Breast Cancer Screening Guidelines

While there are wide differences of opinion among prominent organizations about preferred breast cancer screening guidelines, most breast cancer is first detected bythe hands of women or their health care providers. The American College of Obstetricians and Gynecologists (ACOG) notes that self-exams are effective in detecting breast cancer for a majority of women although this finding conflicts with  the United States Preventive Services Task Force (USPSTF), and the American Cancer Society (ACS). These two organizations jointly recommend against teaching women how to perform self-exams of their breast and discourage screening by the hands of nurses and physicians.

In their current "Practice Bulletin” the American College of Obstetricians and Gynecologists states:

“Although breast-self examination is no longer recommended [by USPSTF ], evidence of the frequency of self-detection of breast cancer provides strong rationale for breast self-awareness in the detection of breast cancer. Approximately 50% of cases of breast cancer in women 50 years and older and 71% of cases of breast cancer in women younger than 50 years are detected by women themselves. (40, 41). For example, 43% of the 361 breast cancer survivors who participated in the 2003 National Health Interview Survey reported detecting their cancer themselves (42). Additional evidence of the important role of breast cancer self- detection comes from a study of low-income women who received breast cancer care through California’s Breast and Cervical Cancer Treatment Program. Of the 921 women in the cohort, 64% detected their breast cancer (43)”.

Although well-intentioned, organizations differ in their opinions and the data selected to support them, issuing press releases may be a disservice to women worldwide. More than 500,000 women die each year from breast cancer and there is little disagreement that most women find their own cancer and at a late stage. Discouraging women and their healthcare providers from learning to perform a thorough, skilled breast exam has a global impact that is unlikely to improve the outcomes for the vast majority of women.

Progress in BSE and CBE

Many of the studies that inspired criticism of breast self-examination (BSE) and clinical breast exams (CBE) were conducted before it was known how to perform the exam effectively and before the advent of advanced breast cancer treatment options.  Women and researchers relied on pamphlets and video demonstrations as teaching devices that failed to address the central question of the tactile sense: what does a lump actually feel like?  To improve tactile  breast exam skills, the National Science Foundation supported development and validation of  a hands-on computer- guided training technology that is now in use teaching students in colleges of medicine and nursing as well as obgyn residents and advanced practice nurses. The platform trains hands to perform accurate clinical breast exams and validates acquisition of the requisite skills. The results of training are reported in terms of sensitivity,  specificity and percent of tissue examined as trainees advance through a series of increasingly complex palpation modules.

Annotated bibliography: Physical Examination of the Breast

A significant number of women present with palpable breast cancer even with a normal mammogram within 1 year. Am J. Surg 2010 Dec;200(6):712-7. Haakinson DJ, Stucky CC, Dueck AC, Gray RJ, Wasif N, Apsey HA, Pockaj B. “Patients presenting with palpable masses on SBE or CBE even with a normal mammogram within 1 year tended to have more aggressive tumors… resulting in more aggressive therapy ”

Palpable presentation of breast cancer persists in the era of screening mammography. J Am Coll Surg. 2010 Mar;210(3):314-8. Mathis KL, Hoskin TL, Boughey JC, Crownhart BS, Brandt KR, Vachon CM, Grant CS, Degnim AAC. “Patients with palpable presentation were younger than those with screen-detected cancer (mean age 57 versus 62 years…” abstract  p1

Discovery of breast cancers within 1 year of a normal screening mammogram: how are they found? Ann Fam Med. 2006 Nov-Dec;4(6):512-8. Carney PA, Steiner E, Goodrich ME, Dietrich AJ, Kasales CJ, Weiss JE, MacKenzie, T. “Having a lump and both a personal and a family history of breast cancer was the most common reason why women initiated a health care visit.”

Self-Detection Remains a Key Method of Breast Cancer Detection for U.S. Women. J Womens Health 2011 Jun 15. [Epub ahead of print] Roth MY, Elmore JG, Yi-Frazier JP, Reisch LM, Oster NV, Miglioretti DL. “Most women survivors  (57%) reported a detection method other than mammographic examination.”

