Understanding Breast Self-Examinations (BSE)

Updated: Mar 23


Hi, my name is Roma (she/her) and I am the author of this post! I am a cis, heterosexual, South Asian woman. I currently reside in Burlington, Ontario which is on the traditional territories of the Haudenosaunee, Anishinabewaki, Neutral, and Mississauga peoples. I would like to let you know that I do not have any lived experience with breast cancer and I am not a medical professional. This post was written to inform you about the existing research behind Breast Self-Exams to aid in decision-making about this controversial topic. This post discusses research in the Black, Hispanic, and transgender communities. I do not intend to speak on behalf of these communities nor do I claim to understand the complex relationship that any individual may have regarding their breasts, breast self-exams, or breast cancer. However, I do believe it is important to bring more attention to scientifically-backed research that focuses on communities that are historically and currently under-researched. I hope you find this post helpful and engaging!


Introduction

A breast self-examination (BSE) is a physical examination that anyone with breasts can conduct at home. BSE involves feeling and visually inspecting your breasts, usually monthly, to feel for any notable changes (1). Initially, this examination was recommended as a form of breast cancer screening. The idea behind this was that regular BSE may lead someone to feel an irregularity (such as a mass or lump) that could lead to earlier detection of breast cancer (2).


In this post, we will discuss the research around BSE to help you decide if you want to incorporate regular BSE into your self-care routine.


We will go over:

  1. The official recommendations for BSE

  2. Arguments against BSE (framing the official recommendations)

  3. Arguments in favour of BSE

  4. Considerations for transgender folks

  5. How to conduct a proper BSE (if you decide that you would like to do so)


Recommendations

The following are the official recommendations for BSE by the Breast Disease Committee of the Society of Obstetricians and Gynaecologists of Canada (3):


Breast self-examination should not be routinely taught to women. (ID)
A full discussion of breast self-examination, including risks, should be provided for the woman who requests it. (IMA)
If a woman makes an informed decision to practise BSE, care providers should ensure she is taught the skills and that she performs self-examination proficiently. (IMA)

Arguments against Breast Self-Examinations

Despite being a mainstay in breast cancer screening recommendations up until the early 2000s, large population-based studies in China, Russia, and the UK have found that conducting a BSE does not reduce breast cancer mortality (4-6). In other words, in studies where one group of participants performed regular BSE and one group didn’t, the rates of deaths due to breast cancer were the same between groups. Studies also report negative effects of BSE. The first negative effect is an increase in the rate of benign biopsies -- that is, an increase in biopsies of a mass of tissue that is not cancerous (4-6). Second, people with breasts who do “feel something” in their breast may experience anxiety and distress about something that is likely not cancerous (based on the low rate of BSE findings being cancerous) (7).


Disclaimer: The researchers did not specify the gender identity of women that were included in studies 4-7. Historical representation leads us to believe that only cis women were included.


The lack of evidence supporting BSE compounded with its negative consequences motivated the recommendations outlined above.


Arguments in Favour of Breast Self-Examinations

Still, there is support for BSE by breast cancer patient advocacy groups, medical organizations, and some doctors who highlight the positives of this practice (8-10). Notably, it is an easy-to-conduct examination that can be done at home and is accessible to all people with breasts. Many supporters of BSE claim that it was a life-saving exercise for them and that the costs of the examination are relatively mild compared to its life-saving potential (11).


Those with a family history of breast cancer or a BRCA1 or BRCA2 gene may be recommended to do a BSE by their doctor because of their higher risk (10, 12). As a young person, you may want to conduct BSE as there are no other breast cancer screening tools for women <40 years of age who are not at higher-than-normal risk for breast cancer (13).


Recently, it has been suggested that BSE may be an effective tool in low- to middle-income countries where breast cancer is diagnosed at a later stage and mammography is not common or is inaccessible (14-15).


