Breast self-examination: defining a cohort still in need

French college of gynecologists and obstetricians (CNGOF) recommendations for clinical practice: Place of breast self-examination in screening strategies

Breast cancer is the most common female cancer in the world. Numerous studies have shown that the risk of metastatic disease increases with tumor volume. In this context, it is useful to assess whether the regular practice of formal breast self-examination (BSE) as opposed to breast awareness has an impact on the number of cancers diagnosed, their stage, the treatments used and mortality.

DESIGN

The Commission of Senology (CS) of the Collège National de Gynécologie et Obstétrique Français (CNGOF) respected and followed the Grading of Recommendations Assessment, Development and Evaluation method to assess the quality of the evidence on which the recommendations were based.

METHODS

The CS studied 16 questions individualizing four groups of women (general population, women aged over 75, high-risk women, and women previously treated for breast cancer). For each situation, it was determined whether the practice of BSE versus abstention from this examination led to detection of more breast cancers and/or recurrences and/or reduced treatment and/or increased survival.

RESULTS

BSE should not be recommended for women in the general population, who otherwise benefit from clinical breast examination by practitioners from the age of 25, and from organized screening from 50 to 74 (strong recommendation). In the absence of data on the benefits of BSE in patients aged over 75, for those at high risk and those previously treated for breast cancer, the CS was unable to issue recommendations. Thus, if women in these categories wish to undergo BSE, information on the benefits and risks observed in the general population must be given, notably that BSE is associated with a higher number of referrals, biopsies, and a reduced quality of life.

Knowledge, attitude, and practice of breast self-examination is associated with general self-care and cultural factors: a study from Tamil Nadu, India

AIM

Breast cancer is the most prevalent type of cancer among women. One form of care related to early detection of breast cancer is breast self-examination (BSE). However, evidence on knowledge, attitude, and practice (KAP) of BSE and its determining factors are minuscule in an Indian context. Therefore, the present study primarily examined the prevalence of KAP of BSE. Further, its association with general self-care and cultural factors was determined.

METHODS

This cross-sectional study obtained data from 412 women (Mn age = 26.63) from two rural localities of Vellore district, Tamil Nadu, India. Self-reported questionnaires of KAP of BSE, self-care, and cultural factors were applied. Statistical analyses include independent sample t-test and binomial logistic regression.

RESULTS

The majority of the sample had inadequate knowledge (58%), unfavourable attitudes (73.8%), and poor practice (89.6%) of BSE. The general self-care among the sample was moderate. Self-care was found to be a significant predictor of knowledge (b = 0.07, p < .05) and attitude (b = 0.092, p < .05) toward BSE. Shyness was identified as a negative predictor of KAP. Discouraged breast health discussions predicted inadequate knowledge, and not being educated by family/friends had a negative impact on knowledge and practice. A preference for same-gender physicians led to an unfavourable attitude toward BSE.

CONCLUSION

The observed negative trends in KAP of BSE are concerning. The results imply that girls and women should be educated and encouraged to practice BSE and promote self-care behaviours. At the same time, efforts to reduce cultural barriers may be helpful to promote the KAP of BSE.

[Place of breast self-examination in screening strategies. French College of Gynecologists and Obstetricians (CNGOF) recommendations for clinical practice]

OBJECTIVES

Breast cancer is the most common female cancer in the world. In France, over 60,000 new cases are currently diagnosed, and 12,000 deaths are attributed to it annually. Numerous studies have shown that the risk of metastatic disease increases with tumor volume. In this context, it is useful to assess whether the regular practice of breast self-examination (BSE) has an impact on the number of cancers diagnosed, their stage, the treatments used and mortality.

DESIGN

the CNGOF's Commission de Sénologie (CS), composed by 17 experts and 3 invited members, drew up these recommendations. No funding was provided for the development of these recommendations. The CS respected and followed the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method to assess the quality of the evidence on which the recommendations were based.

METHODS

The CS studied 16 questions concerning BSE, individualizing four groups of women (general population, women aged over 75, high-risk women, and women previously treated for breast cancer). For each situation, it was determined whether the practice of BSE compared with abstention from this examination led to the detection of more breast cancers and/or recurrences and/or reduced treatment and/or increased survival.