Measuring performance in clinical breast examination. Br J Surg. 2010 Aug;97(8):1246-52.  Wishart GC, Warwick J, Pitsinis V, Duffy S, Britton, PD. “performance measures…could help to identify clinicians who have a lower sensitivity for CBE and who may therefore require feedback and further training.”

Tumor Characteristics Associated With Mammographic Detection of Breast Cancer in the Ontario Breast Screening Program.  J Natl Cancer Inst 2011.Jun 22;103(12):942-50. Epub 2011 May 3 Kirsh VA, Chiarelli AM, Edwards SA, O’Malley FP, Shumak RS , Yaffe MJ, Boyd, NF  “…77% of these were true interval cancers, detected clinically in the 1–2 year interval between screening examinations…” p4

Improved Clinical Breast Examination Competencies Via Intelligent Simulator Training, July 7, 2012   Meeting of the German Society for Senologie, Stuttgart Goldstein M.K.*, Mehn M.A.*, Pennypacker H.S.*, Brost B.C.** Petersen W.O.**, Nicometo A.M.**,  MammaCare* and Mayo Clinic** "Two independent trials found that the CBE Simulator produced significant gains in clinical breast examination skills suggesting that this technology may improve the accuracy and quality of breast cancer screening."

Barton, M. B., Harris, R., & Fletcher, S. W. (1999). Does this patient have breast cancer? The screening clinical breast examination: Should it be done? How? Journal of the American Medical Association, 282(13), 1270-1280. " "Our recommendation incorporates practices from the Mammacare method, because its components have been validated in independent investigations of CBE technique"

Artmann, A., Heyne, M., Kiechle, M., & Harbeck, N. (2005, June 20 Suppl.). Breast self-examination training and counseling as motivation strategies for breast awareness and participation in breast cancer screening programs (ASCO Annual Meeting Proceedings, Part 1). Journal of Clinical Oncology, 24(18S), 1027.

Narod, S.A. (2014). Reflections on screening mammography and the early detection of breast cancer. Current Oncology, 21(5), 210-214.

Vaz-Luis, I., et al. (2014). Outcomes by tumor subtype and treatment pattern in women with small, node-negative breast cancer: a multi-institutional study. Journal of Clinical Oncology, 32(20), 2142-2150.

Adams, C. K., Hall, D. C., Pennypacker, H. S., Goldstein, M. K., Hench, L. L., Madden, M. C., Stein, G. H., & Catania, A. C. (1976). Lump detection in simulated human breasts. Perception and Psychophysics, 20, 163-176.

Atkins, E., Solomon, L. J., Worden, J. K., & Foster, R. (1991). Relative effectiveness of methods of breast self-examination. Preventive Medicine, 14(4), 357-367.

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May 8, 2018
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Breast Self-Exams Work – Find Breast Cancer Missed on Mammograms Women Report

Women self-detect breast cancer with their hands, cancer that was missed by mammograms according to women and research. At first this may seem to contradict  or even disrupt traditional practices, but biological and clinical evidence supports the women. Hundreds of touch receptors in our fingers comprise an exquisitely sensitive network that improves with practice by establishing new neural pathways (tactile maps) that recognize complex textures as well as the presence of unusual changes within them.  By applying this knowledge to the detection of small breast tumors, MammaCare scientists, with the support  of the National Cancer Institute and National Science Foundation, began the  process of training  every hand that examines a woman, including her own.

