Why Doctors Should Not Encourage Breast Self-Exams

Various health organizations offer clashing mammogram recommendations that range from annual mammograms starting at age 40 to eliminating routine mammograms altogether. Who can you trust?

Clashing mammogram recommendations ranging from annual mammograms starting at age 40 to eliminating routine mammograms altogether are offered by various health organizations. It’s hard to know who to trust given all the various conflicts of interest. A good place to start is the U.S. Preventive Services Task Force (USPSTF). Its 2009 recommendations “ignited a firestorm” of controversy by recommending pushing back the start of routine mammograms from age 40 to 50 and doing them every other year instead of annually. This evoked “a swift and decidedly passionate condemnation from members of the public, the media, and also ardent supporters of screening within the medical fraternity itself.”

As I discuss in my video Flashback Friday: Should Women Get Mammograms Starting at Age 40?, although most people have never even heard of the USPSTF, it is “considered the leading independent panel of private sector [nongovernmental] experts in breast cancer prevention and primary care,” and its “evidence-based recommendations” are considered to be the “gold standard for preventative care.” It has a reputation of sticking more with the science. For example, the USPSTF recommended against teaching women to do breast self-exams. Why? Because it doesn’t appear to work. It was put to the test when hundreds of thousands of women were randomized to perform self-exams or not. Researchers not only didn’t find any benefit to doing them, they only found harms, including double the number of women who had to get biopsies taken. Self-exams were not shown to decrease the risk of getting breast cancer, dying from breast cancer, or catching tumors in earlier stages.

To be clear, the USPSTF didn’t come out against breast self-examination—only against teaching women to do them. That’s because reminding women to perform self-exams only appeared to cause harm with no benefit. If you do discover an abnormality, then definitely tell your doctor. But telling women to get in the practice of looking seems to do more harm than good. Yet, most doctors continue to teach women to perform self-exams.

If self-exams haven’t been shown to help and, in fact, have been shown to harm, why do doctors keep calling for them? Because that’s just what we’ve been telling women forever. Medical inertia may trump women’s health, even without a multibillion-dollar industry pushing for the practice to continue and even without Big Business tipping the scales.

Let’s now consider mammograms. We spend billions of dollars of revenue every year by sticking with the status quo. Perhaps the “$8 billion consumed annually by screening mammography might be better spent on something else,” although “one person’s cost is another person’s income.” These billions of extra dollars from the status quo may “best explain the organized resistance to the implementation of the reasonable USPSTF recommendations.” Breast radiologists, for example, denounced the expert panel, “implying that the panel members were guilty of a callous disregard for the life and well-being of women,” while the American College of Radiology receives millions of dollars in donations from mammogram machine manufacturers.

In the case of self-exams, it was put to the test and the science was clear. It’s a no-brainer that the harms outweigh the benefits when there apparently are no benefits. The same appears to be the case with starting mammograms at age 40. It was put to the test to specifically address “the population-wide efficacy of mammography screening starting at the age of 40 years.” It started out looking like screening from age 40 might help, but ultimately failed to show any benefit in terms of lowering one’s risk of dying from breast cancer. Instead, the researchers just found harms, including over-diagnosis and all the chemotherapy, radiation, and surgery that resulted from detecting what looked like cancer but might never have caused problems if they hadn’t been picked up. Yet when the USPSTF tried to explain this once again in its 2016 recommendations, the firestorm was reignited with full-page advertisements taken out in major newspapers. At 4:08 in my video, I show one of these ads, which asked, “Which of our mothers, wives, daughters & sisters would it be OK to lose?” Statements like that “misrepresent” the science and “disrespect our mothers, wives, daughters, and sisters,” rather than saving their lives. It’s time to “douse the flames and clear the smoke so that we can clearly see what the evidence shows…”

Evidence schmevidence! was Congress’s reaction. Then they snuck some language into the Affordable Care Act “to interpret any reference to ‘current’ USPSTF breast cancer screening recommendations to mean those issued ‘before 2009’—in other words, its 2002 recommendations,” which had recommended annual mammograms starting age 40. “Essentially, Congress is requiring health insurers to ignore modern scientific assessments and instead use 14-year-old guidance,” read an article published in the prestigious Journal of the American Medical Association. “Although many women’s health advocates applauded the congressional mandate, it actually undermines women’s rights to make informed decisions based on the best scientific evidence.”

This happened once before, 20 years ago, when a National Cancer Institute consensus panel arrived at a similar conclusion and the Senate voted unanimously to “ignore” them. The number one killer of women is heart disease. Why not focus our billions on more effective interventions? Since health care dollars are limited, maybe we could be doing more for women’s health.

It could have been worse, though. The original bill “would have denied funding for any future USPSTF mammography recommendation.” Period. “Some members of Congress have gone further, proposing to alter the Task Force’s composition to include ‘stakeholders from the medical products manufacturing community’” so they can play a more direct role in influencing policy.

Wasn’t that self-exam thing wild? Counter-intuitive results like that should serve as a good cautionary tale for why, ideally, we should put everything to the test.

That’s one of the reasons I decided to take on this topic. There’s just so much confusion, combined with the corrupting commercial interests of a billion-dollar industry. As with any important health decision, everyone should be fully informed of the risks and benefits, and make up their own mind about their own bodies. This is the third in a 14-part series. If you missed the first two, see Nine out of Ten Women Misinformed About Mammograms and Mammogram Recommendations: Why the Conflicting Guidelines?.

For the rest of the series, see:

KEY TAKEAWAYS

Recommendations for mammograms vary from annual screening from age 40 to avoiding them completely, and conflicts of interest muddy the waters.
The U.S. Preventive Services Task Force (USPSTF), considered the leading independent panel of breast cancer prevention and primary care experts, recommends routine mammograms from age 50, not 40, and only every other year rather than annually.
When researchers found that performing self-exams were not shown to decrease the risk of getting breast cancer, dying from breast cancer, or catching tumors in earlier stages, the USPSTF recommended against teaching women to do breast self-exams, yet most physicians still teach women to perform them, likely due to medical inertia.
The USPSTF’s “evidence-based recommendations” are thought to be the “gold standard for preventative care,” yet its guidance has been widely criticized by the medical status quo. Indeed, the backlash against the USPSTF has been widespread and damning, including by some members of Congress.
Billions are spent each year by screening mammography and the American College of Radiology receives millions in donations from mammogram machine manufacturers, so it’s no wonder breast radiologists, for example, denounced the expert panel.
When mammograms from age 40 were put to the test, researchers found they not only failed to show any benefit in terms of lowering risk of dying from breast cancer, but they were actually harmful, such as from over-diagnosis and the chemotherapy, radiation, and surgery that resulted from detecting what looked like cancer but might never have caused problems if they hadn’t been picked up.

For more on breast cancer, see my videos Oxidized Cholesterol 27HC May Explain Three Breast Cancer Mysteries, Eggs and Breast Cancer and Flashback Friday: Can Flax Seeds Help Prevent Breast Cancer?

I was able to cover colon cancer screening in just one video. If you missed it, see Should We All Get Colonoscopies Starting at Age 50?.

Also on the topic of medical screenings, check out Flashback Friday: Worth Getting an Annual Health Check-Up and Physical Exam?, Is It Worth Getting Annual Health Check-Ups? and Is It Worth Getting an Annual Physical Exam?.

In health,

Michael Greger, M.D.

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