From OncoLog, April 2006, Vol. 51, No. 4
Cancer Screening Guidelines Revised: One on One with Dr. Therese Bevers
by Martha Morrison
How does recent research affect our recommendations about breast self-exams? Is it beneficial for women to perform breast self-exams every month? Is it all right to tell some patients they will never need a Pap smear again? These are some of the major issues The University of Texas M. D. Anderson Cancer Center physicians considered when updating the institution’s cancer screening guidelines (http://www2.mdanderson.org/depts/oncolog/06/4-apr/4-06-3.html). While most of the guidelines stayed the same, there were changes to the breast and cervical screening guidelines. We asked Therese B. Bevers, M.D., medical director of the Cancer Prevention Center at M. D. Anderson Cancer Center, to discuss these changes and explain how physicians can best use the guidelines.
Q: What is the role of primary care physicians in interpreting cancer screening guidelines?
Dr. Bevers: While the guidelines are available for patients to see, physicians are the ones who need to interpret them in light of an individual patient’s circumstances. The guidelines are for individuals at average risk for a specific cancer site and are not applicable to everyone. Doctors can best determine whether the guidelines are appropriate for a particular patient. They know their patients and can decide whether a patient is at average risk and the guidelines are appropriate or if a patient is at increased risk and needs something different.
We must tailor our screening recommendations to our patients’ risks for a particular type of cancer, their other health conditions, and their life expectancies. For example, if a woman has severe heart disease and wouldn’t be able to tolerate treatment, it may not be appropriate for her to undergo mammography.
Doctors and patients should discuss and routinely re-discuss risk factors. If a patient’s risk factors change, we need to reevaluate and perhaps change his or her cancer screening recommendations.
Q: Do women who have had total hysterectomies still need cervical cancer screenings?
Dr. Bevers: Some groups believe that a woman who has had a total hysterectomy can stop cervical cancer screening altogether, unless the hysterectomy was for cervical cancer or a precancerous condition. But we were concerned that this didn’t take into account the possibility of a woman’s risk factors changing over time. Certainly, we recognize that with women living longer, they may have new sexual partners later in life. These new partners create new opportunities for exposure to the human papillomavirus, the primary cause of cervical cancer.
As doctors, we need to periodically reassess a woman’s risk factors—we can’t flatly and permanently say a particular woman will never need a Pap smear again. Therefore, to keep physicians in the equation, M. D. Anderson’s guidelines state that beginning at age 30 years, a physician and patient may choose to do Pap smears less frequently than once a year, depending on her risk factors, and assuming she has had three or more consecutive annual exams with normal findings.
Physicians have a crucial role in administering the guidelines, and they should discuss the issue regularly with their patients.
Q: A very important study conducted in Shanghai (Journal of the National Cancer Institute, October 2, 2002) evaluated the effectiveness of instructing women in how to perform breast self-exams. The findings helped form M. D. Anderson’s new breast screening guidelines. What was the study about and what was learned from it?
Dr. Bevers: Interestingly, the Shanghai study showed that instructing women in how to do breast self-exams did not change breast cancer outcomes. The study divided 266,040 participants into two groups and followed them for 10 years. The intervention group was taught how to perform breast self-exams, attended reinforcement sessions, and was reminded to perform breast self-exams monthly. The second group—the control group—received no educational intervention on breast self-exams.
Ultimately, researchers found that equal numbers of breast cancers were detected in the two groups. Surprisingly, the study found that the cancers in the intervention group weren’t diagnosed at an earlier stage than in the control group and the breast cancer–related death rate in the two groups was equal. There was even a downside to breast self-exams: the group of women who were instructed in breast self-exams actually had more false-positive results than the control group.
Importantly, though the women in the control group weren’t instructed in breast self-exams, they were still able to find breast lumps. This tells us that women don’t have to be taught how to check their breasts and that people touch their bodies, consciously or unconsciously, and will call their doctors if something is unusual.
Millions of dollars a year have been spent on teaching women how to perform breast self-exams—from large cancer organizations to local hospitals, to the time in the doctor’s office, to the production of shower cards. So much effort has been put forth—and now, the Shanghai study has shown that even without teaching women a technique, they can, and will, find breast masses. Wouldn’t it be better to spend the money and time promoting screening tests that have been proven to be beneficial?
Q: M. D. Anderson now recommends “breast self-awareness.” What is it and how does it differ from “breast self-exams”?
Dr. Bevers: “Breast self-awareness” means that a woman should be familiar with her breasts so she will notice any changes and report them to her doctor without delay.
The term “exam” implies that you are taking a test and there is a right and wrong way to do it, which some women may find intimidating and even off-putting. But there is no wrong way for a woman to check for changes in her breasts. When women say to me, “I don’t do breast self-exam because I don’t know how to do it,” I assure them that they know their breasts better than anyone and are in the best position to identify a change in their breasts.
Some women say their breasts are naturally lumpy and they are concerned that they wouldn’t be able to distinguish between that and a tumor. I assure them that, in all likelihood, they would be able to, and I use this scenario to illustrate: I ask them to imagine picking up a bag of grapes and feeling the lumps and bumps of the grapes. I explain that their breasts are made up of numerous lobules, so it is natural for their breasts to feel lumpy, like the bag of grapes. Then, I tell them to imagine that a rock or marble has been added to the bag of grapes. They would know there was something unusual or different there, wouldn’t they? And it’s the same with their breasts. If something feels different, women will be able to distinguish it from normal breast lumps.
This message is reassuring for women. Women know what feels “normal” in their own breasts and are the ones most likely to notice something different that may signal a problem.
Q: What would you say to physicians who may be reluctant to recommend “breast self-awareness” instead of “breast self-exams”?
Dr. Bevers: Doctors should be relieved that they no longer have the responsibility to teach women how to do breast self-exams. Physicians often did not have the time to do this before. They now can have the comfort of knowing that even without teaching women how to check their breasts, the women will still be able to notice a problem. Most women who have found cancerous lumps weren’t doing formal self-exams. Instead, they found their lumps naturally—while taking a shower or changing clothes.
Breast self-awareness is a win-win for the patient and the doctor. The patient is reassured that she will notice a change and doesn’t have to worry if she is examining herself correctly. And the doctor can focus on other important issues during clinic visits. There are many screenings and preventive measures to talk with patients about, so if one isn’t of benefit, let’s use the time to talk about the strategies that do have proven benefits.For more information on this topic or for questions about M. D. Anderson’s treatments, programs, or services, call askMDAnderson at (877) MDA-6789.
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