Breast self-examination is regularly practiced by one out of four women. After all, more than 90 percent of cancers are found by women themselves, and we all have heard that early detection is the key to “winning the war on cancer.” Early detection is encouraged by the American Cancer Society, the American College of Radiology and the Canadian Association of Radiologists. Should more women examine themselves and be regularly examined by their physicians? The answer would be a resounding yes if regular examination could prevent untimely deaths from breast cancer. But the evidence just isn’t there. In fact, this seemingly innocent test could actually result in more harm than good.
There’s no doubt that on the average, women who examine their breasts regularly will find their cancers earlier than women who don’t or who are more casual about it. Finding cancers early has some advantages (deforming surgery may not be necessary, for instance), but a longer life isn’t necessarily one of them (Lancet 2:654, 1985)
Three recent studies-in Australia, Britain and Japan-have shown discouraging results for the ability of breast self-examination to improve survival. In the Australian study, 32,000 women were taught self-examination, but early results showed no difference in survival between those who examined themselves and those who did not (Australian New Zealand Journal of Surgery 58:289, 1988). In the Japanese study, breast examination by physicians detected 116 cases of breast cancers in 111,571 women. As in the Australian study, these women did not experience longer lives as a result of early detection (Japanese Journal of Surgery 17:377, 1987). In the British study, 63,636 women were taught breast self-examination, but after seven years, researchers concluded there was no difference in survival between these women and the female population in general (Lancet 2:412, 1988).
You would think if a cancer is found earlier, the chances of living longer would be greater. Unfortunately, “early” cancer is not early at all; it has been growing, on the average, for 10 years. The smallest lumps that can be detected by breast self-examination are the grape-sized ones. Lumps reach this size after approximately 10 years of cancerous growth. In more than 90 percent of cases, the cancer has already metastasized, or spread throughout the body into distant areas-the liver, lungs or brain. From this explanation, you should understand why breast self-examination for early detection is a misnomer: How can 10 years be described as early? Even mammography, or x-ray examination of the breasts, doesn’t provide early detection. A mammogram can detect a tumor only six months to two years earlier than breast self-examination, but the cancer has still been growing for at least eight years on the average. And even though a few studies indicate that mammography shows some survival benefits for some age groups, the survival gain is actually small.
At the turn of the century, women considered to have detected breast cancer in its early stages had tumors the size of grapefruit. Obviously this size tumor indicated a very late stage of disease, and the women soon died. Nowadays women are encouraged to check their breasts monthly, have yearly mammograms and see their doctor for regular checkups. An early tumor is now considered to be the size of a pea. Yet the woman with breast cancer today has no better chance of survival than the woman of nearly a century ago. They both live the same number of years, because the cancer in both cases has already spread to other parts of the body where effective treatment is not possible. (The metastasized cancer, not the breast cancer is what eventually kills.) The modern woman doesn’t live longer-She just lives with the knowledge longer.
So who is better off? The woman who knows about her cancer for only three years before she dies, or the woman who knew about her cancer for eight years before she died? I could easily make a case that the early detection caused greater emotional suffering for the second woman. She had more years to know she was ill-years to worry that she would probably die too early in life. She also had more years to be tested and treated by her doctors, and to no avail for her ultimate survival. (See “But Treatment Helps, Right?” page 51.)
For many women, repeatedly looking for cancer in their breasts induces fear and anxiety, a condition so common that it has a name: cancerphobia. This distress is particularly intense after a woman discovers a lump and is waiting for a biopsy (removal of a small piece of a suspected tumor for laboratory analysis) to determine its true nature. Worry is certainly unnecessary for the 80 percent of women who have lumps that are later found not to be cancerous.
Besides anxiety, there are other stresses associated with surgery to investigate breast lumps: financial costs, personal inconvenience, discomfort, pain, deformity and (rarely) death from the surgery. Again, medical investigation is unnecessary for those four out of five women with lumps that are not found to be cancer.
And here is one of the most overlooked risks to breast self-examination: complacency. Women who believe that self-examination alone will help them discover breast cancer early enough to “do something about it” will be falsely reassured, because ultimately, an overwhelming majority of women who are diagnosed with breast cancer will die of cancer. Yet the women are given a false sense of security. Their complacency may make them miss the one thing that could prevent cancer from ever occurring: changing to a more healthful diet.
The standard American high-fat diet has been linked in many studies to the development of breast cancer. Conversely, a low-fat vegetarian diet has been show to reduce obesity and the levels of hormones in the women’s body contribute to breast cancer. I believe that if women realize that the lethal nature of breast cancer is unaltered by breast self-examination detection (and only slightly benefited by mammography and chemotherapy but not benefited by surgery or radiation), they will be much more interested in a low-fat diet-the only effective approach to avoid cancer. Even the American Cancer Society agrees that we should cut down our intake of meat, dairy products and fats, and increase our intake of grains, fresh fruits and vegetables. Furthermore, even after a woman develops breast cancer, changing from a rich diet that promotes breast cancer to a low-fat vegetarian diet that supports good health could slow further cancer growth and prolong a woman’s life.
