June | July 2003 AWHONN Lifelines 195

One of the most serious health problems a woman can

face is the diagnosis of breast cancer. Breast cancer has

many risk factors, such as delayed child bearing, early menar-

che, late pregnancy, late menopause, exposure to cyclic estro-

gen, age, diet, personal and family health history, and socio-

economic status. A woman has a one in nine chance of devel-

oping breast cancer during her lifetime

(www.pennhealth.com), and breast cancer is the second lead-

ing cause of cancer death in the U.S. (www.4woman.gov).

Even though rigorous efforts at early detection have

decreased the stage of breast cancer at diagnosis, a significant

proportion of new breast cancers continue to be diagnosed at

an advanced stage. Despite the availability of mammographic

screening, a majority of infiltration breast cancers continue

to be discovered by women themselves (Facione & Giancarlo,

1998). On the other hand, in spite of the advances in technol-

ogy to improve early diagnosis and an increased emphasis on

education to promote awareness of early detection, 46,000

women die annually. A significant number of these losses

could be prevented through risk reduction measures, yet

many women do not practice breast self-exams or receive

adequate clinical screening (George, 2000).

Many breast cancer deaths may be delayed or averted by

secondary prevention methods, screening, and early detec-

tion. This is especially true for women who are 40 years old

or younger, as the disease is more aggressive and difficult to

treat in these women (Taylor, 2002). Mammograms are not

routinely performed in this age group, and therefore clinical

(performed by the health care provider) and self–breast

exams are imperative for the diagnosis of breast cancer.

Eighty percent of breast cancers that are not found with

mammography are discovered by the woman herself.

Therefore, breast self-exams are an important defense in the

fight against breast cancer and the key to complete recovery.

Breast self-exams are a personal decision for many

women. A breast self-exam involves the careful, regular, sys-

tematic examination of the breasts to look for any changes

that may have developed since the last examination (Clarke &

Savage, 1999). The changes that a woman should look for

include a lump (which may feel like a pea), any sudden

change in the size and/or shape of the breast tissue, a rash,

pain, nipple discharge or indentation of the nipple. It’s

important to do the breast exam at the same time during the

menstrual cycle to create a baseline from which to judge

abnormalities and to establish a routine (www.4woman.gov).

It’s recommended that a breast self-exam is performed a few

days after the end of the menstrual period. During this time

breasts are less tender and swollen. Regular self-examinations

allow the woman to become familiar with her breasts and

determine what looks and feels normal, and she is therefore

more likely to notice a change. Any changes should be imme-

diately reported to a health care provider for proper follow-up.

Regular breast self-exams can result in the detection of

smaller tumors and therefore contribute to a greater choice of

treatments and an increased survival rate. It’s imperative that

breast cancer be detected as early as possible for the best

chance at complete recovery. Meta-analysis studies of breast

self-exam practice and nonpractice among breast cancer

IsBreast

Still Worthwhile?Self-Examination

All women need to be

aware of changes in

their own bodies and

need to know how to

do a breast self-exam

correctly, realizing

that it does not

replace a regular visit

to the health care

provider for a check-

up and screening

patients provide evidence that the breast cancer

of women who practice breast self-exams was

detected at an earlier stage than was the breast

cancer of those who do not practice the proce-

dure (Clarke & Savage, 1999).

The efficacy of breast self-exam behavior

cannot be adequately evaluated until breast

self-exam proficiency is considered. The

knowledge of the woman on the proper mech-

anism in which to perform a breast self-exam

is dependent on the education technique pro-

vided. Many providers do not take the appro-

priate amount of time in the well visit to pro-

vide proper instruction for breast self-exams.

Many patients are left to read a pamphlet and

look at the pictorial guide, without a proper

demonstration or verbal instruction on how to

perform them accurately. Health care providers

can provide a more informative service to

patients than what is typically given to help

ensure proper technique and early detection.Even though statistical data indicate that

breast self-exams are crucial in the health ofwomen, many governmental agencies havetaken differing viewpoints. The AmericanCancer Society originally recommended thatall women over age 20 examine their breastsonce a month. This organization, which hasnow taken a more moderate approach, hasbegun to deemphasize the role of the breastself-exam (Sommerfeld, 2002). There havebeen recent recommendations from theCanadian Task Force on Preventive HealthCare that breast self-exams be excluded fromperiodic medical examinations and thatwomen no longer be routinely taught how todo breast self-exams (Buuren, 2001). This taskforce also stated that breast self-exams maycause more harm than good because ofincreased doctor’s visits and biopsies forbenign lumps combined with increased worry,anxiety and, possibly, false reassurance. TheU.S. Preventive Services Task Force concludesthat the evidence is insufficient to recommendfor or against teaching or performing routinebreast self-examination. The National BreastCancer Coalition, a grass-roots breast canceradvocacy group, urges women not to wastetheir time doing breast self-exams, for whichthere is no scientific evidence of a benefit, andget involved in lobbying efforts to find some-thing that does work (Sommerfeld, 2002).

In October of 2002, a report from a largestudy in China proclaimed that breast self-exams were a “waste of time.” This study didnot show that breast self-exams had an effecton mortality. The women in the instructiongroup did not find their tumors when theywere any smaller or at a less advanced stagethan women in the control group that did notget the intensive breast self-exam instructions.Not only was there no reduction in overallmortality in the instruction group after 10 to11 years of follow-up, but there was the sugges-tion that women who routinely check theirbreasts are at a greater risk of undergoing morebenign biopsies. More biopsies lead to anincreased potential for false positive results,which can result in increased anxiety andexcessive interventions and treatments.

