Breast Self-Exam (BSE): A layer of Protection
We believe that doing monthly BSE provides a woman with a layer of protection in detecting small breast cancers and thus reducing the risks associated with delayed detection. Diagnostic delays are a major issue for women under 40 who are more likely to have faster growing cancers than older women.
We believe that the concept of using breast cancer mortality reduction as a measure of success is unrealistic. There are simply too many variables influencing mortality rates to accurately define the role of BSE. I know from my experience that women who are not committed to doing self-exam often present with more advanced cancers that have a lower probability of long-term survival.
However, it is also true that BSE has limitations. From decades of experience, we know that women who learn to do BSE with confidence can detect small potentially curable breast cancers. Patients are often better at detecting small breast cancer than are most doctors as described in the stories of the following two patients.
Patient no. 1:
Kristin was 34 yrs. old when she noted a subtle change in her left breast. She was seen by her primary care physician who reassured her that her exam was negative and she was “too young to develop breast cancer”. She saw me as a second opinion, and my impression was the area of her concern was not suspicious. However, as is our standard policy, a directed ultrasound was done which showed a small suspicious mass that on biopsy proved to be invasive breast cancer. She underwent a lumpectomy plus radiation. On her 10th year follow up visit she continued to be tumor free, and she was delighted with her cosmetic result.
Patient no. 2:
Michelle was a 22-year-old college student who found a small lump in her right breast. Over a two-year period, she saw multiple physicians, and each doctor told her that she was too young to have breast cancer and not to worry! At age 24 she developed back pain and an MRI showed metastatic changes. Subsequent breast biopsy revealed an invasive breast cancer. A simple diagnostic ultrasound preformed at the time she was seen could have been lifesaving.
There are three important lessons to learn from these stories. The first is to never accept the statement that “you are too young to get breast cancer”. The second lesson is that if a young woman is concerned about a lump, a diagnostic ultrasound should be done on the area of concern. Finally, if a women is concerned about the advice she receives from her initial consultation, she should get a second opinion from a breast surgeon.
What age to start?
We recommend women start doing BSE by the age of 21 or as soon as their breasts develop, and we encourage them to repeat it monthly. Pre-menopausal women should do the exam 7-15 days after the onset of the menstrual period. During this time interval estrogen levels are low, and the breasts are less tender. Post-menopausal women can pick a day of the month to do BSE and perform the exam the same day each month.
How we can help:
How to do a “Proper” Breast Self-Exam (BSE)
The best time to start doing BSE is after a physician or an experienced nurse has performed a clinical breast exam and determined it to be normal. Following the clinical exam, the patient should set aside the time needed to learn the pattern of her normal breast tissue. Once confidence in the baseline exam is achieved, repeat self-exam each month. Any change should be reported to her health care provider (1-3). (Link to our BSE monthly reminder program and our self-exam video).
Menstruating women are advised to do breast self-exam 5-15 days after the onset of their period when estrogen levels are the lowest and the breasts are least tender. Post-menopausal women can pick the day of the month to do BSE and should do it around the same day each month.
The goal is for women to become confident in their baseline examination. Once this confidence is achieved, the next step is to report any change to a physician. It is important to remember that women who perform regular BSE are often better than most doctors in detecting subtle changes in their breast.
If you find a change on BSE a breast ultrasound directed to the area of the patient’s concern should be performed. In women under 30 with a negative exam and a negative ultrasound, a 2–3-month follow-up exam is indicated. If symptoms have progressed, a second opinion with an experienced breast surgeon is recommended.
A diagnostic mammogram limited to the area of the patient’s concern is considered safe in women 30 and older. Judgement is required in recommending a “diagnostic mammogram” in women under age 30. It is a decision that is best left to an experienced breast surgeon and an experienced radiologist.
In cases in which the clinical and diagnostic evaluation is not definitive, a biopsy or short interval follow up examination is indicated. This decision is best left to an experienced breast surgeon.
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