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Breast Self-Examination: Importance, Techniques and Guidelines

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For combating the menace of breast cancer, it is imperative that the cancer is detected early. Breast self-examination is a technique used in an attempt to detect breast cancer in its early stage. During this procedure, a woman examines her breasts herself to detect any lump or other suspicious changes related to breast cancer.

Importance of Breast Self-Examination

Apart from skin melanoma, breast cancer is the most common cancer effecting women in the USA, with almost 202,964 woman affected by it in 2007. It affects women of all races and ethnicities. It is also the leading cause of death and was the cause of mortality of 40,598 American women in 2007. According to the American Cancer Society, although it is impossible to prevent breast cancer, 93% women can survive for at least five years after treatment if the disease is diagnosed at an early stage. Therefore, clinicians lay a great emphasis on compliance with the different screening techniques available for early detection of breast cancer.

Until recent years, breast self-examination had been promoted as a low cost cancer screening technique. Several retrospective and prospective studies done in the past showed that women who routinely examined their breasts presented with smaller tumors and were less likely to have axillary lymph node involvement compared to women who did not examined their breasts.

In a study by Peter Grenwald, et al, published in the New England Journal of Medicine, the researchers examined the effects of breast self-examination on the stage of breast cancer diagnosis in 293 women. They found that the cancer was detected in stage I in 37.7% cases when the women self-examined their breasts as compared to 53.8% cases which were detected during routine physician examination, and 27% cases which were detected accidentally. 69% women, who practiced self-examination of breasts, detected their cancer by this procedure. Even the tumor size was found to be 6.1 mm smaller at the time of presentation in cases detected through self-examination. The researchers suggested that mortality due to breast cancer could be reduced by 18.8% to 24.4% through self-examination of breast or through routine physician examination.

Another added benefit of breast self-examination seen was that women performing this procedure regularly were found to be more motivated to seek medical attention, including mammography and clinical breast exams if available.

Right time for Breast Self-Examination

The ideal time for breast self-examination is at the end of menstruation or seven days after the start of the period. When performed just before or during the menstrual period, the breasts may feel unusually lumpy and can give rise to false positive results. Breast self-examination should be repeated at the same time of menstrual cycle every month so that hormonal changes, which can be attributed to the different phases of the menstrual cycle, can be ruled out.

Technique of Breast Self-Examination

The sensitivity of a breast self-examination depends upon:

  • The position of breasts during examination
  • The amount of area palpated
  • The pattern in which the breast tissue is palpated
  • The variations in the amount of pressure exerted during palpation

The American Cancer Society has laid down the following guidelines for breast self-examination:

  1. The ideal position of the woman while performing breast self-examination is lying down, as this spreads out the breast tissue over the chest wall. This makes the tissue thin and the process of palpation thereby easier. So, the woman should lie down flat on an even surface with her right arm under her head.
  2. Then she should palpate the right breast with the pads of middle three fingers of her left hand. The palpation can be done in two ways to ensure complete coverage of the breast tissue, namely the vertical strip pattern or the pie- wedge pattern. During palpation, the woman should look out any lump, hard knot or thickening of the breast tissue.
  3. The vertical strip pattern involves palpating the breast in an up and down motion. It starts at an imaginary line drawn straight down the side from the underarm and moving across the breast to the middle of the chest bone (sternum or breastbone). The entire area from the collar bone up to the ribs should be palpated. Clinically, the vertical strip pattern of breast self-examination is a better way of palpating the breast tissue.
  4. The pie- wedge pattern of palpation involves palpating the entire breast tissue, moving outwards from the nipple in overlapping concentric rings.
  5. The woman doing breast self-examination is supposed to exert three levels of pressure while palpating the breast. For areas close to the skin, a light pressure exerted by the finger pads will do. Medium pressure is required for deeper tissue while firm pressure is required to palpate the tissue closest to the rib cage. Every spot on the breast tissue should be covered by exerting each pressure level.
  6. All these steps should be repeated on the left breast using the right hand.
  7. The next step in breast self-examination is inspection of the breasts in front of the mirror. The woman should examine her breasts with palms pressing firmly on the hips. This contracts the breast muscles and makes any changes in the breast tissue more obvious. Then, she should inspect her breasts with her arms overhead.
  8. She should look out for any changes in the shape or size of the breast. She should notice if there is any dimpling or puckering of the breast tissue, any itchy, scaly scar or rash on the nipple, retraction or change in position of the nipple, or any spontaneous discharge from the nipple. The discharge from the nipple could be watery, milky, yellowish or blood tinged. It is important to note that the size of both the breasts is rarely identical. However, any marked difference in the sizes may be because of some underlying pathology.
  9. The next step involves the examination of the armpits to rule out any suspicious growth of the axillary lymph nodes. For this, the woman should examine her underarms after slightly lifting the arms. Raising the arms too much will make the skin of the area tout and it will be difficult to palpate for any lump. Examination of underarms can be done in either standing or sitting position.

Breast self-examination is no longer recommended by the American Cancer Society

After being recommended by experts as an important screening technique for breast cancer for almost forty years, the American Cancer Society announced in 2003 that the procedure is no longer recommended. This announcement was done on the basis of results of several studies which have shown that there is no specific advantage of regular breast self exams.

Researchers from the Cochrane Collaboration, after reviewing two previously published population based studies held in Russia and China involving 388,535 women, came to the conclusion that breast self-examination can do more harm than good. It was seen that of all the participants, 587 died of breast cancer. Of these, 292 women had routinely performed breast self-examination while 295 had not. The difference was too small to show any added benefit of breast self-examination. Going a step further, the researchers warned about the potential harm due to self-examination. They found that it may put women at risk for unnecessary treatment. It was seen in the two studies that women who performed breast self exams underwent 3,406 biopsies with benign results. This was two times more than the number of biopsies in women who did not perform self exams.

It has also been seen that finding a lump during breast self-examination can dramatically increase the stress levels in the woman. The procedure does not seem to provide any extra benefit to routine clinical examination and mammography. Moreover, an increased level of awareness about the possibility of breast cancer, by paying attention to any changes in the breast while engaging in normal, daily activities, has been found to be as good as performing a routine breast self-examination. Therefore, the National Cancer Institute does not print a breast self-examination guide in its breast cancer booklet, any longer.

Experts at both the American Cancer Society and the National Cancer Institute fear that women may consider self-examination as a substitute for important screening procedures like mammography, which have a proven track record. This may put them at an even higher risk of developing breast cancer.

Not all experts agree that breast self-examination is not useful

Despite the fact that breast self-examination is no longer recommended by the American Cancer Society, not all experts agree to this view. There are many cancer specialists who feel that downplaying the importance of breast self-examination is not the step in right direction. According to Nan Leslie, Ph.D., associate professor of the School of Nursing at West Virginia University, a woman is more aware of her body than any physician. It is easier for her to notice any abnormal change in her breast tissue and report it to her health care provider. Therefore, minimizing the importance of breast self-examination may not be very advisable.

Current guidelines of the American cancer Society regarding breast self-examination

According to a review of current American Cancer Society guidelines and issues in cancer screening, women should be informed about the potential benefits, limitations, and harm associated with breast self-examination, despite the fact that it is no longer recommended. Whether a woman wants to perform it or not should be entirely her choice. If she decides to opt for it, she should be given directions regarding the proper technique to be followed during the procedure, and her method should be evaluated from time to time.

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