I actually found the lump a year earlier while doing a self-breast exam but was told two separate times it was only a cyst. So imagine my surprise when I met with a plastic surgeon at Johns Hopkins in Baltimore for a consult to remove the “cyst” only to be told later it was cancer. -WUSA9 ...Like many young breast cancer patients, Sliwerski was blindsided by her diagnosis. She was just 33, the first-time mother of a 3-month-old, Penelope, when she noticed a lump in her left breast. A month later, she learned she had invasive breast cancer. - Chicago Tribune Harris said early detection of breast cancer is key. She is a fitness enthusiast and was familiar with her body when she noticed a lump that turned out to be cancerous. - MRT Knight had recently been screened but noticed a painful lump during a self-breast exam in early February. She put off seeing the doctors for a couple of weeks, expecting it to be benign like the others she had found….Knight urges everyone, especially those with family history, to seek regular screenings, conduct breast exams and act quickly when something doesn't feel right. - Lancaster Reagle Gazette As Amber Pritchett was doing a breast self-examination in early spring, she found a lump…The 33-year-old human resources employee at Mercer University didn’t think much of it since no one in her family had breast cancer...“It’s probably nothing to worry about. Probably just dense breast tissue,” the doctor told her….Her malignant tumor was four to five centimeters, or nearly two inches in diameter, when she was diagnosed Aug. 28. - Miami Herald Findings published in the Journal of Women’s Health: “Despite increased use of screening mammography, a large percentage of breast cancers are detected by the patients themselves. Patient-noted breast abnormalities should be carefully evaluated. - NCBI I had a mammogram seven months before I found the lump, and it was all clear,” the Seneca Falls resident remembered. “I was getting ready for a trip to Honduras. I brushed (the lump) off. It wasn’t painful, so I went on the vacation. - Fit Times Although Stewart was only 35 and had no family history of breast cancer, the conversation with her daughter encouraged her to do a self-exam. The lump she found in her left breast was cancerous." - The Pilot Turns out she was thirty-seven when she first felt the lump in her breast. She made an appointment with her local doctor, who passed it off as nothing, and continued to say it was nothing for two years—even though it kept getting bigger. - New Yorker The speaker at Monday’s Breast Cancer Awareness Ceremony urged others to regularly do self-breast exams. In Vicki Mathess’ case, her self exam – done in between her yearly mammograms – led to her diagnosis of stage two breast cancer. “I had a mammogram two months before and the mammogram was negative,” she said. “In two months, through a self exam, I discovered a lump. - The Record Delta I actually found the lump a year earlier while doing a self-breast exam but was told two separate times it was only a cyst. So imagine my surprise when I met with a plastic surgeon at Johns Hopkins in Baltimore for a consult to remove the “cyst” only to be told later it was cancer. - WUSA9 I had found a mass in my right breast due to my favorite bra didn't fit. I hand wash all of my bras so I know it wasn't cause my bra had shrunken. By doing a self-exam I found a golf size lump in my breast, said Edwards - KGUN9 Three weeks ago, I was diagnosed with breast cancer. I could only feel the lump whilst lying down and it completely disappeared [when I was] standing up. - Self

October 27, 2017
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Science of Self-Exams Taught at Blessing Breast Center

Sheila Hermesmeyer, oncology nurse and MammaCare BSE Instructor, has many roles at Blessing Breast Center, where she has worked for 38 years. Hermesmeyer is Blessing Hospital’s Breast Center Navigator, helping patients understand their diagnoses, addressing barriers to care, coordinating the monthly lymphedema screening clinic, and shepherding women through the often-complicated process of breast cancer diagnosis and treatment. She summarized her multiple clinical and support activities modestly, “I wear many hats.” Her community outreach is one more hat.

As a MammaCare certified instructor, Sheila organized outreach to the community that has stimulated buy-in from physicians. Oncologists and internal medicine physicians now encourage their patients to participate in her classes, “The oncologists put up MammaCare posters in the exam rooms and inform patients about my MammaCare classes,” says Sheila, whose Introduction to MammaCare BSE class is held four times a year. Flyers about the classes inform internal medicine physicians at the clinic and are even distributed by outreach nurses who walk at the community mall to boost the program’s visibility.

Sheila explains how she learned the science behind breast self-exams. “I was mimicking my doctor’s technique before I went to the MammaCare training in Chicago.” The women who participate in her MammaCare classes report that learning the procedure directly from an instructor is most helpful. “One women was 37 when she was diagnosed and brought all her girlfriends to the MammaCare class.”