For similar reasons, BSE is recommended for individuals who do not have access to primary care physicians. In the US, Black and Hispanic women face barriers to accessing primary care such as income level, insurance status, education level, employment status, residential segregation, language barriers, and mistrust in the medical system (16-17). Women who do not have regular access to primary care are less likely to get regular mammograms (18). This may also explain why breast cancers are diagnosed at more advanced stages in racialized women.


As a result of these complex system-level factors which limit access to care, studies have found that BSE may be more effective in Black and Hispanic women. In a US-based study of 1,643 Black women 40-75 years of age, conducting BSE was associated with a 4-5x higher rate of self-detected breast cancer relative to mammography-detected breast cancer (19). In another US-based study in an inner city hospital in the US that serves primarily Black and Hispanic women, 61% of women newly diagnosed with breast cancer presented with a self-detected mass (20).


Disclaimer: The researchers did not specify the gender identity of women that were included in studies 19-20. Historical representation leads us to believe that only cis women were included.


The efficacy of BSE in other groups with limited access to care such as Indigenous women, recent immigrants, and sexual and gender minorities is still unexplored. We would like to acknowledge that addressing the systemic disparities in access to primary care and regular mammography is of utmost importance for these communities and that BSE should not be treated as a band-aid solution for breast cancer screening in these women.


Considerations for Transgender Folks

To our knowledge, there are no studies specifically assessing the efficacy of BSE in transgender men, transgender women, and non-binary people with breasts. However, there are breast cancer screening recommendations for this population that mention BSE.


In general, male-to-female (MtF) transgender individuals who have undergone gender-affirming top surgery are not recommended by guidelines to perform BSE (21). However, many MtF trans people may find this a gender-affirming exercise and may already perform informal BSE -- if this sounds like you, you can read our section below on how to perform a more formal BSE for breast awareness. MtF transgender individuals are recommended to get regular mammograms if over the age of 50 and taking or having took gender affirming hormones for more than 5 years (22).


Female-to-male (FtM) transgender individuals who have undergone top surgery are not recommended BSE since most of the breast tissue has been removed; however, you should still talk to your doctor about your risk of breast cancer (21). FtM transgender individuals who have not undergone top surgery are recommended to follow the same breast cancer screening guidelines as cis women (21, 23). Therefore, BSE is not strictly recommended or required, especially if you find this harmful to your gender identity. Mammogram is recommended every two years after age 50 (23).


Conclusions

Proponents of BSE now suggest treating it as a form of “breast awareness” rather than a breast cancer screening tool (1, 24). In other words, it is a monthly ritual that can help you become more aware of what your breasts “typically” feel like. If you do happen to feel something atypical or concerning, this is something you should discuss at your next doctor’s visit.


At the end of the day, you must decide for yourself whether you want to include BSE as a routine health practice. This decision must be “informed” -- in other words, you must consider the risks and benefits of BSE, some of which have been mentioned in this article. You may also consider discussing the risks and benefits of BSE and how to conduct a proper BSE with your doctor so you can get more personalized recommendations.


If you find BSE anxiety-inducing, uncomfortable, or if you simply do not want to do it, that is completely okay (unless you are told differently by your doctor). There is no need to feel guilty about not doing a BSE. Conversely, if you want to incorporate BSE into your care routine, then go for it! Just make sure you are using the proper technique.

Note: There are possible risks/benefits not mentioned in this article.


Guidelines on how to conduct a proper BSE

If you have decided that you would like to incorporate BSE as a monthly practice, here are some guidelines on how to do a proper BSE (1, 25):

  • Use the pads of three fingers to methodically feel around your breast. Check the entire area from the collar bone to the bottom of the bra line and armpit to breastbone. It can help to section off the different parts of your breast in your head. For example, starting at your collarbone and then imagining different times on a clock as you feel around the breast.

  • Use three pressure levels (light, medium, and firm) to feel at different depths of your breast tissue. Use all three pressure levels at each part of your breast. You can palpate each section in small coin-sized circular motions.

