of the trials of BSE training (in which most women reported practising it regularly) showed lower mortality in the BSE group (pooled relative risk 1.01, 95% CI 0.92-1.12). They did show that BSE is associated with considerably more women seeking medical advice and having biopsies. Regular BSE is not an effective method of reducing breast cancer mortality.

Randomized trial of breast self-examination in Shanghai: final results

BACKGROUND

Among women who practice breast self-examination (BSE), breast cancers may be detected when they are at an earlier stage and are smaller than in women who do not practice BSE. However, the efficacy of breast self-examination for decreasing breast cancer mortality is unproven. This study was conducted to determine whether an intensive program of BSE instruction will reduce the number of women dying of breast cancer.

METHODS

From October 1989 through October 1991, 266,064 women associated with 519 factories in Shanghai were randomly assigned to a BSE instruction group (132,979 women) or a control group (133,085 women). Initial instruction in BSE was followed by reinforcement sessions 1 and 3 years later, by BSE practice under medical supervision at least every 6 months for 5 years, and by ongoing reminders to practice BSE monthly. The women were followed through December 2000 for mortality from breast cancer. Cumulative risk ratios of dying from breast cancer were estimated using Cox proportional hazards models. All statistical tests were two-sided.

RESULTS

There were 135 (0.10%) breast cancer deaths in the instruction group and 131 (0.10%) in the control group. The cumulative breast cancer mortality rates through 10 to 11 years of follow-up were similar (cumulative risk ratio for women in the instruction group relative to that in the control group = 1.04, 95% confidence interval = 0.82 to 1.33; P =.72). However, more benign breast lesions were diagnosed in the instruction group than in the control group.

CONCLUSIONS

Intensive instruction in BSE did not reduce mortality from breast cancer. Programs to encourage BSE in the absence of mammography would be unlikely to reduce mortality from breast cancer. Women who choose to practice BSE should be informed that its efficacy is unproven and that it may increase their chances of having a benign breast biopsy.

Preventive health care, 2001 update: should women be routinely taught breast self-examination to screen for breast cancer?

OBJECTIVES

To evaluate the evidence relating to the effectiveness of breast self-examination (BSE) to screen for breast cancer and to provide recommendations for routine teaching of BSE to women in various age groups as part of a periodic health examination.

OPTIONS

Routine teaching of BSE to women.

EVIDENCE

The electronic databases MEDLINE, PreMEDLINE, CINAHL, Health-STAR, Current Contents and the Cochrane Library were searched for abstracts and full reports of studies published from 1966 to October 2000 that evaluated the effectiveness of BSE in reducing breast cancer mortality. In addition, references of key papers were searched and experts consulted to ensure that all relevant articles had been identified.

OUTCOMES

Prevention of death from breast cancer was viewed as the most important outcome; other outcomes examined included the stage of cancer detected, the rate of benign biopsy results, the number of patient visits for breast complaints, and psychological benefits and harms.

VALUES

The recommendations of this report reflect the commitment of the Canadian Task Force on Preventive Health Care to provide a structured, evidence-based appraisal of whether a manoeuvre should be included in the periodic health examination.

BENEFITS, HARMS AND COSTS

Breast cancer is the most frequently diagnosed cancer among Canadian women, accounting for 30% of all new cancer cases each year. In 2000 an estimated 19,200 Canadian women would have been diagnosed with breast cancer, and 5500 would have died from the disease. To date, 2 large randomized controlled trials, a quasi-randomized trial, a large cohort study and several case-control studies have failed to show a benefit for regular performance of BSE or BSE education, compared with no BSE. In contrast, there is good evidence of harm from BSE instruction, including significant increases in the number of physician visits for the evaluation of benign breast lesions and significantly higher rates of benign biopsy results.

RECOMMENDATIONS

Women aged 40-49 years: Because there is fair evidence of no benefit, and good evidence of harm, there is fair evidence to recommend that routine teaching of BSE be excluded from the periodic health examination of women in this age group (grade D recommendation). Women aged 50-69 years: Because there is fair evidence of no benefit, and good evidence of harm, there is fair evidence to recommend that routine teaching of BSE be excluded from the periodic health examination of women in this age group (grade D recommendation). The lack of sufficient evidence to evaluate the effectiveness of the manoeuvre in women younger than 40 years and those 70 years and older precludes making recommendations for teaching BSE to women in these age groups. The following issues may be important to consider: Women younger than 40 years: There is little evidence for effectiveness specific to this group. Because the incidence of breast cancer is low in this age group, the risk of net harm from BSE and BSE instruction is even more likely. Women 70 years and older: Although the incidence of breast cancer is high in this group, there is insufficient evidence to make a recommendation concerning BSE for women 70 years and older. Important note: Although the evidence indicates no benefit from routine instruction, some women will ask to be taught BSE. The potential benefits and harms should be discussed with the woman, and if BSE is taught, care must be taken to ensure she performs BSE in a proficient manner.

VALIDATION

The findings of this analysis were reviewed through an iterative process by the members of the Canadian Task Force on Preventive Health Care. The task force sent the final review and recommendations to 4 independent experts, and their feedback was incorporated in the final draft of the manuscript.

SPONSORS

The Canadian Task Force on Preventive Health Care is funded through a partnership between the Provincial and Territorial Ministries of Health and Health Canada.

