Know Thyself

Last November, the United States Preventive Services Task Force (USPSTF) published a controversial article in the Annals of Internal Medicine, creating a firestorm in the general media as well as the medical profession.  In brief summary, it recommended against routine mammography for women under 50 years old and over 74 years of age.  The USPSTF also failed to find evidence that at-home self breast exams and exams in a clinic resulted in a decrease in breast cancer mortality, ultimately "recommend[ing] against clinicians teaching women how to perform breast self-examination" (see citation at the end).  These guidelines created such a brouhaha, that Congress felt the need to legislate against the use of these recommendations regarding mandatory insurance coverage.  The Patient Protection and Affordable Care Act signed into law this past March requires that insurance companies cover "evidence-based items or services that have in effect a rating of 'A' or 'B' in the current recommendations of the United States Preventive Services Task Force [PPACA as amended, Section 2713(a)(1)]," but...

For the purposes of this Act, and for the purposes of any other provision of law, the current recommendations of the United States Preventive Services Task Force regarding breast cancer screening, mammography and prevention shall be considered the most current other than those issued in or around November 2009.  [PPACA as amended, Section 2713(a)(5)].

Now I have not read enough of the literature to comment confidently on the utility of these guidelines.  I have read articles from different groups that support or refute this science.  The scientific community seems to fall into both camps, and I'll let them debate the merits of mammography and biopsies.  Personally, I have difficulty supporting the idea that Congress should be able to strike down science as worthless, but that discussion is for another blog.  Today I am more concerned about the recommendations not to teach women a self-breast examination (SBE).  Having learned the full breast exam this past week, and having a mother who is a breast cancer survivor, I feel the need to tackle the SBE head on.

We can't screen every person for every disease; it's that simple.  We just don't have the resources or the money.  Most people would say that if there was a test that costs $10,000 to catch 1 person in every 1,000,000,000 from dying, screening wouldn't be an option.  However, if it is easy, cheap, and noninvasive to screen for a fairly common problem, then why not?  The gray area becomes significant, however, when costs go up and the number needed to treat (NNT), or screen, increases.  If the likelihood for developing breast cancer in your 40s were 1 in 2, everyone would be screened.  But what about 1 in 20, or 1: 50, or 1:2000.  Mammograms, MRIs, and biopsies do have associated morbidities, so when does performing the test outweigh the risks?

Here I make an argument for an easy, inexpensive, noninvasive test.  A test that actually costs nothing. A test that any woman can be taught.  A test that doesn't require any high-tech diagnostic equipment or special procedures.  This test requires just a few minutes of your time and two hands.

Subjectively it makes sense that a self-breast exam would be a wonderful screening tool for early prevention.  Women are recommended to start monthly self-screenings after their first menstrual cycle, but rarely do.  The key is to learn what "normal" feels like.  Say a woman starts these monthly exams at age 15.  By age 45, she has performed about 360 self exams.  You better believe that she will know something is different or wrong if she feels an abnormal lump or a round calcification on her 361st exam.

Being an athlete I have a tendency to use sports analogies.  When I was swimming, we used to take our heart rate at least a few times a practice.  This was fairly regular by the age of 14, and aerobic sets were a huge part of my training even through college.  If, during this time, I averaged seven practices a week, with 1 HR reading each day, that's 1 reading x 7 days a week x 50 weeks a year with breaks x 8 years.  That's at least 2,800 times I took my heart rate (and I can assure you that I've taken it much more than that).  The key is that, by the end of college, I didn't even have to count the actual heart rate.  I could feel my pulse and know immediately if it was 140 or 170 beats per minute.  In reality, I didn't even have to take my pulse.  I could estimate HR very accurately by my swimming pace, or by how exhausted I was at the end of an interval.  I knew my body.

Example #2.  My preceptor, a pediatrician, has been guessing the weight of children since the beginning of his residency.  He estimates the weight of every child that comes into his clinic, and then puts the child on the scale.  After almost 30 years, he has it down to a science.  He has no need for the scale because he's seen thousands and thousands of children, and weighed them all.  He knows their weight through experience and repetition.  (And now you know how those people at the state fair guess your age and weight... it's all practice, with a little bit of technique!).

It's hard for me to understand why, if providers properly and thoroughly teach women how to do a self-exam, and if women consistently perform this test monthly, we won't see results.  Women are recommended to do the exam a few days after their cycle when the breast is the least tender.  Some breasts have normal lumps, and these lumps may change throughout the cycle.  So it is important to identify "normal" at the same time each month.  These lumps can be identified during a clinical exam, and women can be taught what is normal and what is abnormal (NB: per our teachers: if it feels like a frozen pea, you might want to consult your physician).  So why shouldn't we empower women to know and understand their bodies?  Nobody knows your body better than you.  Shouldn't we empower patients to help their providers know their bodies just as well?  Especially because we may only see a patient once a year.

I've written numerous times about the patient who was assigned to me last year during Medicine and Society.  She is a perfect example of this empowerment.  A few years ago, she developed a pain in her side.  She already had had one bout with cancer, and this pain felt much like the onset of years before.  When she told her physicians, it was initially dismissed, but they agreed to run a few tests.  The tests came back negative, but she pushed and pushed.  Something was wrong, she could feel it, and it felt like cancer.  A couple appointments later, 3 liters of fluid were drained from her thorax, and the cancer was back.  She knew her body.

I won't refute the scientific merits of the USPSTF's recommendations; that battle is for the experts.  I personally think we overmedicalize here in America and we test too damn much.  But, if the test is free, easy, and noninvasive, why not?  Women can learn the SBE through pamphlets or during a normal exam.  It doesn't even take much of the provider's precious time.  It's simple.

So why not?  Learn the self-exam, do it every month, and know thyself.


US Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement.Ann Intern Med. 2009 Nov 17;151(10):716-26, W-236.