  • Take your time. It may help to consider this a self-care exercise. You can choose to do your examination in the shower or lying down in bed. However, your breasts may feel different when lying down versus standing so be consistent. It is best to do both a visual and physical exam.

If you have a disability that prevents you from conducting a BSE in the suggested manner, it is likely you are still able to do a BSE if you wish to do so and this should be discussed further with your doctor.


Some important things to note are that you should do a BSE at the same time every month since how your breasts feel can change depending on where you are in your cycle. It is best to pick a time in your cycle when your breasts are least tender (1, 25). If you do not experience a monthly cycle, it is still best to pick the same date each month to establish a routine (9, 25).


The first time you do a BSE, it may feel a bit weird or scary. The breast can be a naturally lumpy and irregular-feeling tissue. However, with a consistent routine you should get familiar with how your breasts feel. Any visual or physical changes such as a lump or discharge should be discussed further with your doctor. If this does occur, try not to panic as most breast changes are not caused by cancer (1, 25).


If you have any feedback on this post or any of the content created by missINFORMED, please reach out to us at info@missinformed.ca. We appreciate and welcome all feedback as we are committed to continuous growth and improvement of our organization.


Find out here on how to access gynecological care near you.


References

  1. Mayo Clinic. Breast self-exam for breast awareness. Available from: https://www.mayoclinic.org/tests-procedures/breast-exam/about/pac-20393237. [Accessed 29th Dec 2020]

  2. Eggertsen SC & Bergman JJ. Breast self examination: Historical and current progress. The Journal of Family Practice;1983,16(4): 713-716. Available from: https://www.mdedge.com/familymedicine/article/181633/breast-self-examination-historical-perspective-and-current-progress?sso=true.

  3. Rosolowich VR, Lea RH, Levesque P, Weisberg F, Graham J, McLeod L, et al. Breast self-examination. Journal of Obstetrics and Gynaecology Canada;2006,28(8): 728-730. Available from: https://doi.org/10.1016/S1701-2163(16)32223-X.

  4. Thomas DB, Gao DL, Ray RM, Wang WW, Allison CJ, Chen FL, et al. Randomized trial of breast self-examination in Shanghai: Final results. Journal of the National Cancer Institute;2002,94(19): 1445-1467. Available from: https://doi.org/10.1093/jnci/94.19.1445.

  5. Semiglazov VF, Moiseyenko VM, Bavli JL, Migmanova NS, Seleznyov NK, Popova RT, et al. The role of breast self-examination in early breast cancer detection (results of the 5-years USSR/WHO randomized study in Leningrad). European Journal of Epidemiology;1992,65(3): 391-396. Available from: https://doi.org/10.1007/BF00146366

  6. UK Trial of Early Detection of Breast Cancer group. 16-year mortality from breast cancer in the UK Trial of Early Detection of Breast Cancer. The Lancet;1999,353(1968): 1900-1914. Available from: https://doi.org/10.1016/S0140-6736(98)07412-1.

  7. Calan MW, Chamberlain J, & Moss S. Compliance with a class teaching breast self examination. Journal of Epidemiology and Community Health;1983,37(4), 264-270. Available from: https://doi.org/10.1136/jech.37.4.264.

  8. Boraas M & Gupta S. Breast self-exam. Available from: https://www.breastcancer.org/symptoms/testing/types/self_exam. [Accessed 30th Dec 2020]

  9. Johns Hopkins Medicine. Breast self-exams. Available from: https://www.hopkinsmedicine.org/breast_center/treatments_services/breast_cancer_screening/breast_self_exam.html. [Accessed 30th Dec 2020]

  10. University of Utah. Are breast self exams worth it? Available from https://healthcare.utah.edu/the-scope/shows.php?shows=0_cjs8tl66. [Accessed 30th Dec 2020]

  11. Lerner BH. When statistics provide unsatisfying answers: revisiting the breast self-examination controversy. Canadian Medical Association Journal;2002,166(2): 199-201. Available from: https://www.cmaj.ca/content/166/2/199.