RESULTS

BSE should not be recommended for women in the general population, who otherwise benefit from a clinical breast examination (by the attending physician or gynecologist) from the age of 25, and from organized screening from 50 to 74 (strong recommendation). However, in the absence of data on the role of BSE in patients aged over 75, those at high risk of breast cancer and those previously treated for breast cancer, the CS was unable to issue recommendations. Thus, if women in these latter categories wish to undergo BSE, they must be given rigorous training in the technique, and information on the benefits and risks observed in the general population. Finally, the CS invites all women who detect a change or abnormality in their breasts to consult a healthcare professional without delay.

CONCLUSION

BSE is not recommended for women in the general population. No recommendation can be established for women aged over 75, those at high risk of breast cancer and those previously treated for breast cancer.

The Effect of Educational Intervention on Knowledge, Attitude, and Practice of Women towards Breast Cancer Screening

Background. Early identification of breast cancer may result in earlier treatment and a lower mortality rate. This fact has resulted in the development of screening programs to detect breast cancer in its early stages; thus, the current study sought to investigate the influence of educational intervention on knowledge, attitude, and practice about breast cancer screening in Izeh, Khozestan Province, Iran. Materials and Methods. This experiment was carried out on the women of Izeh city in 2019. This study included 120 women who were randomized into the experimental and control groups at random (60 in the experimental and 60 in the control groups). Before and two months after the intervention, data were collected using a researcher-created questionnaire by the control and education groups. The intervention program for the intervention group included eight educational sessions over the course of two months. The SPSS 20 statistical program was used to examine the data, as well as the paired $t$ -test, independent $t$ -test, and Chi-square. Results. There was no significant difference between the experimental and control groups’ mean scores of knowledge, attitude, and practice prior to the educational intervention, but a significant difference was observed after the intervention, with the experimental group obtaining significantly higher mean scores of knowledge, attitude, and practice ( $P=0.05$ ).Conclusion. In the present study, the educational intervention on the knowledge, attitude, and practice towards breast cancer screening led to the increased scores of the experimental group compared to control group.

Breast Self-Examination - the case for a second look

Purpose of Review

Breast Self-Examination (BSE) remains controversial despite the 2009 United States Preventive Service Task Force (USPSTF) recommendation against teaching of BSE. The USPSTF recommendations were based on results from the Shanghai Study, high-quality randomized trial of BSE in 266,064 Chinese factory workers from 1989-1991; women instructed in BSE did not have a significant difference in mortality versus uninstructed controls. Regardless of the outcome of the Shanghai Study, the practice of BSE in the United States (U.S.) over the past 25 years has been associated with a marked reduction in the size of breast cancer identified by women.

Recent Findings

In the Shanghai study, BSE was tested in China from 1989-1991. During this time period, Chinese breast cancer screening and treatment was not consistent with standard-of-care in U.S. and Europe. Breast cancer was a rare illness in China in the 1980's. Treatment was not standardized; there was no breast imaging or margin assessment of the tumor. Tumor markers (e.g. estrogen receptor, progesterone receptor) were not reported. The Shanghai Study did not report in detail on the anti-cancer agents provided to women who enrolled in the trial.

Summary

BSE needs to be rigorously re-evaluated under current standard of care.

Palpable Breast Findings in High-risk Patients: Are Self- and Clinical Breast Exams Worthwhile?

OBJECTIVE

To assess breast imaging findings, biopsy rates, and malignancy rates in areas of palpable concern in women at high risk for breast cancer.

METHODS

An IRB-approved retrospective review of a tertiary cancer center's breast imaging database was performed. Breast imaging and electronic medical records of high-risk women with palpable findings detected on self- or clinical breast examination from January 1, 2010, to January 1, 2016, were reviewed. Descriptive statistical analyses were conducted.