Breast self-examination: an analysis of self-reported practice

The aim of this study was to investigate the relationship between the performance of breast self-examination (BSE) and age, place of residence, ethnic background and religion, as well as whether a group willing to take part in an interview regarding BSE mirrored the whole population. Six hundred and ninety-four (69.4%) women, aged 25-80, responded to the questionnaire. Of these, 69.6% examined their breasts. Whether the subjects lived in urban or rural areas was of no importance for practising BSE, nor was country of birth or number of years in Sweden. A larger proportion of women aged 45-80 practised BSE compared with women aged 25-44 (P < 0.001), the former practising BSE once a month or more. Step-wise logistic regression analysis showed that, for the whole sample as well as for the interview group, age was the only significant predictor of breast self-examination (P < 0.001). There were no significant differences between the whole sample and the interview group. The importance of younger women performing the examination is stressed. Due to nurses being strategically located in a wide range of geographical locations, allowing them to meet women in different settings, they are a good choice for motivating women to practise BSE.

The practise of breast self-examination over a six-year period following teaching

The null hypothesis is that there is no difference in the performance of breast self-examination (BSE) with respect to three teaching methodologies. A total of 614 women were randomly assigned to a group receiving content only, one receiving content plus supervised practise on a model with implanted lumps or one receiving content plus instruction on their own breasts. It has been established that all groups increased significantly their frequency of practise and level of confidence (Alcoe SY, Gilbey VJ. McDermot RSR, Wallace DG. The effects of teaching breast self-examination: reported confidence and frequency of practise over a six-year period. Patient Educ Couns 1994; 23: 13-21). This paper considers the steps undertaken during BSE and the changes likely to be noticed through factors labelled Technique, Observation, Inspection and Palpation. The factors have been created from 35 items reflecting multiple aspects of the procedure as reported at four follow-ups. The group wherein teaching involved practise on their own breasts achieved higher scores than the other groups. Scores for Technique and Inspection are better maintained over time than are those for Observation and Palpation.

The effects of teaching breast self-examination: reported confidence and frequency of practise over a six-year period

Breast self-examination (BSE) was taught to 614 women. They were randomly assigned to one of three groups identified as content only, content plus supervised practise on a model with implanted lumps and content plus individual instruction on their own breasts. They were followed for 6 years. Reported frequency of practise and level of confidence increased at a significant level within all groups. The increase persisted at each of four follow-ups. An analysis of variance determined there was no significant difference between groups in the changes in frequency and confidence. Thus, the method of teaching had little impact on the long-range practise of BSE in terms of these two variables. It was observed that 10.8% of the group receiving individual instruction would not accept teaching on their own breasts. Less than 1.5% in each of the other groups would not accept all aspects of the teaching protocol for their respective group. This development should be taken into account in determining whether practise on one's own body is a necessary component of BSE teaching programs.

The practice of breast self-examination results in the earlier detection and better clinical course of Japanese women with breast cancer

Using a questionnaire survey, we analyzed the relationship between the frequency of breast self-examination (BSE) and the clinical stage and course of breast cancer in Japanese patients. BSE had been performed monthly by only 5.4% of the patients (M group), occasionally by 35.4% (O group), and not at all by 59.2% (N group). There was a positive relationship between more frequent BSE and an earlier clinical stage, the percentages of Tis/stage 0 and I for the M, O, and N groups being 83%, 44%, and 36%, respectively (P < 0.05). The mean maximum tumor diameters for the three groups were 1.7 cm, 2.5 cm, and 3.0 cm, respectively. The tumor size in the M and O groups was significantly smaller than that in the N group at P < 0.01 and P < 0.05, respectively. The percentages of patients in the M, O, and N groups who underwent breast-conserving therapy were 42%, 11%, and 19%, respectively, with patients who had performed monthly, BSE more frequently undergoing breast-conserving therapy (P < 0.05). At a median follow-up time of 34 months, 0%, 3.8%, and 7.6% of the patients from the M, O, and N groups, respectively, had died of breast cancer, the overall survival curve of the M group being significantly better than that of the N group (P < 0.01). This retrospective study suggests the positive correlation of BSE frequency with earlier detection, and a more favorable clinical course in Japanese breast cancer patients.

Method of tumor detection influences disease-free survival of women with breast carcinoma

BACKGROUND

Screening mammography provides the primary means of reducing breast cancer mortality. Clinical breast examination (CBE) and breast self-examination (BSE) may be complementary screening modalities enabling palpation of interval cancers and detection of tumors not visualized by mammography; however, their combined contribution to improving prognosis has not been evaluated adequately.

METHODS

Disease-free survival was assessed in relation to method of tumor detection among 729 consecutive patients treated by mastectomy and axillary dissection for primary breast carcinoma between 1976 and 1978.

RESULTS

Disease-free survival at 10 years was significantly higher after detection by mammography (77% of 30 patients) or CBE (78% of 101 patients) compared to self-detection (64%). The hazard ratio of recurrence associated with clinical examination or mammography in contrast to self-detection was significantly reduced to 0.55 (95% CI, 0.37-0.81; P = 0.001). In addition, annual CBE, compared to less frequent clinical palpation, reduced the risk of recurrence controlling for detection modality (P = .03). In multivariate analyses, the method of detection and frequency of clinical breast examination remained statistically significant prognostic factors after controlling for number of screening mammograms, history of prior breast surgery, family history of breast cancer, and age at diagnosis. Differences in self-examination frequency were not associated with prognosis.

CONCLUSIONS

Among patients diagnosed before widespread mammography screening, tumor detection by CBE was associated with a significant reduction in recurrence compared with detection by self-palpation. Improvement in the frequency and quality of CBE and BSE may enhance the contribution of these modalities to early detection, complementing the role of screening mammography in reducing breast cancer mortality rates.