  12. Zalewski, S. Should you do breast self-exams? Available from: https://healthblog.uofmhealth.org/cancer-care/should-you-do-self-breast-exams. [Accessed 30th Dec 2020]

  13. Canadian Cancer Society. Screening for breast cancer. Available from: https://www.cancer.ca/en/cancer-information/cancer-type/breast/screening/?region=on. [Accessed 30th Dec 2020]

  14. Miller AB & Baines CJ. The role of clinical breast examination and breast self-examination. Preventative Medicine;2011,53(3): 118-120. Available from: https://doi.org/10.1016/j.ypmed.2011.05.001.

  15. Hassan LM, Mahmoud N, Miller AB, Iraj H, Mohsen M, Majid J, et al. Evaluation of effect of self-examination and physical examination on breast cancer. The Breast;2015,24(4): 487-490. Available from: https://doi.org/10.1016/j.breast.2015.04.011.

  16. Arnett MJ, Thorpe RJ, Gaskin DJ, Bowie JW, & LaVeist TA. Race, medical mistrust, and segregation in primary care as usual source of care: Findings from the exploring health disparities in integrated communities study. Journal of Urban Health;2016,93(3): 456-467. Available from: https://doi.org/10.1007/s11524-016-0054-9.

  17. Escarce JJ, Kapur K. Access to and Quality of Health Care. In: National Research Council (US) Panel on Hispanics in the United States; Tienda M, Mitchell F, editors. Hispanics and the Future of America. Washington (DC): National Academies Press (US); 2006. 10. Available from: https://www.ncbi.nlm.nih.gov/books/NBK19910/. [Accessed 30th Dec 2020]

  18. Ahmed AT, Welch BT, Brinjikji W, Farah WH, Henrichsen TL, Hassan M, et al. Racial Disparities in Screening Mammography in the United States: A Systematic Review and Meta-analysis. Journal of the American College of Radiology;2017,14(2): 157-165. Available from: https://doi.org/10.1016/j.jacr.2016.07.034.

  19. Szukis HA, Qin B, Xing CY, Doose M, Xu B, Tsui J, et al. Factors Associated with Initial Mode of Breast Cancer Detection among Black Women in the Women’s Circle of Health Study. Journal of Oncology;2019,9: 1-18. Available from: https://doi.org/10.1155/2019/3529651.

  20. Zhang Z, Rao R, Mango VL, Wilson-Gardner P, Velpalle S, & Ojutiku O. Presentation of self-detected breast mass in minority women with limited access to care: Can self-examination assist in early cancer detection? Clinical Imaging;2021,70: 89-92. Available from: https://doi.org/10.1016/j.clinimag.2020.10.032.

  21. Deutsch, MB (ed.). Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People. Available from http://www.readinghealth.org/app/files/public/1455/transgenderpgacg61716.pdf. [Accessed 30th Dec 2020]

  22. Canadian Cancer Society. Trans women and breast cancer screening. Available from: https://www.cancer.ca/en/prevention-and-screening/reduce-cancer-risk/find-cancer-early/screening-in-lgbtq-communities/trans-women-and-breast-cancer-screening/?region=on. [Accessed 30th Dec 2020]

  23. Canadian Cancer Society. Trans men and chest cancer screening. Available from: https://www.cancer.ca/en/prevention-and-screening/reduce-cancer-risk/find-cancer-early/screening-in-lgbtq-communities/trans-men-and-chest-cancer-screening/?region=on. [Accessed 30th Dec 2020]

  24. Memorial Sloan Kettering Cancer Center. Breast Self-Awareness and Breast Self-Exams (BSE). Available from: https://www.mskcc.org/cancer-care/patient-education/breast-self-awareness-breast-self-exam. [Accessed 30th Dec 2020]

  25. HealthLink BC. Breast self-examination. Available from: https://www.healthlinkbc.ca/health-topics/hw3791. [Accessed 30th Dec 2020]


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