Blessing Hospital hosts many events for Breast Cancer Awareness Month. A speaker series was hosted by Sheila Hermesmeyer and Blessing Hospital, commemorating the 40th anniversary of the movie “Pretty in Pink” with a special showing of the film. The event included a representative from the 3D breast center and a dietitian to answer questions followed by the movie screening. Throughout the month, the hospital and breast center also participate in a T-shirt drive to raise funds that support the cost of mammograms and breast care for indigent women in the Quincy, Illinois community. For more information on Sheila Hermesmeyer, Blessing Breast Center, and Breast Cancer Awareness Month at Blessing Hospital, please visit https://www.blessinghealth.org/treatments/breast-center.

October 12, 2017
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Women and Clinicians Learn Breast Exams Skills Despite “Prohibition”

Antique US Government policies continue to resist safe, low-cost breast cancer screening leaving women and their healthcare providers in a confusing and costly screening fog.

Informed clinicians and women are constrained by an influential US agency recommendation against teaching women how to perform breast self exams and against breast cancer screening exams by the hands of trained healthcare providers. Although the recommendations are based on outdated reports, poorly trained hands and limited treatment options, the agency's position exerts a strong, international influence over healthcare policy and practices. Their  curious edict to not  teach or learn breast exam skill was first issued in 2002 and is repeated to the present day, The plain take-home for the half million women who die every year is that they would be better off not being taught by their provider to correctly perform a self-exam or even receive screening by skilled clinicians. 

Naturally, without learning, exams performed by women and their providers will generate higher rates of false positives and more missed tumors. Yet the agency, in reissuing their recommendation, ignores strong evidence that the standards for proficient performance of clinical and personal breast exams are known, free and safe alternatives to the practice of mass, x-ray mammograms.

Equally troubling is the exclusion or insubstantial consideration of landmark evidence that contradicts the agency's reports and media releases. Although their edict has had mass impact in effectively discouraging women and their practitioners from learning and teaching how to perform skilled exams, independent regional and national evidence indicates that the long hiatus is lifting or should be despite USPSTF discouragements. 

For example:

Physicians and scientists at the University of Washington’s Department of Global Health reported this year that most women receiving care at an urban clinic in Peru detected their own breast cancer finding nearly half of the cancers at early stages. Published in May, in the American Medical Association journal JAMA Onclology,  women who received a previous clinical breast exam by the hands of  trained practitioners were the most likely to find their own breast cancer in its earliest stages. These results add support to the recent, massive Canadian National Health Service study of 89,000 women reporting that physical (clinical) examination by trained nurses coupled with self-exam instruction detects the same number of breast cancers as do mammograms. This twenty five year study of 89,000 Canadian women was reported in the prestigious British Medical Journal.  

The annotated findings below provide additional, compelling evidence in support of a change in US policy  for teaching women and for training clinicians how to perform skilled exams and how to teach women.

Breast cancer presentation and diagnostic delays in young women. Cancer. 2014 Jan 1;120(1):20-5. doi: 10.1002/cncr.28287. Nov 11. 2014  Ruddy KJ, Gelber S, Tamimi RM, Schapira L, Come SE, Meyer ME, Winer EP, Partridge AH

