Preventive health care, 2001 update: should women be routinely taught breast self-examination to screen for breast cancer?

OBJECTIVES: To evaluate the evidence relating to the effectiveness of breast self-examination (BSE) to screen for breast cancer and to provide recommendations for routine teaching of BSE to women in various age groups as part of a periodic health examination. OPTIONS: Routine teaching of BSE to women. EVIDENCE: The electronic databases MEDLINE, PreMEDLINE, CINAHL, Health-STAR, Current Contents and the Cochrane Library were searched for abstracts and full reports of studies published from 1966 to October 2000 that evaluated the effectiveness of BSE in reducing breast cancer mortality. In addition, references of key papers were searched and experts consulted to ensure that all relevant articles had been identified. OUTCOMES: Prevention of death from breast cancer was viewed as the most important outcome; other outcomes examined included the stage of cancer detected, the rate of benign biopsy results, the number of patient visits for breast complaints, and psychological benefits and harms. VALUES: The recommendations of this report reflect the commitment of the Canadian Task Force on Preventive Health Care to provide a structured, evidence-based appraisal of whether a manoeuvre should be included in the periodic health examination. BENEFITS, HARMS AND COSTS: Breast cancer is the most frequently diagnosed cancer among Canadian women, accounting for 30% of all new cancer cases each year. In 2000 an estimated 19,200 Canadian women would have been diagnosed with breast cancer, and 5500 would have died from the disease. To date, 2 large randomized controlled trials, a quasi-randomized trial, a large cohort study and several case-control studies have failed to show a benefit for regular performance of BSE or BSE education, compared with no BSE. In contrast, there is good evidence of harm from BSE instruction, including significant increases in the number of physician visits for the evaluation of benign breast lesions and significantly higher rates of benign biopsy results. RECOMMENDATIONS: Women aged 40-49 years: Because there is fair evidence of no benefit, and good evidence of harm, there is fair evidence to recommend that routine teaching of BSE be excluded from the periodic health examination of women in this age group (grade D recommendation). Women aged 50-69 years: Because there is fair evidence of no benefit, and good evidence of harm, there is fair evidence to recommend that routine teaching of BSE be excluded from the periodic health examination of women in this age group (grade D recommendation). The lack of sufficient evidence to evaluate the effectiveness of the manoeuvre in women younger than 40 years and those 70 years and older precludes making recommendations for teaching BSE to women in these age groups. The following issues may be important to consider: Women younger than 40 years: There is little evidence for effectiveness specific to this group. Because the incidence of breast cancer is low in this age group, the risk of net harm from BSE and BSE instruction is even more likely. Women 70 years and older: Although the incidence of breast cancer is high in this group, there is insufficient evidence to make a recommendation concerning BSE for women 70 years and older. Important note: Although the evidence indicates no benefit from routine instruction, some women will ask to be taught BSE. The potential benefits and harms should be discussed with the woman, and if BSE is taught, care must be taken to ensure she performs BSE in a proficient manner. VALIDATION: The findings of this analysis were reviewed through an iterative process by the members of the Canadian Task Force on Preventive Health Care. The task force sent the final review and recommendations to 4 independent experts, and their feedback was incorporated in the final draft of the manuscript. SPONSORS: The Canadian Task Force on Preventive Health Care is funded through a partnership between the Provincial and Territorial Ministries of Health and Health Canada.