The incidence and mortality rates from breast
cancer continue to increase in the United Kingdom,
and the disease is the most common cause of death in
women aged 35 to 54 years. Various aetiological
factors have been identified, but the known risk factors
are not sufficiently predictive to form the basis of
programmes for the primary prevention of breast cancer.
A range of studies are currently evaluating the
benefits of screening by clinical examination and
mammography to increase the likelihood of early diagnosis
and treatment. This report describes a study which
examines the alternative approach of an education programme
designed to promote breast self-examination (BSE) among
women aged 15 to 64 years, and which, at the same time,
documented the diagnosis and management of breast disease
in a circumscribed community in Daventry, Northamptonshire.
The education programme was carried out over 6 months
by a full-time research health visitor. Women were taught
within established work or leisure groups, with additional
open meetings in the health centre. The teaching
consisted of a set of slides, which were presented by the
health visitor, and followed by an open-ended discussion.
A teaching model was available for women to practise their
BSE technique. As well as teaching the method of BSE,
the education programme stressed that most breast problems
are not due to cancer, that earlier diagnosis improves the
chance of curing breast cancer and that BSE both increases
the likelihood of early diagnosis and gives reassurance
that everything is all right. Publicity was provided
(iii)
through posters, leaflets, an article and advertisements
in the local newspaper and by word of mouth. The leaflets
explaining BSE were distributed at each talk, and the
health visitor was available in the health centre at
certain times for women who wanted an individual
consultation.
Using the age-sex register as an age-stratified
sampling frame, postal questionnaires were sent to
600 women before the education programme and to the
same 600 and to a new sample of 600 women afterwards.
f
Before the programme, most women (87%) had heard of BSE,
although only 13% said that they practised it regularly
each month. Those women who had heard about BSE from,
or been taught BSE by, a health professional were more
likely to report practising it. Other factors which
increased the level of reported practice were uptake of
cervical cytology and a history of breast cancer in a
relative or close friend.
After the programme only 2% women reported that they
had not heard of BSE, and 23% now said that they practised it
every month. About one-fifth of the sample had attended
a talk given by the health visitor, over half of these at
their place of work. Almost all of those who used the
practice model reacted favourably to it. Very few women
expressed anxiety about the programme itself or about BSE,
although there were various indications of underlying fears
about breast cancer, which probably stem from direct
experience of the disease rather than from health education.
The GP consultations were monitored, and there were no
instances of women attending because of unreasonable
anxiety caused by the programme. The number of women
consulting with breast symptoms did increase slightly
during the programme, but there was no evidence
that this resulted from ill-founded worries.
Data were collected during the programme and in
the 6 month periods immediately before and immediately
afterwards on all women consulting their GP with breast
symptoms. A total of 239 women, age range 13 to 90
years, were seen by the 9 general practitioners, with
the only woman partner seeing the greatest number of
patients. About one-third of women presenting with
either a breast lump or pain had waited for one month or
more before consulting their GP. Although 20% women
were referred to hospital, only 4% were found to have
primary breast cancer. Thus, the breast disease seen
in general practice is almost entirely benign and often
appeared to represent physiological variation. The
women who had primary breast cancer were diagnosed by
the GP in two-thirds of cases. Diagnostic difficulty
and delay in general practice and hospital tended to occur
in those women without the typical symptom of a painless
lump. The follow-up arrangements in general practice
for women referred to hospital and for women who were
asked to re-attend their GP for subsequent review of their
symptoms appeared rather haphazard.
These data on GP workload indicate that to improve
the management of breast cancer by reducing the delay
in diagnosis it may be necessary to make several changes.
Both women and their doctors need to recognise the
potential significance of symptoms other than the classical
painless lump. GPs may have to accept a greater number
of women consulting with what prove to be minor breast
symptoms, and a larger proportion of women may
need to be referred to hospital. All women
who are found not to have breast cancer require
reassurance about this, and about the value of their
consultation. At the same time, review and follow-up
procedures should be improved to ensure that symptomatic
women are monitored and that adequate assessment and support
is given to those women who require treatment for breast
cancer. Any changes in practice should be carefully
evaluated.
Although the programme to promote BSE achieved
some modest changes, the scope of such programmes is
probably limited. Several specific problems were
identified - for example, the value and difficulty
of involving health professionals, the continuing gap
between knowledge and behaviour in BSE and the
uncertainty about the benefits afforded by BSE.
Health education at a more general level faces a
variety of difficulties, some of which are discussed,
and BSE must be considered within this context. It
is suggested that any teaching about BSE should be
coupled with education about the benefits of reducing
diagnostic delay. Wherever possible, this teaching
should be given within routine health care, with the
health professionals being provided with the appropriate
expertise, literature and materials. BSE would thus
become part of a wider strategy designed to promote
the secondary prevention of breast cancer.