Most young women detect their own breast cancers… Palpable presentation of breast cancer persists in the era of screening mammography. J Am Coll Surg. 2010 Mar;210(3):314-8. Mathis KL, Hoskin TL, Boughey JC, Crownhart BS, Brandt KR, Vachon CM, Grant CS, Degnim A Patients with palpable presentation were younger than those with screen-detected cancer (mean age 57 versus 62 years… Self-Detection Remains a Key Method of Breast Cancer Detection for U.S. Women. J Womens Health. 2011Aug; 20(8): 1135-9. Roth MY, Elmore JG, Yi-Frazier JP, Reisch LM, Oster NV, Miglioretti DL Conclusion: Most women survivors (57%) reported a detection method other than mammographic examination. A significant number of women present with palpable breast cancer even with a normal mammogram within 1 year. Am J. Surg 2010 Dec; 200(6): 712-7. Haakinson DJ, Stucky CC, Dueck AC, Gray RJ, Wasif N, Apsey HA, Pockaj B. Results: Patients presenting with palpable masses on SBE or CBE even with a normal mammogram within 1 year tended to have more aggressive tumors… resulting in more aggressive therapy.”  Twenty-five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial. BMJ. 2014 Feb 11;348:g366. doi: 10.1136/bmj.g366. Miller, A. B., Wall, C., Baines, C. J., Sun, P., To, T., & Narod, S. A. Upon finding that most cancers were palpable at mammography screening visits, Miller et; al. concluded: From this we infer that if there is benefit from a mammography only screening programme, it is derived through cancers detectable by a thorough breast physical examination. Discovery of breast cancers within 1 year of a normal screening mammogram: how are they found? Ann Fam Med. 2006 Nov-Dec; 4(6): 512-8. Carney PA, Steiner E, Goodrich ME, Dietrich AJ, Kasales CJ, Weiss JE, MacKenzie, T.  Having a lump and both a personal and a family history of breast cancer was the most common reason why women initiated a health care visit.  Measuring performance in clinical breast examination. Br J Surg. 2010 Aug;97(8):1246-52. Wishart GC, Warwick J, Pitsinis V, Duffy S, Britton, PD. Performance measures…could help to identify clinicians who have a lower sensitivity for CBE and who may therefore require feedback and further training.  Tumor Characteristics Associated With Mammographic Detection of Breast Cancer in the Ontario Breast Screening Program. J Natl Cancer Inst 2011.Jun 22;103(12):942-50. Epub 2011 May 3 Kirsh VA, Chiarelli AM, Edwards SA, O’Malley FP, Shumak RS, Yaffe MJ, Boyd, NF.  …77% of these were true interval cancers, detected clinically {clinical breast exams} in the 1–2 year interval between screening examinations… Excessive resections in breast-conserving surgery: a retrospective multicentre study. Breast J. 2011 Nov-Dec; 17(6): 602-9. Krekel N, Zonderhuis B, Muller S, Bril H, van Slooten HJ, de Lange de Klerk E, van den Tol P, Meijer S. Of all tumors, 72% (525/726) were palpable, and 28% (201/726) were nonpalpable. The tumor stage was T1 in 492 patients (67.8%) and T2 in 234 patients (32.2%).  Does This Patient Have Breast Cancer? The Screening Clinical Breast Examination: Should It Be Done? How? Journal of the American Medical Association, 1999 Oct, 6: 283(13), 1687-9.  Barton, M.B., Harris, R. & Fletcher, S.W. …MammaCare’s standards for teaching and practicing effective CBE emerged from an extensive series of laboratory studies measuring lump detection and breast examination skills using tactually accurate breast models embedded with small, simulated lesions. How best to teach women breast self-examination. A randomized controlled trial. Annals Intern Med. 1990 May 15;112(10):772-9. Fletcher SW, O’Malley MS, Earp JL, Morgan TM, Lin S, Degnan D. Mammacare instruction resulted in more long-term improved lump detection and examination technique use than did traditional instruction or physician encouragement. Breast self-examination instruction should emphasize lump detection skills.  Improved Clinical Breast Examination Competencies Via Intelligent Simulator Training, July 7, 2012   Meeting of the German Society for Senologie, Stuttgart Goldstein M.K.*, Mehn M.A.*, Pennypacker H.S.*, Brost B.C.** Petersen W.O.**, Nicometo A.M.**,  MammaCare* and Mayo Clinic** Two independent trials found that the CBE Simulator produced significant gains in clinical breast examination skills suggesting that this technology may improve the accuracy and quality of breast cancer screening.

M.K. Goldstein, Ph.D.

