Your views and letters


The practice of breast self-examination (BSE) has long been advocated by nurses and other health professionals as a non-invasive and inexpensive procedure to improve the early detection of breast cancer. While some of the first observational studies on BSE did show it to be beneficial in reducing breast cancer mortality (Hackshaw & Paul 2003), more recent large scale randomized controlled trials and meta-analyses have failed to demonstrate any reduction in breast cancer mortality rates among those who practice BSE (Thomas et al. 2002, Kösters & Gøtzsche 2003). Moreover, regular breast examination increases the risk of breast biopsy for benign breast lumps in the BSE group (Thomas et al. 2002). Therefore, I read with interest the paper by Alkhasawneh et al. (2009) in a recent issue of this journal on nurses’ knowledge and practice of BSE. The rationale for the study is that nurses who practice BSE regularly would therefore be more knowledgeable about breast cancer screening and be more likely to teach their clients about BSE. The authors state that “it is therefore important for nurses as educators to have appropriate information and positive attitude toward early detection of breast cancer” (p. 413). I agree with this statement but I would suggest that in addition to the potential benefits of BSE, the authors should also have included some discussion of the lack of proven benefits of BSE and the potential harm of BSE that has been reported in more recent studies. The evidence of the lack of demonstrable benefit of BSE has been sufficiently compelling that many cancer prevention organizations (i.e. US National Cancer Institute, US National Breast Cancer Coalition, Canadian Task Force on Preventive Health Care, and NHS Cancer Screening Programme) and the Cochrane Group no longer recommend that low-risk asymptomatic women perform monthly BSE (Knutson & Steiner 2007). Guidelines developed by the World Health Organization (2009) for the development of National Cancer Control Programmes in countries around the world, state that “given the present level of evidence, the national cancer control programme should not recommend screening by breast self-examination and physical examinations of the breast.” These recommendations are not without controversy, however, and the American Cancer Society, while no longer recommending regular BSE, still considers BSE an option for women (Smith et al. 2009). Additionally, others argue that the more recent studies still had methodological weaknesses and that the evidence against BSE is not yet conclusive (Kearney & Murray 2006). However, many cancer organizations and experts agree that women who choose to continue to practice monthly BSE should be fully advised of the potential benefits, limitations, and harms (Thomas et al. 2002, Smith et al. 2009).

The primary purpose of this letter is not to debate the merits, or lack thereof, of BSE. I believe that the article by Alkhasawneh et al. (2009) would have been strengthened by presenting a more comprehensive overview of the current evidence and controversies about BSE. Failure to do so can mislead the reader. If nurses remain unaware of the evidence for and against BSE, this may further add to the confusion of women about the importance of regular BSE and other preventive health practices.