RESULTS

Imaging correlates for 322 palpable findings in 238 high-risk women included 55/203 (27.1%) on mammography, 183/302 (60.6%) on US, and 20/47 (42.6%) on MRI. Biopsies were performed for 104/322 (32.3%) palpable findings: 95/104 (91.3%) under imaging guidance and 9/104 (8.7%) under palpation after negative imaging. Of 322 palpable findings, 16 (5.0%) were malignant in 16/238 (6.7%) women, yielding a positive predictive value of biopsy of 16.8% (95% CI: 9.2%-24%). Women diagnosed with cancer had 16/16 (100%) sonographic, 9/14 (64.3%) mammographic, and 7/7 (100%) MRI correlates. Cancer histopathology included 12 invasive ductal carcinomas, 1 ductal carcinoma in situ, 1 invasive lobular carcinoma, 1 malignant phyllodes tumor, and 1 metastatic carcinoid tumor. Over two years of follow-up imaging in 183/238 (76.9%) women were reviewed; 7/183 (3.8%) were diagnosed with breast cancer at least one year after presenting with a palpable concern in a different location.

CONCLUSION

High-risk women with palpable findings exhibit a 6.7% malignancy rate, indicating the value of imaging workup in this population. In our cohort, imaging demonstrated a high negative predictive value.

Women's knowledge, attitude, and practice of breast self- examination in sub-Saharan Africa: a scoping review

Background

Breast cancer (BC) is a non-communicable disease with increased morbidity and mortality. Early detection of BC contributes to prompt linkage to care and reduction of complications associated with BC. Breast self-examination (BSE) is useful for detecting breast abnormalities particularly in settings with poor access to healthcare for clinical breast examination and mammography. Therefore, we mapped evidence on women’s knowledge, attitude, and practice of BSE in sub-Sahara Africa (SSA).

Methods

We conducted a systematic scoping review using Arskey and O’Malleys’ framework as a guide. We searched PubMed, Google Scholar, CINAHL, and Science Direct databases for relevant studies on women’s knowledge, attitude and practice on BSE. Studies included in the review were from SSA countries as defined by the World Health Organization published from 2008 to May 2019. Two reviewers independently screened the articles at the abstract and full-text screening guided by inclusion and exclusion criteria. All relevant data were extracted, and a thematic analysis conducted. The themes were collated, and a narrative summary of the findings reported.

Results

Of the 264 potentially eligible articles identified from 595,144, only 21 met the inclusion criteria and were included for data extraction. These included studies were conducted in 7 countries of which 11 were conducted in Nigeria; two each in Ethiopia, Ghana, Cameroon, and Uganda; and one each in Kenya and Sudan. Of the 21 included studies, 18 studies reported evidence on BSE knowledge and practice; two on only knowledge; one on only practice only; and six presented evidence on women’s attitude towards BSE. The study findings suggest varying knowledge levels on BSE among women in SSA countries. The study findings also suggest that BSE practice is still a challenge in SSA.

Conclusion

There is a paucity of published literature on women’s knowledge, practice, and attitude of BSE in SSA. Hence, this study recommends further studies on knowledge, practice, and attitude of BSE, to identify contextual challenges and provide evidence-based solutions to improve women’s knowledge, practice, and attitude of BSE in SSA.

Breast Cancer Knowledge Among Male High School Students in Saudi Arabia

Breast cancer (BC) accounts for 24 % of all women cancer cases diagnosed in Saudi Arabia each year. Awareness is extremely important in combating this disease. This study was undertaken to assess male high school students' response to BC. This cross-sectional survey was performed on male high school students across schools in Jeddah. A questionnaire gathered data on respondent demographics, beliefs about BC, BC risk factors, early screening methods, and role of men in BC. Statistical analysis was done using SPSS 20. A total of 824 students participated, with an average age of 17.0 years. There was more than 50 % agreement that early detection of BC enhances the chances of recovery, that BC is treatable, and that clinical breast examination and breastfeeding provide protection from BC. Around half the survey population thought that BC was fatal and contagious. Fewer than 50 % thought that BC was inherited and related to smoking, consumption of contraceptive pills, repeated exposure to radiation, obesity, and wearing a bra and that breast tumors were all malignant and spread to different parts of the body. Others knew that mammograms should be performed periodically. A high percentage persuaded their relatives to have mammograms and provided them with psychological support. Knowledge of BC among male high school students in Saudi Arabia is still limited, and, therefore, programs and activities need to be established to increase awareness among high school students.

