Breast self-examination

VERYONE IS VERY FAMILIAR with the rationale un-E derlying the advocacy of breast self-examination (BSE) for early detection of breast cancer.However, it should be recognized that such advocacy exists in a curious context, characterized by many paradoxes: BSE is very "low tech" in an era when "high tech" is given high priority; BSE, examination by lay eyes and fingers, is deemed important when professional eyes and fingers are not particularly well trained or even very interested in the same task; BSE focuses on an anatomical structure, which is the source of both pleasure and fear rendering many women reluctant to practice BSE; the reward for excellent BSE is the identification of disease, but the danger is false reassurance, and both are negative outcomes; BSE skills are complex, not easily performed, and not effortlessly mastered; clear benefits from BSE have yet to be demonstrated; in developed countries, the marginal benefit of BSE over and above screening with mammography with or without clinical examination is probably very small.Nonetheless, interest in and advocacy of BSE continues.If the evidence on BSE is reviewed one can identify six studies encompassing the period 1978 to 1987 which, from case series of women with breast cancer, concluded that BSE was associated with smaller cancers at diagnosis'-6 (Table 1) whereas another five studies were not able to show this effect (Table 2).7-'1Overall there are a number of problems which apply variously to all these studies: as retrospective studies they were subject to bias; objective evidence of BSE competence was lacking; not all women necessarily responded; even with BSE practice, the tumors were often large; potential benefit may have been obscured by poor technique or by application of other screening modalities; clinical stage was not always congruous with pathologic stage; and comparisons were two-fold, i.e., BSE instruction offered versus no BSE instruction, and BSE practiced versus not practiced (Table 1).Often cited as a potential hazard of BSE is false reassurance with consequent delay in self-referral for profes-