Senior Scientist and Director

The MammaCare® Foundation

Lab: (352) 375-0607

markgoldstein@mammacare.org

Supported in part by:

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Does This Patient Have Breast Cancer? The Screening Clinical Breast Examination: Should It Be Done? How? "Our recommendation incorporates practices from the Mammacare method, because its components have been validated in independent investigations of CBE technique" JAMA 283(13), (p. 1276), Barton, M.B., Harris, & Fletcher, S.W.

September 7, 2017
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What Does a Breast Cancer Lump Feel Like?

Feeling a lump is the first symptom of breast cancer for many women but as explained below, breast tissue is naturally lumpy and most lumps are normal. The most common question asked is: "What does breast cancer feel like?"

To answer that question, the National Cancer Institute (NCI) supported research and development of standards and creation of tactually accurate breast models that teach fingers what to feel for. These breast model contain polymer replicas of excised lumps found in real breast tissue. With practice, women can learn to feel the difference between these lumps and normal, healthy tissue.

What Does a Benign Breast Lump Feel Like?

There are many reasons why you may feel a lump in your breast. Most of the lumps you may feel are likely benign. Common causes of benign breast lumps include:

  • Normal swelling and tenderness
  • Fibroadenoma (normal fibrous tissue)
  • Fat necrosis (bruised, injured or dead fatty tissue)
  • Breast cysts (benign water filled lumps) Infection
  • Lipoma (encapsulated group of fat cells) benign changes in breast cells.

What Does a Breast Cancer Lump Feel Like?

Breast cancer often presents itself when a woman notices something out of the ordinary in her breast, a lump that feels different from the feeling of surrounding tissues and structures or a change, something new and different that was not felt before. That is why it is important to know what your breasts normally feel like so that you will notice a difference that persists.

Can I Learn to Feel the Difference?

Yes, fingers are exquisitely well designed to detect the difference between normal breast tissue because suspicious lumps are tactually different. There have been many attempts to describe in words or on videos what our fingers feel during a breast exam. Words like hard, soft, irregular shape, defined borders, fixed, or movable can be useful, but to get it right we must teach our fingers, not just hear about it with our ears or viewing videos or by reading instructions. As one woman reported after practicing the correct technique, "you cant palpate a pamphlet."

The Power of Touch   

We use touch—our tactile sense—to feel our pulse, to feel for a contact lens that fell on the floor, to feel whether a tomato is too ripe or too firm, and even to feel and interpret the tiny paper dots called Braille. Our tactile sense is so highly advanced that scientists and engineers devote entire careers to trying to create robots that emulate a few of its brilliant sensory capabilities. When properly trained, the sense of touch can also be used to detect suspicious lumps at their earliest stages.

A substantial body of evidence confirms that a large proportion of breast cancers are first found by fingers, frequently the woman's own. This is because most breast cancers are solid tumors and can be palpated (felt) by hand. With training on standardized breast models, fingers learn to detect small suspicious changes that feel different than normal lumpy breast tissue.

 

Research on Breast Exam Standards: Learning What to Feel For

A team of scientists and physicians at the University of North Carolina at Chapel Hill identified the most effective method for teaching women how to do breast self-exam, in a study called "How Best to Teach Women Breast Self-Examination: A Randomized Controlled Trial." Women were randomly assigned into three groups to learn how to learn to do breast self-examination using three different techniques. The first group of women was taught tactile BSE skills using MammaCare's standardized breast simulations (models). The second group of women was taught BSE using traditional printed material—a pamphlet. The third group of women was encouraged to perform BSE without any instruction.

The study reported:

"Mammacare instruction resulted in more long-term improved lump detection and examination technique use than did traditional instruction or physician encouragement. "

 

About the Author

Mark Goldstein, Ph.D., was a member of the scientific team on the National Cancer Institute research project that validated the procedures for effective physical examination of the breast. He is a Senior Scientist at the MammaCare Foundation and has devoted his scientific career to advancing the early detection of breast cancer.

July 8, 2014
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