The American Cancer Society is an outstanding organization that does many fine things in the war against cancer, supporting patients and their families, cancer researchers and the public. One of its contributions has been a compendium of recommendations for screening individuals at average risk for cancer, which it has made available for the guidance of the public for many decades. This set of recommendations is generally well reasoned and supported by the existing scientific evidence, though the recommendations of the ACS tend to be more liberal or aggressive than those of the U.S. Preventive Services Task Force, which provides the most rigorous set of recommendations in terms of being data-driven and evidence-based.
Those readers of a certain age will surely recall that for many decades the breast cancer screening recommendations of the ACS included, in addition to mammography and clinical breast examination, a recommendation for monthly breast self-exam (BSE) by each woman. This recommendation engendered a whole panoply of sub-recommendations on exactly how BSE should be performed: the day of the month (for those who were premenopausal), which part of the hand/fingers to utilize for palpation, how to hold your arm during BSE, etc. This led to a virtual mini-industry with the publication of brochures and pamphlets, along with courses and lectures on the subject at community centers and at women’s groups. I can appreciate that BSE provided a form of self-empowerment for women at a time when there was considerable fear and anxiety regarding a dreaded disease.
It should be noted that the ACS, possibly in order to maintain some degree of gender-equality, simultaneously listed a recommendation for monthly testicular exams by men for the early detection of testicular cancer. As with BSE, there were instructions on the correct time and manner in which to undertake this procedure. I do not recall any courses on how to do testicular exams, and I don’t believe I go out on a limb if I say I do not recall any of my friends ever mentioning that they practiced this procedure. I never did.
More importantly, neither of these recommendations ever had a real shred of evidence or data to support its utilization. Both were promulgated solely on the basis of what I mentioned two weeks ago: The screening recommendation seemed logical and intuitive, was cheap, easy, noninvasive and nontoxic, and certainly, even if it did not help, could not hurt.
If you check the ACS recommendations for the past decade, you will find that both these recommendations have been deleted. What happened?
The answer is a truly remarkable study that was published by investigators from the Fred Hutchinson Cancer Research Center in Seattle in 2002. The study, a randomized trial, was conducted in Shanghai, China. Rather than randomizing individual women, the study randomized factories—519 textile factories where women were the primary employees.
These factories were randomized to either be in the BSE group or the control group.
Approximately 266,064 women worked in these 519 factories, so effectively there were 133,000 women in each group. Between 1989 and 1991, the experimental group was provided with instruction on how to do BSE with occasional reinforcement sessions. They had practice sessions under medical supervision every six months for five years and ongoing reminders to practice BSE monthly. Both groups were followed through 2000 for breast cancer mortality, i.e., 10-11 years of follow-up. At the end of that time, there were 135 breast cancer deaths in the BSE group and 131 breast cancer deaths in the control group for no difference.
The story does not end there. Over the course of the trial, many more lumps were identified by the women practicing BSE than in the control group and thus leading to biopsies of what proved to be benign lesions. Specifically, there were 2,761 benign lesions diagnosed in the experimental group versus 1,505 in the control group. Thus, it is clear that BSE not only did not reduce breast cancer mortality, but also increased the rate of false positives and unnecessary breast biopsies. Thus, the practice was not harmless.
I would not want the take-home message from this to be, God forbid, that some reader concludes that if she detects a suspicious new lesion in her breast, which she recognizes as new, that she ignores it or delays bringing it to the attention of her healthcare provider—primary care physician, gynecologist, whomever. There is a distinction between detection of a new lesion, which falls into the category of a symptom and requires appropriate diagnostic evaluation, and screening, which is the regular application of a test to look for an abnormality. We may recognize when we feel warm that a fever requires diagnosis and management, but we don’t typically take our temperature daily to screen for a fever.
Alfred I. Neugut, MD, PhD, is a medical oncologist and cancer epidemiologist at Columbia University Irving Medical Center/New York Presbyterian and Mailman School of Public Health in New York.
This article is for educational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment, and does not constitute medical or other professional advice. Always seek the advice of your qualified health provider with any questions you may have regarding a medical condition or treatment.
