Breast Cancer Detection Methods

Epidemiology

The Agency for Healthcare Research and Quality has issued its recommendations for breast cancer screening. In this article, they make a few different recommendations. First, they recommend screening for women 50-74 years. They note that women under 50 should make the choice for themselves as to whether or not they wish to begin screening. They note that there is little evidence to support screening age 75 onward. This body, however, recommends against teaching breast self-examination.

Also noted is that "the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination beyond mammography. They also find that there is insufficient evidence of incremental benefits for the use of digital mammography or MRI. The lack of evidence does not mean that these things are ineffective or do not provide value, just that there is no evidence that they do, which is different.

The most controversial aspect of this recommendation is the recommendation against teaching self-examination. They italicize "teaching" as if to back away from saying that they are arguing against self-examination itself, which is a wishy-washy position. They should either be for or against breast self-examination. This is not a body that strictly represents health care professionals, so their recommendations on the matter should not be aimed only at health professionals. Everybody else is left to wonder what they think of self-examination. This is a very odd way to address this issue.

There are a couple of other interesting elements to this. First, other studies have indicated that breast self-examination confers no benefit (Rosotowich, 2006). It is worth, however, considering the context. The agency does not outline their reasons for their stance on the issue, but another paper outlines one of the arguments against BSE, namely that it increases physician visits for benign lesions and also increases benign biopsy results (Baxter, 2001). The first point is logical fallacy -- physician visits will increase without BSE, because the patients will need to be screened professionally. The second point has no merit either -- a physician has to order the biopsy so clearly physicians are screening the patient subsequent to the BSE. Given how terrifying cancer is for most people, they are going to want to see a physician about anything suspicious, regardless of BSE training or not. Physicians not wanting to see patients is hardly a cause to say that BSE is harmful -- false positives are okay, it is false negatives that are the problem. The Agency's recommendation is simply not a patient-centric approach.

The other point of controversy here is that BSE can help women feel at ease when they are healthy, without having to undergo mammography. Given the cost of health care -- and in many countries or even poor communities the access to health care -- BSE might be the best defense. It is an exercise is privilege to think that anybody can easily substitute expensive medical care whenever they want. For most women in the world, BSE is better than nothing because they won't be willing to pay the high cost of a physician visit unless the genuinely feel they need to. It is one thing for a Canadian agency to recommend only mammography, but unethical for an American one to do the same, knowing that many women will not see a doctor for preventative care because of the prohibitive cost. Mammograms are not a particularly costly procedure, but they aren't free most of the time, and the very poor do not always have the means to pay, nor the means to travel for a free clinic that might be offered. Get doctors to do them for free, and you can justify this recommendation.