The greatest advantage to breast self-examination is finding a small cancer, thereby increasing a woman’s chances of having a non deforming lumpectomy (removal of the tumor only, not much of the adjoining tissue) rather than a mutilating mastectomy (removal of the entire breast). Breast cancer surgery should be limited to removal of only the obvious cancer. The scientific literature does not support any more radical therapy. Understand, though, that a lumpectomy doesn’t improve a woman’s chance of survival; it merely removes the tumor before it becomes unsightly or so overgrown that more major surgery is needed.
So the cynic in me asks: Who benefits from early detection by breast self-examination? The doctors who prescribe the tests and treatments, the hospitals and laboratories where the tests and treatments are performed, and the manufacturers who supply the equipment and materials for all those tests and treatments undeniably all benefit from breast self-examination (and any method designed for early detection of any disease). I am not implying that health professionals are swindlers. I believe these people are well intentioned, but the facts stand: The financial bias favors detecting and treating diseases instead of prevention.
To cast any doubt on the advantages of breast self-examination appears to be sacrilegious. But the advocates of self-examination have the responsibility to prove its benefits, and they clearly have not done so. To accept something as a proven advantage to your life without carefully considering all sides of the issue could do more harm than good.
Cancer? Chances are, It’s Not
Almost every American woman has lumps in her breasts at some time. Fortunately, 80 percent of the lumps found are not cancer and only 1 in 10 women will ever develop breast cancer. Certain physical characteristics increase the chance that the lump will turn out to be non cancerous (Annals of Internal Medicine 103:79, 1985). If a lump is soft and cystic (filled with fluid), there is only a 10 percent chance it’s cancer. (Women with many cystic lumps have what is called fibrocystic breast disease, which is not cancer.) A solid, hard mass, however, has a 60 percent chance of being cancer. The most common breast lumps-those with edges that are regular, smooth and distinct-are cancerous less than 10 percent of the time. Conversely, if the edges of the lump are irregular-jagging in and out with solid projections-the chance of their being cancerous is about 60 percent.
Lumps that are easily “moved” only have about 15 percent chance of being found cancerous. A cancerous tumor invades other tissues, including other breast tissue, underlying muscle and the overlying skin. When other tissue is invaded, the tumor becomes less easily movable, or “fixed.” Fixed tumors have a 50 percent chance of being cancer. Benign lumps, such as those in fibrocystic breast disease, often grow and shrink with the changes in a woman’s hormone levels. These non cancerous growths are largest at onset of menstrual bleeding and shrink after the monthly period. Cancers, conversely, are found only to enlarge.
Lumps in older women are most likely to be cancerous because cancer is more common with age. A family history of cancer or a personal history of fibrocystic breast disease may make you more suspicious that your lump is a cancer. Regardless, any suspicious lump should be evaluated by your health practitioner. Fibrocystic breast lumps do not need to be removed, but cancerous tumors should be-ideally when they are small enough for only minor surgery. – J.M.
But Treatment Helps, Right?
By the time breast cancer is detected with even the most sophisticated methods, most cancer already has spread to other parts of the body. If you understand why early detection of cancer by breast self-examination doesn’t add years to a woman’s life, you will understand why most treatments for cancer also do not boost life span. In fact, the state legislature of Hawaii has made it law that women with breast cancer must be informed of this failure of treatment. A brochure prepared by the Hawaii Medical Association and the American Cancer Society, Hawaii Division, states, “When disease is localized to the breast, current information shows equal survival from any of the various therapies (treatments) that remove all the detectable tumor. When disease is spread throughout the body, no form of local therapy has been shown to improve survival.”
In fact, some treatments can do harm. Studies have reported that radiation therapy (treatment by means of x-rays or radioactive substances) decreases a breast-cancer patient’s life span from 1 to 10 percent. A recent study reported in the British Medical Journal (298:1611, 1989) revealed that if radiation is done on the left breast, risk of heart disease increases 65 percent. In addition, radiation therapy for breast cancer doubles a woman’s chance of dying from cancer in other parts of the body.
Chemotherapy (treatment by drugs) likewise has dubious results as far as survival, but there are harmful effects. Although the drugs chosen for chemotherapy are toxic to cancer cells, they also depress the immune system and decrease the body’s ability to fight off microbial infection and defend itself against cancer (Journal of the American Medical Association 252:2611, 1984). The adverse effects also include hair loss, depression, diarrhea, vomiting and oral ulcers.
But all the news is not so bleak. Breast cancer is a slow-growing disease. Fifty percent of middle-aged women diagnosed with breast cancer will still be alive 14 years later. And although there’s no conclusive research, preliminary data suggests that women who maintain an ideal weight and consume a low-fat diet may have longer survival rates than other women diagnosed with breast cancer. The evidence has become so overwhelming that the National Cancer Institute has started a study treating breast-cancer patients with a low-fat diet. And there’s even more evidence that staying trim and cutting the fat will prevent cancer in the first place. – J.M.
Title: Breast self-examination has a harmful side. (Includes related information) (column)
Pub: Vegetarian Times
John A. McDougall. N150 (Feb 1990 n150):pp49(3)