To BSE or not to BSE? What you need to know about breast self-exams

Hutch News

To BSE or not to BSE?

What you need to know about breast self-exam and self-awareness

Oct. 20, 2014
A video produced by the Scottish government encourages women to get breast cancer screening and know their breasts.

Not a week goes by that the airwaves and Internet aren’t swirling with information on mammograms and the benefits of early detection and screening.

But where does the humble breast self-exam fit into this picture? Should women still perform BSEs on themselves? Or do we put all of our “eggs” – if you’ll pardon the expression -- in one breast-screening basket?

“Mammogram is just one piece of the whole screening process,” said Dr. Julie Gralow, a clinical researcher and breast cancer oncologist with Fred Hutchinson Cancer Research Center and its treatment arm, Seattle Cancer Care Alliance. “Screening involves visual inspection and breast self-awareness and knowing what’s normal for you.”

Heidi Trott, a nurse practitioner and three-time breast cancer survivor who counsels newly diagnosed patients, said SCCA encourages breast self-exam but that breast self-awareness is even better.

“I use the term awareness rather than examination,” she said. “It’s important to inspect the breast, to look at it in the mirror, to get a sense of what your breast tissue feels like.”

Many women don’t perform BSEs, said Trott, because they simply don’t know what’s normal and what’s not.

“A lot of women have lumpy, bumpy breasts and they worry that it’s all cancer,” she said. “I say that’s all the more reason to [know your breasts]. If you get a sense of what your breast tissue feels like, of the lumps and bumps that wax and wane, then you’ll know what’s normal for you. And you’re more likely to pick up something that feels different because you’re aware of how your breast tissue actually feels.”

While a large Fred Hutch study published in 2002 found that BSEs didn’t change breast cancer survival rates in countries where no other screening was available and the U.S. Preventive Services Task Force does not recommend clinicians spend time teaching women BSE, Trott said women are often the ones responsible for finding the lump, bump or breast change that leads to a breast cancer diagnosis.

“The last statistic I saw was that 40 percent of women with breast cancer find their own lump or breast change,” she said. “They picked up a change that led to a diagnosis of breast cancer.”

Trott recommends women examine their breasts once a month but said doing it more than that is counterproductive, as “you’re less likely to pick up subtle changes if you do it too often.”

Wondering what, exactly, you should be looking for and when you should start? Read on:

Start in your 20s.  SCCA recommends that beginning in their 20s, women should start to learn about the benefits and limitations of BSE and start to become “breast aware” by learning how their breasts normally look and feel. A doctor or health care provider can show you how to effectively examine your own breasts.

Look at your breasts in a mirror. Trott said eyeballing your breasts is just as important as feeling for lumps. “It’s important to inspect the breast and look for skin changes or nipple changes,” she said. Sometimes, those changes can be subtle. Gralow said one of her patients happened to notice that one breast started looking flatter than the other. “She noticed her breasts looked visually different and that prompted her to do an exam and seek medical attention when she felt a lump under the flattening.”

Remember, breast changes can be normal. Not all lumps, bumps and changes in the breast will turn out to be breast cancer. In fact, according to the American Cancer Society, even most biopsy results aren’t cancer. Breast changes happen for all kinds of reasons:  menstrual cycles, birth control pills, pregnancy, aging and menopause. Get to know your breasts so you can identify what’s normal and what’s not.

Lumpy, bumpy breasts can also be normal. Many women have fibrocystic breasts, which means their breasts can sometimes be tender and full of lumps and bumps that can mimic cancer. These lumps are perfectly normal and are simply related to hormonal ups and downs, Gralow said. “Some women feel them more or have bigger changes, but that’s normal,” she said. “[Breast lumps] are very cyclic when we’re young and menstruating.” Gralow advises 20- and 30-something women to wait for one or two menstrual cycles before seeing a doctor about any unusual or painful lumps.

Cancer does not always show up as a lump. While a new lump or mass is the most common symptom of breast cancer, different types of cancer can present in different ways. Invasive lobular carcinoma, which accounts for approximately 10 to 15 percent of all breast cancers, may show up as a thickened area of the breast or as a puckering, dimple or retraction, as if the skin is being pulled from the inside. Inflammatory breast cancer, which accounts for about 5 percent of breast malignancies, also doesn’t usually show up as a lump. Instead, the breast may be swollen, red, warm to the touch and appear infected or pitted, like the surface of an orange. “A lot of people aren’t as aware of this type of breast cancer, and it is aggressive,” Trott said. Wondering what you should look for? Check out this helpful video produced by the Scottish government.

