Breast protection at your fingertips

Don't let fear or lack of confidence keep you from using this valuable tool

Breast self-examination (BSE) is among our most powerful tools against breast cancer. The combination of monthly BSE, annual physician exams and regular mammograms forms a "screen" through which few early cancers can pass undetected. And a new study suggests that, with adequate BSE training, women can do a more thorough exam than most doctors.

That's the good news. The bad news is that few women actually practice BSE--even among those who know better. We were disturbed to find that less than half (47 percent) of the 16,000 Prevention readers who participated in our Women's Health Practices Survey last year do it. Nationally, however, women are even less inclined to practice this lifesaving technique. The American Cancer Society estimates that a mere 18 to 36 percent of all women do BSE.

"Why?" we asked. Here's what women told us--and what the nation's top breast-cancer experts say you should know:

I'm afraid of what I might find. "I think every woman is afraid of doing BSE--even me, and breast cancer is my specialty," says Janet Osuch, M.D., breast-cancer surgeon and associate professor of surgery at Michigan State University in East Lansing. But, she adds, the odds are in women's favor. Fully 80 percent of all breast lumps aren't cancer--they're more likely to be harmless fluid-filled cysts, fibroadenomas, or benign noncancerous tumors referred to as "fibrocystic lumps."

The advantage of BSE is that a woman who does it regularly and thoroughly can detect lumps as small as one-quarter inch to one-half inch (see chart). If the lump is cancer, then there's a good chance she caught it early and can be effectively treated without losing her breast. The size of the tumor is the primary factor in evaluating women for lumpectomy--the breast-conserving surgical procedure in which the lump, the surrounding tissue and the lymph nodes under the arm are removed. "A woman who finds a one-quarter to one-half-inch lump has a 90 to 95 percent chance of having a lumpectomy instead of a mastectomy," says Jeanne Petrek, M.D., a breast surgeon at Memorial Sloan-Kettering Cancer Center, New York.

I have a mammogram every year. Mammograms are excellent screening tools (they can pick up tumors too small to be felt) but they're not perfect, says Barnett Kramer, M.D., M.P.H., associate director of the early detection and community oncology program at the National Cancer Institute. They do miss malignant tumors and miss a larger proportion in younger women.

"There's a small percentage of cancers that you might not actually see on a mammogram but that you can feel," explains Patti Wilcox, R.N., a nurse practitioner at the Breast Clinic at Johns Hopkins Oncology Center in Baltimore. This happens especially in younger women, whose breast tissue is dense with ducts and milk-producing glands that may be indistinguishable from tumors on mammogram film. Plus, there's a chance you could develop a tumor in the interval between mammograms.

That's why physical exams (and monthly breast self-exams, in particular) are so important. By palpating your breasts, your doctor may discover a lump the mammogram missed. And if you're trained in BSE and practice the method regularly, you've got yourself well protected between office visits.

I'm in my 30s. In fact, the American Cancer Society (ACS) suggests that women begin practicing BSE at age 20. "While the risk of developing breast cancer at that age is very low, the earlier you get into the habit of doing self-exams, and the longer you do them, the more likely you will be able to discover a change in your breast early," says Terry Ades, R.N., director of nursing programs.

Another good reason to begin early: Breast cancer doesn't strike just older women. "It's true," she says, "75 percent of all cases are discovered in women age 50 and older. But about 46,000 women under 50 are diagnosed with breast cancer each year." That's equal to all of the cases of in-vasive cervical cancer and uterine cancer combined.

"Women in their 30s are good about getting Pap smears regularlybecause they recognize they're at riskfor cervical cancer--but the fact is,breast cancer in that age-group is 10 times more common than cervical cancer," Dr. Osuch notes.

I find it almost impossible to distinguish an abnormal lump in my generally lumpy breasts. "Your only responsibility is to look for a change in what you usually feel when you do your exam," says breast-cancer specialist Wilcox. Wilcox, a nurse practitioner who trains women in BSE, likens normal breast tissue to lumpy oatmeal. "What you're looking for is something that isn't consistent with the usual lumpy-oatmeal consistency of your breast tissue, whether it feels like a grape, a peanut or a piece of gravel," she says.

If you think you feel a new lump, but you're not sure, check the same area of your other breast for comparison. "Your other breast is your built-in point of reference," Dr. Osuch says. "If you feel the same thing in the mirror-image location in the opposite breast, then what you're feeling is normal for you. That can be extraordinarily reassuring."

If the lump is in one breast only and it appears just before or during your period, repeat your self-exam seven days after the day your period began. Hormonal changes during the menstrual cycle naturally make breasts more lumpy--that's why experts recommend that premenopausal women do BSE a week postperiod, when breast tissue is back to normal.

Don't be afraid to call your doctor if you have any doubt.

I read a pamphlet about BSE, but I'm still not sure I know what I'm doing. Pamphlets, shower cards, even videos illustrating the basics of BSE can help remind us what to do. But most experts agree that the best way to learn BSE is during a one-on-one session with a qualified instructor.

Studies show that learning BSE in individual sessions practicing on silicone breast models is more effective in improving a woman's ability to detect breast lumps than learning through pamphlets or videos alone.

Generally, the jellylike silicone breast models are constructed to simulate healthy breast tissue, with abnormal lumps embedded in different sections (hidden under flesh-colored plastic, so you can't see them). Some of the lumps are pebble-hard; some soft, like a kitchen sponge. They can be fixed just under the skin, anchored deep, close to the ribcage, or they can move freely. "Experiencing the feelof the different types of lumps cangive you a better idea of what to lookfor," says Barbara Rimer, Dr.Ph., director of cancer prevention, detection and control research at Duke Comprehensive Cancer Center in Durham, North Carolina.

