Routinely teaching breast self-examination is dead. What does this mean?

Physical examination of the breast is not a single test. Among clinicians (where it is termed “clinical breast examination” or CBE), it has various degrees of accuracy, depending on the clinician and his or her technique (1). Among women (where it is termed “breast self-exam” or BSE), it is sometimes an accurate test, but often it is not (2,3). In either case, physical examination of the breast is a difficult examination to learn to do well, especially when searching for the subtle changes that can signal early breast cancer (2,4–9). Physical examination of the breast is a skill taught to the fingers; it is sometimes confused with the knowledge of the clinical significance of a lump in the breast. One can have little skill at detecting slight asymmetrical thickening in the breast yet understand that, should a breast lump be detected in the usual course of bathing or dressing (i.e., without a systematic search plan), it is potentially serious and should be clinically evaluated. One of the striking changes in the presentation of breast cancer in the United States over the past 25 years is the reduction in the size of lumps discovered by women themselves. Large breast lumps are much less common now than before. Although it is not clear that the practice of BSE has improved during this time, it is clear that women have a greater appreciation (call it “awareness”) now than they did before about the importance of a lump of any size. It may be that having this knowledge rather than having BSE skill has reduced the size of detected breast lumps. Whether this reduction in the size of women-detected breast lumps has contributed to the recent reduction in breast cancer mortality is uncertain (10).