CONCLUSION
 
Testicular cancer is an important public health problem that needs to be addressed. The only known risks
are all predetermined; therefore, a focus on earlier diagnosis and treatment through regular TSE is
indicated. The most important factors involved in this sample of pediatric residents teaching TSE to
their patients include confidence in performing a testicular examination,confidence in teaching TSE, and
knowing someone with testicular cancer. Residency program directors could use this information to help
ensure that their program is fulfilling their residents’ educational needs pertaining to male health.
Information in this study could be used to design a theory-based educational intervention to help increase
residents’ teaching practices. The HBM could be used to increase physician promotion of TSE and then
ultimately increase young male individuals’ TSE practices.

   ACKNOWLEDGMENTS
 
We thank Kate Wilson for technical assistance with the management of the Internet survey.

   FOOTNOTES
 
Received for publication May 3, 2002; Accepted Nov 21, 2002.

Reprint requests to (J.S.B.) Medical College of Georgia Sports Medicine Center, 937 15th St, Augusta,
GA 30912. E-mail: jbrenner@mcg.edu

Presented in part at the annual meeting of the Society for Adolescent Medicine, March 7, 2002, Boston,
Massachusetts.

 
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CMAJ • January 22, 2002; 166 (2)

© 2002 Canadian Medical Association or its licensors 

Letters

Correspondanc
e
Breast self-examination
Nancy Baxter
General surgeon Toronto, Ont.

The debate around the publication of our recommendations 1 regarding the routine

teaching of breast self-examination to Canadian  women has certainly been lively. Our
objectives were to systematically review the published evidence relating to the
effectiveness of routine teaching of breast self- examination to reduce breastcancer
mortality and to provide recommendations for clinicians  regarding teaching breast
self-examination to women in various age groups. We clearly stated that in cases
where women wanted to learn the technique it was important for clinicians to
explain the potential benefits and harms but also to provide thorough  training to ensure
that breast self-examination was properly  and consistently performed. Also lost in the
hue and cry about the review was the important difference between breast self-
examination (a systematic, rigorous and regular examination of the breasts  as a
screening method) and ad hoc finding of breast lumps by  women during the course of
normal activities. Although the majority  of women do not perform breast self-
examination,2 women do find their own breast cancers and do not wait for routine or
chance visits to present their concerns to a physician or nurse. Although  self- detection
was the most frequent method of detection (58.1%)  in a group of women aged 40–49
years who were diagnosed with breast cancer, less than half of the women (20.6%)
found the cancer during breast self-examination. 3

Leo Mahoney raises an interesting point: it may be possible  to teach breast self-
examination in a fashion that reduces the number of false positives, and research in
this area may have some utility. Although decreasing the number of false
positives would not increase the benefit of breast self-examination, atleast the risks
would be reduced. The bottom line is that breast  self-examination education does not
improve detection rates enough to affect survival, on the basis of currently
available evidence.

In their letter, Anthony Miller and colleagues fail to mention  the main finding of the
nested case–control study by Harvey and colleagues: no benefit of regular
performance of breast  self-examination.4 The fact that secondary analyses suggested  a
potential benefit for thorough versus less thorough breast  self-examination is a
distraction from the main finding and is at best useful for generating hypotheses.

Our systematic review methods required that the data included  in the analysis be
published in the peer- reviewed literature.  Unpublished data that may or may not ever
be available for all to scrutinize were excluded. Although information obtained
via personal communications may supplement published data, it cannot  form the basis
of a process meant to be explicit, transparent  and replicable. Should the data to which
Miller and colleagues refer ever be published, an updated review might be warranted.
Unfortunately, Tammy Clifford and colleagues seem to have misinterpreted  several
aspects of the review. First, the analysis is of breast  self-examination as a screening
manoeuvre, not as a diagnostic technique. Breast self- examination cannot be
evaluated in the same way as a diagnostic test. The goal of screening is not  simply
earlier detection, but improvement of relevant outcomes.  It is quite possible to detect
cancer at an earlier stage and thereby increase the time people must live with the
diagnosis without improving outcome: this is clearly not a desirable result.  In contrast
to Ellen Warner's lack of faith in randomized trials,  I believe that the evaluation of
screening through the gold standard of randomized controlled trials is well
established.5 Although there may well be methodologic problems in designing  trials of
breast self-examination education, they can be overcome,  as demonstrated by the
researchers in the Shanghai trial.6

The recent Canadian study cited by Clifford and colleagues was  designed to compare
mammography plus clinical breast examination  to mammography without clinical
breast examination; it does not provide evidence regarding the impact of breast self-
examination because breast self-examination was taught to all participants. 7

Although we acknowledge the point made by Clifford and colleagues  that double
review of evidence is the latest evolution in the  science of systematic reviews (and
indeed has recently been adopted by the Canadian Task Force on Preventive Health
Care), we are unaware of any data that conclusively link singly reviewed  evidence to
definitive bias, in particular when the evidence  has gone through the Canadian Task
Force's process, which involvesthorough internal and external review and debate,
followed by CMAJ's peer review.

Certainly the development of core biopsy techniques for the  evaluation of breast
lesions reduces the morbidity of diagnosis. However, as a general surgeon I will state
that there are many circumstances (i.e., size of breast, location of lesion, inability  to
image lesion, lack of access to advanced technology, patientpreference) in which
excisional biopsies for investigation are still necessary. In any case, unnecessary
procedures are best avoided, particularly if they are not associated with any benefit.

The strong reaction of the public to our findings should indeed  give pause for
reflection. Women believe that breast self-examination  saves lives because, despite a
lack of evidence, they have been told that it saves lives: a triumph of hope over
knowledge. To paraphrase Barron Lerner, a veteran of the heated and
seemingly unending debate over screening mammography, "in the war against  breast
cancer, the benefits of early detection have been oversold." 8 Indeed, some, including
the editors of CMAJ, have put forward the notion that "the rhetoric of cancer puts an
intolerable burden of responsibility and self-determination on the patient," 9 and that
the popular discourse of breast self-examination "blames  women for not doing their
part to reduce high breast cancer mortality statistics, establishes the locus of all
reasons for refraining from the activity with the woman, and chastises these  women for
failing to engage in the activity."10 In the future, sound evidence should be available
before population screening is promoted, particularly when such screening may be
associated with harm.

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