Although this study conducted in China did

not show that breast self-exams had an effect

on mortality, it’s important for women to be

proactive in their own health care. There are

many personal stories from women discovering

their own breast cancer during a self-exam,

even though statistics may reveal that breast

self-exams are not worthwhile. The self-exam is

part of an array of possible detection tools,

which include clinical exams like mammogra-

phy and ultrasound.

“The fact is that American women are dying

at a lower rate than they were ten years ago

from breast cancer, so until you are absolutely

sure you know that something is useless, I

would not stop it,” said Dr. Clifford Hudis,

chief of the breast cancer medicine service at

Memorial Sloan-Kettering Cancer Center in

New York City (www.abcnews.com). All

women need to be aware of changes in their

own bodies and need to know how to do a

breast self-exam correctly, realizing that it does

not replace a regular visit to the health care

provider for a checkup and screening. Breast

cancer death rates are declining, and there is no

exact explanation. There is not enough evi-

dence to determine if current screening meth-

ods, including breast self-exams, are not part of

the equation.

Amy Bell, RNC, BSNWomen’s Health Nurse Practitioner/Clinical

Nurse SpecialistChapel Hill, NC

196 AWHONN Lifelines Volume 7 Issue 3

References

Buuren, Y. (2001, July). Breast self-exams: The benefits and the risks.Retrieved February 25, 2003,from http://www.mochasofa.ca/health/program/articles

Clarke, V., & Savage, S. (1999). Breastself-examination training: Abrief review. Cancer Nursing,22(4), 320-326.

Facione, N., & Giancarlo, C. (1998).Narratives of breast symptomdiscovery and cancer diagnosis:Psychologic risk for advancedcancer at diagnosis. CancerNursing, 21(6), 430-440.

George, S. (2000). Barriers to breastcancer screening: an integrativereview. Health Care for WomenInternational, 21(1), 53-65.

Sommerfeld, J. (2002, October 2). Noeasy answers on breast self-exams. Retrieved February 25, 2003, fromhttp://www.msnbc.com/news

Taylor, G. (2002). Effects of a culturallysensitive breast self-examinationintervention. OutcomesManagement, 6(2), 73-78.

The University of Pennsylvania HealthSystem. Retrieved February 25,2003, from http://www.pennhealth.com

U.S. Department of Health andHuman Services, Office onWomen’s Health. (2001, June).Retrieved February 25, 2003,from http://www.4woman.gov

Willis, M. (2002, October 1). Studysays breast self-exams don’t affectdeath rate. Retrieved February25, 2003, from http://printer-friendly.abcnews.com

Gathering, Sharing Health Data

Realizing that health care

providers must gather informa-

tion, analyze it and share the results

with others in order to learn from

medical errors, the House of Represen-

tatives passed the Patient Safety and

Quality Improvement Act (H.R. 663).

The act encourages providers to do

research and gather data about the

causes of medical mishaps and then

share their findings with other

providers in order to learn ways to

remedy systems and practices.

H.R. 663 protects any “information,

report, memorandum, analysis, delib-

erative work, statement, or root cause

analysis” created by or reported to a

Patient Safety Organization. Such

organizations have yet to be named

but will probably include groups

already in place to survey quality and

operations among health care

providers (e.g., the Joint Commission

on Accreditation of Healthcare

Organizations).

The information described in the

act will be protected from civil or

administrative subpoenas or orders,

discovery process, disclosure under the

Freedom of Information Act, disclo-

sure as evidence in state or federal civil

or administrative proceedings, or use

by an accrediting organization in the

accreditation process or to remove

accreditation. This protection will

allow hospitals and others to share

information freely without fear that

the information will be used against

them by malpractice attorneys or

others.

If passed by the Senate and enacted,

the act would establish Patient Safety

Organizations to collect data from

providers on a voluntary basis and

store them in a national database. Data

would be analyzed to determine best

practices and alternative methods for

correcting or improving operations

within health care facilities to prevent

future errors from occurring.

This act supports the role of health

information management (HIM) pro-

fessionals who identify and code each

diagnosis and condition affecting a

patient in a health care facility. The

diagnoses and conditions identified

and coded include any complications

and contributing causes of death. HIM

professionals can profile and trend the

data in a number of ways and use the

information to identify and track

issues. Ongoing data analysis can also

be used to alert responsible individuals

when a pattern may indicate an

increased risk of error. Protecting such

statistics and patterns and the investi-

gations and reports that result will

open up discussions, increase positive

outcomes and reduce medical errors.

The significance of the data to be

used in analyzing and trending patient

safety emphasizes the importance of

thorough, accurate and timely record-

ing of codes to identify the diagnoses,

significant conditions and procedures

for each patient. A shortage of well-

trained coding professionals, poor

documentation by health care

providers and pressures to provide the

coded data faster can be obstacles to

thorough and accurate data. Each of

these issues must be addressed because

only if the data used in recording and

studying medical errors are reliable

will the vision created by H.R. 633

become a reality.

Cheryl ServaisVice President,

Compliance and Privacy OfficerPrecyse Solutions

Dallas, TX

AWHONN RespondsRegarding Pelvic ExamsWithout Consent

To the Editor of the Wall Street

Journal:

The Association of Women’s Health,

Obstetric and Neonatal Nurses

(AWHONN) would like to respond to

a recent Wall Street Journal article

regarding the practice of performing

pelvic exams without consent on

women who are under anesthesia. It

was with great surprise and dismay

that we read the article, “Using the

Unconscious to Train Medical Stu-

dents Faces Scrutiny” (March 12,

June | July 2003 AWHONN Lifelines 197