Managing breast cancer in younger women: challenges and solutions

Breast cancer in young women is relatively rare compared to breast cancer occurring in older women. Younger women diagnosed with breast cancer also tend to have a more aggressive biology and consequently a poorer prognosis than older women. In addition, they face unique challenges such as diminished fertility from premature ovarian failure, extended survivorship periods and its attendant problems, and the psychosocial impact of diagnosis, while still raising families. It is therefore imperative to recognize the unique issues that younger women face, and plan management in a multidisciplinary fashion to optimize clinical outcomes. This paper discusses the challenges of breast cancer management for young women, as well as specific issues to consider in diagnosis, treatment, and follow-up of such patients.

Predictors affecting breast self-examination practice among Turkish women

BACKGROUND

Breast cancer (BC) is the most common cancer among females in Turkey. Predictors affecting the breast self-examination (BSE) performance vary in developing countries.

OBJECTIVE

To determine the frequency of BSE performance and predictors of self-reported BSEs among women in the capital city of Turkey.

MATERIALS AND METHODS

This cross-sectional study was conducted on 376 Turkish women using a self- administered questionnaire covering socio-demographic variables and BSE-related features.

RESULTS

Of the participants, 78.7% (N=296) reported practicing BSE, whereas 9.5% (N=28) were implementing BSE regularly on a monthly basis, and only 5.7% (N=17) were performing BSE regularly within a week after each menstrual cycle. Multivariate logistic regression modeling revealed that BSE performance was more likely in younger age groups [20-39 years] (p=0.018, OR=3.215) and [40-49 years] (p=0.009, OR=3.162), women having a family history of breast disease (p=0.038, OR=2.028), and housewives (p=0.013, OR=0.353).

CONCLUSIONS

Although it appears that the rates of BSE performers are high, the number of women conducting appropriate BSE on a regular time interval basis is lower than expected. Younger age groups, family history of breast diseases and not being employed were identified as significant predictors of practicing BSE appropriately. Older age and employment were risk factors for not performing BSE in this sample.

Screening magnetic resonance imaging recommendations and outcomes in patients at high risk for breast cancer

The purpose of this study was to determine magnetic resonance imaging (MRI) screening recommendations and the subsequent outcomes in women with increased risk for breast cancer evaluated by oncology subspecialists at an academic center. Patients evaluated between 1/1/2007 and 3/1/2011 under diagnosis codes for family history of breast or ovarian cancer, genetic syndromes, lobular carcinoma in situ or atypical hyperplasia were included. Patients with a history of breast cancer were excluded. Retrospective review of prospectively acquired demographics, lifetime risk of breast cancer, and screening recommendations were obtained from the medical record. Retrospective review of the results of prospectively interpreted breast imaging examinations and image-guided biopsies were analyzed. 282 women were included. The majority of patients were premenopausal with a median age of 43. Most (69%) were referred due to a family history of breast or ovarian cancers. MRI was recommended for 84% of patients based on a documented lifetime risk >20%. Most women referred for MRI screening (88%) were compliant with this recommendation. A total of 299 breast MRI examinations were performed in 146 patients. Biopsy was performed for 32 (11%) exams and 10 cancers were detected for a positive predictive value (PPV) of 31% (based on biopsy performed) and an overall per exam cancer yield of 3.3%. Three cancers were detected in patients who did not undergo screening MRI. The 13 cancers were Stage 0-II; all patients were without evidence of disease with a median follow-up of 22 months. In a cohort of women seen by breast subspecialty providers, screening breast MRI was recommended according to guidelines, and used primarily in premenopausal women with a family history or genetic predisposition to breast cancer. Adherence to MRI screening recommendations was high and cancer yield from breast MRI was similar to that in clinical trials.

Effectiveness of an educational intervention among public health midwives on breast cancer early detection in the district of Gampaha, Sri Lanka

BACKGROUND

Breast cancer is the commonest cancer among Sri Lankan females, accounting for 26% of the cancer incidence in women. Early detection of breast cancer is conducted by public health midwives (PHMs) in the Well Woman Clinics. The aim of the present study was to determine the effectiveness of an educational intervention on improving knowledge, attitudes and practices (KAP) on breast cancer screening among PHMs in the district of Gampaha.