Don’t forget the nipples.  Inverted nipples can be perfectly normal, but a nipple that suddenly becomes inverted is more suspicious, Trott said. Also something to bring to your doctor’s attention: nipple discharge, particularly if it’s a rusty red color and appears just on one side. “This can be normal but it still needs to be reported to your provider,” she said.

Check those armpits, too. When breast cancer spreads, the first place it’s likely to show up is in the lymph nodes within the armpits.  “Sometimes that’s the first time you can feel it, especially if the cancer is deep within your breast,” Gralow said. If you’re thin, it’s perfectly normal to feel these nodes – which are about the size of a pea or smaller -- but they should feel the same on both sides. “If one side is bigger than the other, that’s something that should be checked out,” she said. “That could be a sign of breast cancer.”

Find out if you’re high risk.  Women who inherit a high risk for breast cancer are definitely in the minority, but there are women (and men) who are at increased risk due to their genes. “If you have a strong family history of breast cancer in a first-degree relative like a mother, daughter or sister, we know you’re generally at higher risk,” Gralow said. A family member diagnosed at an early age also is often indicative of genetic risk. SCCA has two clinics designed to assess breast cancer risk. The Breast and Ovarian Cancer Prevention Program is for women with a strong family history, a male relative with breast cancer, or a BRCA1, BRCA2 or other genetic mutation associated with breast and/or ovarian cancer. The Reduce Your Risk clinic is for women who may have some family history of the disease, who have very dense breasts, who have a pre-cancer like DCIS or LCIS, or who’ve had radiation to the chest wall before the age of 40. “If you’re not sure about your risk, you can be seen in our Reduce Your Risk Clinic,” Trott said.  

Find out if you have dense breasts.  Knowing your breast density is important for two reasons, Gralow said. First, women who have very dense breasts have a slightly higher risk of breast cancer. Second, mammograms aren’t as effective at picking up small cancers in a very dense breast because the cancer shows up white and so does the dense tissue. “It’s like finding a snowflake in a snowstorm,” she said. Currently, 19 states have passed legislation making it mandatory to report breast density to both the patient and physician, and Washington state is soon likely to follow suit. “Dense tissue is very normal in young, premenopausal women but as we get older, breast tissue becomes less dense,” Trott said. “In general, having dense breasts is not cause for concern except that it does make it more challenging to find an abnormality. These women may want to be more diligent about their breast awareness and looking for changes.” Want to know more? Check out areyoudense.org.

Mammograms aren’t perfect. On average, mammograms detect breast cancer in 80 to 90 percent of women who have the disease but have no symptoms. However, mammograms are not perfect. Just as screening mammograms can miss cancer in very dense breasts, they can also miss certain types of cancer, such as invasive lobular carcinoma or inflammatory breast cancer. Mammograms can also lead to false-positive results where it looks like you have cancer when you actually don’t. Talk with your doctor to assess your personal risk so you can make the best choices about screening. Questions? Check out SCCA’s new Smart Choices for Breast Health infographic.

Knowledge is power. It may seem strange to spend time looking for something you absolutely do not want to find. But when breast cancer is found and treated early, a woman has more treatment options and a better chance at beating back the disease. “I’ve met many people who won’t get imaging done, who won’t check their breasts, because they’re afraid of the answer,” Trott said. “But early detection is still important, and we do a great job of turning breast cancer patients into survivors. It’s better to be aware than to ignore the signs. Don’t be afraid; it’s better to know.”

Related news:

Diane Mapes is a staff writer at Fred Hutchinson Cancer Research Center. She has written extensively about health issues for nbcnews.com, TODAY.com, CNN.com, MSN.com, Columns and several other publications. A breast cancer survivor, she also writes the breast cancer blog, doublewhammied.com. Reach her at dmapes@fredhutch.org.

Solid tumors, such as those of the breast, are the focus of Solid Tumor Translational Research, a network comprised of Fred Hutchinson Cancer Research Center, UW Medicine and Seattle Cancer Care Alliance. STTR is bridging laboratory sciences and patient care to provide the most precise treatment options for patients with solid tumor cancers.

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