Breast self-examination: should you really 'pledge to check'?

Shopping at my local pharmacy last week, I was taken aback by a product on the counter: “self check breast cream”. Sorry, what? Breast self-examination cream? Is that even a thing?

Looking closer at the bright pink display, I discovered a sales campaign in full swing, seemingly timed to coincide with “breast cancer awareness month”.

Two dollars from each tube sold was going to a breast cancer charity, and there was a ready-to-use social media hashtag – #IPledgeToCheck. In large font was the message “self checking your breasts is important”.

This is a fairly familiar message. But is it true? The evidence is surprisingly complicated.

Breast cancer screening

Breast cancer is a common and important disease. Affecting about one in eight women at some point in their lives, it is the second most common cause of cancer death in Australian women. I’ve seen it profoundly affect many people, including several of my general practice patients. Preventing this would be wonderful.

Cancer screening means looking for cancer in people without symptoms. An established (though still controversial) example is mammography: breast X-rays. Another less established method is breast self-examination.

At first glance, being offered a chance of finding cancer early sounds like a good thing. But it’s more complicated than that. Some screening tests, despite good intentions, fail to help, or even cause harm.

There are various ways screening can mislead us. Screen-detected cancers often show better survival rates than other cancers, but this doesn’t mean the screening is saving lives.

It can instead mean we’re just detecting the cancer earlier without changing its course, or that the screening is picking up some so-called “cancers” that would never have caused symptoms (this is called “overdiagnosis”).

Screening can also cause problems by raising false alarm – discovering a lump that resembles possible cancer, but after a worrisome round of tests turns out not to be.

To best measure the effect of a screening program, we need large “randomised controlled trials” of screening. These are studies in which people are randomly allocated to either screening or normal care, and followed over time to see what happens.

The paradox of breast self-examination

Two large trials of breast self-examination measured important outcomes such as harms and death. In these trials, study staff taught groups of women how to examine their own breasts in a careful, structured manner. Monthly self-examination was encouraged.

These women were followed up and compared to other women who had no training or encouragement in self-examination.

The results of these studies have been brought together and meta-analysed (mathematically combined) in order to summarise our best evidence on the effectiveness of self-examination.

The combined results from nearly 400,000 women are disappointing: encouraging women to examine their own breasts does not prevent any deaths from breast cancer, but does cause false alarm and an increase in the need for biopsies (involving needles or surgical excision).

But here’s the apparent paradox: despite this lack of effectiveness of breast self-examination in these trials, most breast cancers are still discovered because women notice a change in their breasts.

Trying to put these seemingly contradictory facts together can be headache-inducing. How can this all be true?

It must be that significant breast cancers are likely to be detected spontaneously or accidentally by women in the course of normal life, even without self-examination. Adding structured, monthly self-examination sounds wise, even noble, but sadly our best evidence finds it is unhelpful and leads to false alarm.

Why the false alarm? Because it’s normal for breasts to be a little bit lumpy, as firmer glandular breast tissue sits suspended amongst looser fatty tissue. Picking the “signal” of cancer from the “noise” of normal lumpiness can be tricky.

So what should we do?

Authors of breast cancer guidelines have tried to resolve the apparent paradox. They recognise the ineffectiveness of formal regular self-examination, but they also don’t want women to completely ignore their own breasts.

As a sort of compromise, guidelines now talk about breast awareness – having some self-awareness of one’s breasts, and knowing the importance of presenting quickly to a doctor if a change is noted.

This is a prudent message, and it is one I share with my patients. But it’s still unclear exactly where the sweet spot lies between too much self-examination and too little awareness.

These evidence-based uncertainties and nuances are often lost in media messages about breast awareness, and they seem thoroughly lost in this moisturising cream’s marketing campaign. On Twitter and YouTube, the manufacturer actually encourages women to perform daily self-checks, “by making it part of their every day skincare routine”.

To be fair to the manufacturer, the “daily routine” phrase is echoed by Cancer Australia. But Cancer Australia seem more relaxed about the process, stating that no special technique is necessary and suggesting that a more casual awareness in the shower or in the mirror may suffice. At first glance, being offered a chance of finding cancer early sounds like a good thing. But it’s more complicated than that. Some screening tests, despite good intentions, fail to help, or even cause harm.

I haven’t found any evidence to show that using a moisturising cream is necessary or helpful in cancer detection. So it’s not at all clear that this cream will save anyone from bad cancer outcomes, and there’s a real possibility of causing false alarm. While sales help raise money for a worthwhile charity, it’d be more efficient to donate directly.

Is it possible, behind all the pink-tinted pledge-gathering, that the main goal of this campaign is simply to sell moisturising cream?

Brett Montgomery is a general practitioner working academically and clinically. In his clinical work he sometimes treats people who have breast disease.