MATERIALS AND METHODS

Two Medical Officer of Health (MOH) areas in Gampaha district were selected using random sampling as intervention (IG) and control (CG) groups. All the PHMs in the two MOH areas participated in the study, with totals of 38 in IG and 47 in CG. They were exposed to an educational intervention with the objective of using them to subsequently conduct the same among 35-59 year women in the community. Following the intervention, post-intervention assessments were conducted at one month and six months to assess the effectiveness of the intervention.

RESULTS

The overall median scores for KAP among PHMs respectively were as follows. Pre-intervention: IG:58%(IQR: 53- 69%), 90%(IQR: 70-100%) and 62%(IQR: 57-70%). CG: 64%(IQR: 56-69%), 90%(IQR: 70-90%) and 62%( IQR: 50-77%). Post-intervention: one month, IG:96%(IQR: 93-96%), 100%(IQR: 100-100%), and 85%(IQR: 81-89%). CG:67%(IQR: 60- 73%), 90%(IQR: 80-100%) and 65%(IQR: 50-73%). Post-intervention: six months, IG: 93% (IQR: 91-93%), 100%(IQR: 90- 100%), and 81%(IQR: 77-89%). CG: 67%(IQR: 58- 71%), 90%(IQR: 90-100%), and 62%( IQR: 58-73%). All the above post-intervention scores of PHMs in the IG were significantly higher in comparison to CG (p<0.001).

CONCLUSIONS

This planned educational intervention had a significant impact on improving KAP of PHMs for early detection of breast cancer in the Gampaha district.

Real-time evaluation of breast self-examination using computer vision

Breast cancer is the most common cancer among women worldwide and breast self-examination (BSE) is considered as the most cost-effective approach for early breast cancer detection. The general objective of this paper is to design and develop a computer vision algorithm to evaluate the BSE performance in real-time. The first stage of the algorithm presents a method for detecting and tracking the nipples in frames while a woman performs BSE; the second stage presents a method for localizing the breast region and blocks of pixels related to palpation of the breast, and the third stage focuses on detecting the palpated blocks in the breast region. The palpated blocks are highlighted at the time of BSE performance. In a correct BSE performance, all blocks must be palpated, checked, and highlighted, respectively. If any abnormality, such as masses, is detected, then this must be reported to a doctor to confirm the presence of this abnormality and proceed to perform other confirmatory tests. The experimental results have shown that the BSE evaluation algorithm presented in this paper provides robust performance.

International screening and early detection of breast cancer: resource-sensitive, age- and risk-specific guidelines

SUMMARY 

In this article we review the evidence and current controversies surrounding screening and early detection of breast cancer, from the initially positive age-specific randomized trials of the 1970s and 1980s, to the 2009 USPSTF recommendations, 2013 interpretation of SEER data, 2014 Canadian Study updates, and BHGI resource-sensitive guidelines, as well as the few reports available from emerging countries. We will also discuss the burden of breast cancer in low- and middle- income countries with rising incidence rates and advanced stages at presentation, the need for increasing awareness and downstaging of disease. We will discuss the data putting it in perspective for general guidelines for the international scene, and suggest adoption of evidence-based resource-sensitive and risk-specific guidelines, with less reliance on broad age-specific guidelines.

Breast self-examination beliefs and practices, ethnicity, and health literacy: Implications for health education to reduce disparities

OBJECTIVE

This study aimed to quantitatively and qualitatively examine breast cancer screening practices, including breast self-examination (BSE), and health literacy among patients with chronic disease.

DESIGN

A prospective, multi-method study conducted with a targeted purposive sample of 297 patients with diabetes and/or hypertension from four ethnic groups (Latino, Vietnamese, African American, White-American) at an urban community health center.

SETTING

A federally qualified health center in Western Massachusetts.

METHODS

In our four-year study, 297 participants completed cancer knowledge, beliefs, attitudes and screening utilization scales and measures of health literacy. In addition to survey data collection, we conducted in-depth interviews, focus groups, home visits, and chronic disease diaries (n=71).