You should be aware, too, that there are different BSE palpation (touching) patterns, including the traditional circular-pattern technique and the newer vertical-strip technique. (See illustration on page 83.)

Research comparing the different BSE patterns shows that the vertical-strip technique is more effective. Women taught a method called MammaCare, which uses the vertical-strip technique, spend more time examining their breasts, cover more of the breast area and are able to detect more breast lumps (with fewer false alarms) than women who did BSE the traditional way. Not only that, women who were well trained in the MammaCare method were able to pick out significantly more breast lumps in silicone models than a group of physicians and nurse practitioners. "You know your body better than anyone else," says Dr. Petrek. "If you put consistent effort into it, you could become a better breast examiner of your own breasts than I, or any other doctor, could be." (See "My First Lesson in BSE" on page 84 for a complete description.)

Here's how the vertical-strip technique works: Begin just under your collarbone, near your shoulder. Using your opposite hand, press with the pads of your fingers (not your fingertips) in a strip, along the outside of your breast. Work your way down to your bra line. Then slide over about a half inch, and work your way back up to your collarbone. (The rows should overlap a bit, like they do when you're mowing a lawn.) Repeat the pattern until you hit the breastbone. Then switch to the other breast. NOTE: The vertical-strip technique should be performed while lying on a bed. A small pillow or folded towel may be placed under the shoulder on the side of the breast being examined to center and flatten it.

This is different from the concentric-circle pattern you may have seen in some pamphlets. The circular method tends to leave out a large part of the breast--often the fleshy, upper-outer portion of the breast near your armpit, where tumors are typically found in large numbers.

"Your breast is much more than just the part that fits into a bra cup," Wilcox says. "It goes from your armpit to your breastbone, and from your collarbone to your bra line underneath your breast."

My breasts are large and difficult to examine. Larger breasts tend to fall to the outside when you're lying down, so they become thicker in that area and are more difficult to examine in depth. But according to nurse-practitioner Wilcox, there's a special position, which patients call "The Scarlet O'Hara," that can help. To examine your left breast, lie on a bed on your right side, your left hip pointed up to the ceiling. Twist your upper torso and lean your left shoulder back on the bed. Place the back of your left hand on your forehead to flatten the outside of the breast, so you can examine it more easily. Examine the outer half of the breast from the armpit inward. When you've reached the nipple, lie flat on your back and continue to examine yourself from the nipple to the breastbone. Then repeat on the other breast.

It doesn't take a medical degree to do a good breast self-exam, adds Amy Langer, executive director of the National Alliance of Breast Cancer Organizations. "What's most important is to know how your body feels well enough to detect any change."

Dr. Osuch agrees: "The fact remains, women who know their bodies well can, with their doctors, help fight breast cancer."

DIAGRAM: Know thyself: While mammograms are tops for finding the tiniest lumps (see above), they aren't fail-safe. That's where life- and breast-saving lies in your hands. If done regularly and thoroughly, your self-exam may detect lumps small enough to be removed by lumpectomy.

DIAGRAMS: Best for breasts: The vertical-strip technique (right) involves an up-and-down motion with fingers rather than the traditional circular pattern (far right). Including the entire breast area ups the odds of finding any suspicious lump.

PHOTO: A hand

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By Lisa Delaney

SOURCES: Terry Ades, R.N., director of nursing programs, American Cancer Society; Barnett Kramer, M.D., M.P.H., associate director of the early detection and community oncology program at the National Cancer Institute; Amy Langer, executive director, National Alliance of Breast Cancer Organizations, New York City; Janet Osuch, M.D., breast-cancer surgeon, associate professor of surgery, Michigan State University College of Human Medicine, East Lansing; Jeanne Petrek, M.D., attending surgeon, Memorial Sloan-Kettering Cancer Center, New York City; Carol Pilgrim, Ph.D., professor of psychology, University of North Carolina at Wilmington; Barbara Rimer, Dr.Ph., director, Cancer Prevention, Detection and Control Research, Duke Comprehensive Cancer Center, Durham, N.C.; Patti Wilcox, R.N., nurse practitioner, Breast Clinic, Johns Hopkins Oncology Center, Baltimore.

GET INTO THE HABIT
Treat breast self-examination (BSE) like a standing appointment--mark it on your calendar. If your periods come like clockwork, simply mark "BSE" in the square a week after the day your period's scheduled to begin each month. That's the time of the menstrual cycle when your breasts should be less painful and lumpy.

If your period's more unpredictable, or if you're postmenopausal, you may find it helpful to schedule your BSE session on the first of every month. Or tie it in with another monthly activity, like a standing haircut appointment.

Research suggests that having a "BSE buddy" may help, too. That means pairing up with a close friend and agreeing to remind each other with a phone call or a note when it's time for your monthly exam.

WHERE TO GO FOR BSE TRAINING
While experts give high marks to MammaCare, it may be difficult to find an instructor in your area. Large teaching hospitals and cancer centers are your best bet, but start by asking your doctor for a referral.

Most gynecological offices, breast centers--even some mammography centers and family doctors' offices--have nurses on staff who are trained to teach some form of breast self-examination. Most sessions last about 45 minutes. The cost may or may not be included in your office visit.

For more information about MammaCare, write to P.O. Box 15748, Gainesville, FL 32604.

An instructional videotape, complete with breast model, is available for $69 plus postage from MammaCare--but remember, you'll probably do a better self-exam if you learn one-on-one with a qualified instructor.

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