Why don’t doctors recommend breast self-exams anymore?


Q: Should I be doing breast self-exams? Why aren’t they recommended now?

A: You should alert your physician if you notice new changes to your breasts such as dimpling, rash or a lump. But teaching breast self-exams isn’t advised anymore because it hasn’t been shown to prevent breast cancer deaths.

In 2009, the United States Preventive Services Task Force (USPSTF) officially recommended against teaching breast self-exams – a practice that had been widely touted in public health campaigns for years before the guidelines. Those decades-old campaigns are ingrained into many of our memories. I recall cards in the locker rooms at the gym growing up that instructed women on breast self-exam technique.

So it may come as a surprise that they’re no longer recommended.

This doesn’t mean women (and men) should not familiarize themselves with their breasts – even if teaching regular breast self-exams hasn’t been shown to affect mortality.

It’s important to recognize important breast changes people may detect in their routine lives while showering, shaving, applying deodorant or putting on a bra. Around 1 in 5 breast cancer survivors report having found their breast cancer “by accident” this way.

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Why isn’t it better to just check regularly?

The 2009 USPSTF recommendation was based in part on two large randomized controlled trials of breast self-exam of thousands of women published in 2002 and 2003.

In both studies, there was no reduction in mortality rates among the groups randomized to a breast self-exam educational program, but there was evidence of harm. That is, patients who were randomly assigned to do breast self-exams were significantly more likely to undergo invasive breast biopsies for benign lesions.

Undergoing these extra, unnecessary procedures can come with a cost – both in the economic sense, but also to the psychological well-being of the patient. The 2003 study did note that malignant as well as benign tumors were found more often among those in the self-exam group, but that didn’t affect mortality.

What that means is that finding a tumor in your breast (because you are actively looking for it during a regular self-exam) or finding it by accident (when you’re showering or getting dressed) has the same result in terms of your chances for surviving the cancer.

Those studies of breast self-exam were done in countries where at that time there were no large screening mammography programs like in the U.S. Here, we do recommend screening mammography for women every two years starting at age 40. (This advice is recent; previously the recommendation was to start at 50.) Unlike breast self-exams, mammography has been shown to reduce mortality in multiple randomized control trials over the years.

Scientists and physicians recognize this still leaves a worrisome void for those cases that occur before the age of 40. Overall, the incidence of breast cancer in women younger than 40 is low – about 25 cases per 100,000 women in 2019. By comparison, there were about 229 cases per 100,000 women in the 40-to-64-year-old age group and 462 per 100,000 in women 65 to 74.

How to best identify and screen younger people at higher risk (most of those cases are not genetic) is a major source of discussion and ongoing research.

We don’t yet have all those answers, but experts tend to agree that familiarizing yourself with your breasts and recognizing important changes is still critical – even if teaching regular breast self-exams is no longer recommended.

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So how can I reduce my risk of breast cancer?

Some risk factors are not under your control like those related to the age when your period started, pregnancy and menopause. Having dense breasts, which is more common among Black women, also raises breast cancer risk. But some risk factors that you can change include quitting smoking, becoming more physically active and cutting back on alcohol.

It’s also important to ask your family members about their medical history, especially if first-degree relatives have breast or ovarian cancer, as this can increase your own risk.

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What I want my patients to know

It’s scary to hear of rising cancer rates among young people, and you may know of people in your own life who have been diagnosed early. It’s important to understand that guidelines are made through a systematic process based on the risks and benefits on a population-wide level. Experts try to make the highest quality recommendation possible to benefit the greatest number of people and harm the fewest number of people. That math can be very complicated.

However, don’t wait until you are 40 to talk about breast health with your doctor. Every person has individual risk factors that are important to discuss one-on-one with your own physician to determine if there are any reasons you may warrant earlier evaluation.
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Dr. Trisha Pasricha. PHOTO: health.harvard.edu

Trisha Pasricha is a physician at Massachusetts General Hospital and an instructor in medicine at Harvard Medical School.



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