RESULTS

In focus groups, African American, Vietnamese and Latina participants offered interviewers an unprompted demonstration of BSE, reported regular BSE use at particular times of the month, and shared positive feelings about the screening method. In a sample where approximately 93% of women have had a mammogram, many also had performed BSE (85.2%). Women with adequate health literacy were more likely than those with inadequate health literacy to rely on it. Despite being positively inclined toward BSE, Vietnamese women, who had the lowest health literacy scores in our sample, were less likely to perform BSE regularly.

CONCLUSIONS

BSE seemed to be an appealing self-care practice for many women in our study, but we conclude that proper BSE practices may not be reinforced equally across ethnic groups and among patients with low health literacy.

Practice of breast self-examination among women in Malaysia

OBJECTIVES

The objective of this study was to examine the practice and associated factors of breast self- examination (BSE) among Malaysian women.

METHODS

For this cross-sectional study 250 women were selected by a simple random sampling technique. The questionnaire was consisted of three parts: socio-demographic characteristics, knowledge about BSE, and practice of BSE. Obtained data was analyzed using SPSS version 13. T-test and ANOVA test were used to explore the relation between socio-demographic characteristics and the practice of BSE.

RESULTS

About 32% of the participants reported that they have had family history of cancer and about 20% of the participants reported that they have had family history of breast cancer. The majority of the participants (88.8%) have heard about breast cancer and 78.4% of the participants have heard about BSE. Race, marital status, residency, regular exercise, awareness about breast cancer, belief that breast cancer can be detected early, belief that early detection improves the chance of survival, family history of cancer, family history of breast cancer, awareness about BSE, and belief that BSE is necessary, significantly influenced the practice of BSE among women. Practice of BSE on monthly basis was found to be 47.2% among the study participants.

CONCLUSION

The socio-demographic characteristics significantly influence the practice of BSA among women in Malaysia. The findings of this study might not only influence the planning of specific screening interventions and strategies in Malaysia but might also be important for the relevant international communities, interested in the peculiarities of BSE incidence in different countries.

Clinical and self breast examination remain important in the era of modern screening

BACKGROUND

Breast cancer screening recommendations are in flux. We reviewed the methods of detecting newly diagnosed breast neoplasms at our institution.

METHODS

A retrospective review of patients stratified by age was performed to compare mammography with self- (SBE) and clinical (CBE) breast examination methods of cancer detection from 2005 to 2009.

RESULTS

We identified 782 patients. Patients aged <50 years were more likely to present with palpable disease (P < 0.001). Overall, 75% of patients had a mammogram within 24 months. There was a higher incidence of Tis tumors and lower incidence of T1 tumors if patients had mammography performed within 12 months versus 13-24 months (P < 0.01); tumor size, hormonal status, and lymph node (LN) status were comparable between these two groups. Patients diagnosed by SBE/CBE who had mammography performed within 12 months versus 13-24 months did not differ statistically according to tumor characteristics. In the screened cohort (mammography within 24 months), the majority of patients (64%) were diagnosed by mammography. Cancers detected by SBE/CBE were larger tumors (2.4 vs. 1.3 cm), higher grade, more frequently ER- (29 vs. 16%), triple-negative (21 vs. 10%), and lymph node-positive (39 vs. 18%; all P ≤ 0.01). There were no statistically significant differences in tumor size, T stage, or hormonal status in patients who had analog versus digital mammography.

CONCLUSIONS

Whereas the majority of patients had image-detected breast cancer, a significant number of image-screened patients presented with palpable disease, which were more aggressive cancers. Until imaging techniques are refined, SBE and CBE remain important for breast cancer diagnosis.

Management of the asymptomatic BRCA mutation carrier

Current management of an asymptomatic BRCA mutation carrier includes early initiation and intensive cancer screening in combination with risk reduction strategies. The primary objectives of these interventions are earlier detection and cancer prevention to increase quality of life and prolonged survival. Existing recommendations are often based on the consensus of experts as there are few, supportive, randomized control trials. Management strategies for unaffected patients with BRCA mutations are continually redefined and customized as more evidence-based knowledge is acquired with regard to current intervention efficacy, mutation-related histology, and new treatment modalities. This review provides an outline of current, supported management principles, and interventions in the care of the asymptomatic BRCA mutation carrier. Topics covered include surveillance modalities and risk reduction achieved through behavioral modification, chemoprevention, and prophylactic surgery.