Deputy Managing Editor
sampson.nanton@cnc3.co.tt
For decades, women have been taught that the monthly breast self-examination was one of their strongest weapons against breast cancer.
The advice became so ingrained in public health messaging that many came to believe that if they examined themselves regularly and could not feel a lump, then there was little to worry about.
But according to breast surgical oncologist Dr Lyronne Olivier, modern medical evidence has changed that understanding.
The self-examination remains important, he says, but it should no longer be viewed as the frontline defence against the disease.
Instead, women should embrace something broader, more comprehensive and ultimately more effective, that is, breast awareness.
“What changed was evidence,” Dr Olivier said during an interview with Guardian Media.
“Everything that we promote, everything that we discuss and everything that we suggest should be based on evidence. Years ago, breast self-examination became widely accepted advice, but when large studies involving hundreds of thousands of women were conducted, the evidence showed that teaching self-examination by itself did not reduce deaths from breast cancer.
“The evidence is very clear. That does not mean self-examination is not important. It simply means that it is not enough on its own.”
The distinction is an important one, particularly in Trinidad and Tobago, where breast cancer remains the leading cancer diagnosis among women and one of the leading causes of cancer deaths.
According to international data, one in eight women will develop breast cancer during their lifetime, while local health officials have repeatedly highlighted the growing concern over women presenting for treatment only after the disease has already advanced.
For Dr Olivier, one of the biggest challenges remains changing public perception.
“A lot of women feel that because they checked their breasts and they didn’t feel a lump, they don’t have breast cancer.
“That is not the entire picture. Breast cancer is not simply about whether you can feel a lump or not. By the time some lumps become large enough to feel, the disease may already be more advanced than we would like.”
More than feeling for a lump
That is where breast awareness comes in.
Unlike traditional self-examination, breast awareness involves understanding what is normal for one’s body and identifying any changes, however subtle, that may require medical attention.
“Breast awareness incorporates self-examination, but it also includes changes in appearance, changes in the skin, nipple discharge, discomfort and changes in symmetry,” Dr Olivier explained.
“The goal is not necessarily for a woman to say, ‘Doctor, I have breast cancer.’ The goal is for her to say, ‘Doctor, something about my breast is different from what is normal for me.’ That difference is what matters.”
The surgeon says women should become familiar with the appearance of their breasts as much as their feel.
Standing before a mirror and examining the breasts with arms at the side, hands on the hips and arms raised above the head can reveal changes that fingers alone may never detect.
Skin dimpling, tugging, distortion or pulling may all be signs that require further investigation.
“Cancer has a tendency to invade surrounding tissues and pull structures towards itself,” he explained.
“Sometimes that pulling creates dimpling in the skin or changes around the nipple. Those visual signs can appear before a woman ever feels a lump.”
Warning signs women should not ignore
Women are also advised to pay attention to nipple discharge, particularly if it occurs spontaneously or affects only one breast.
Bloody discharge is especially concerning.
Redness and inflammation can sometimes indicate infection, but in rare cases may point to inflammatory breast cancer, one of the more aggressive forms of the disease.
Lumps beneath the arm should not be ignored either.
“One of the first places breast cancer can spread to is the axilla, which is the medical term for the armpit,” Dr Olivier said.
“That is why examining under the arm is just as important as examining the breast itself.”
The dangerous myth about pain
Perhaps one of the most dangerous misconceptions surrounding breast cancer is the belief that cancer equals pain.
Dr Olivier says that assumption frequently costs women valuable time.
“Human beings are conditioned to believe that if something doesn’t hurt, then something can’t be wrong.
“I see women in clinic who tell me, ‘Doc, I felt the lump months ago, but it wasn’t painful, so I wasn’t worried.’ Unfortunately, by the time pain develops, the tumour may have grown larger, involved the skin or affected surrounding nerves.”
He says pain is actually uncommon in early breast cancer.
“Breast cancer is usually a painless disease process. Only about three to five per cent of breast cancers present with pain and, when they do, they are often more advanced than the cancers we detect through screening.”
Timing your self-checks
Timing also matters when it comes to self-examinations.
For women who are still menstruating, Dr Olivier recommends examining the breasts about one week after the end of a period.
“After menstruation, the breast tissue is softer and less dense, making it easier to identify subtle changes,” he explained.
“Before a period, the breasts are often swollen and engorged, which can make normal tissue feel abnormal and make abnormalities harder to identify.”
Post-menopausal women should simply choose a fixed date each month and remain consistent.
“There should be some structure to it. It should not be random. The important thing is becoming familiar with what is normal for you so that any changes become obvious.”
When mammograms enter the picture
But regardless of age, self-examination should be accompanied by clinical examinations and imaging.
For women considered to be at average risk, annual clinical breast examinations should begin around age 30, while regular mammographic screening should start at age 40.
That recommendation, Dr Olivier noted, was strengthened following significant international research published in recent years.
“There was debate for years about whether screening should start at 45, 50 or even 55, but the evidence became increasingly clear that beginning mammographic screening at age 40 significantly reduced breast cancer mortality.
“The reduction in deaths associated with regular mammographic screening was substantial, and that is why many recommendations shifted towards earlier screening.”
Screening mammograms are designed to identify cancers before they become visible or can be felt by patients or doctors.
The earlier a tumour is detected, the greater the chances of cure.
Who is considered high risk?
Some women, however, fall into a high-risk category and require earlier intervention.
These include women with BRCA genetic mutations, strong family histories of breast or ovarian cancer, previous chest radiation exposure or multiple family members diagnosed with cancer at young ages.
For these patients, screening can begin as early as age 25 and may involve MRI scans alongside mammograms.
“You have average-risk women and then you have high-risk women,” Dr Olivier explained.
“For those high-risk patients, screening starts earlier because their lifetime risk of developing breast cancer is significantly higher. The earlier we begin surveillance, the better our chances of detecting disease before it becomes clinically apparent.”
MRI scans are often preferred in younger women because breast tissue tends to be denser, making mammograms less effective on their own.
Treatment has changed dramatically
There is, however, encouraging news for women diagnosed with breast cancer today.
Treatment options have evolved dramatically over the last decade, moving beyond a one-size-fits-all approach towards highly personalised care.
“No one person decides the treatment plan anymore,” Dr Olivier said.
“The surgeon, medical oncologist, radiation oncologist, radiologist, pathologist, nurses, psychologists and the patient’s family all become part of the decision-making process. It is a true multidisciplinary approach, and that gives patients the best possible outcomes.”
Doctors are now able to study the biological behaviour of tumours and tailor therapies accordingly, while newer immunotherapy treatments are showing promise for some of the more aggressive cancers.
“Cancer is intelligent in many ways.
“Some cancers can effectively switch off the body’s immune response. What some of these newer treatments do is switch the immune system back on and allow it to recognise and attack cancer cells again. That is one of the areas where we are seeing some of the most exciting advances.”
For all the advances in medicine, however, Dr Olivier believes the most powerful weapon remains early detection.
And that begins with changing how women think about breast health.
“I never want women to leave this conversation believing that breast self-examinations are no longer important.
“What I want them to understand is that self-examination should be one part of a much bigger picture. Breast awareness, regular clinical reviews and appropriate screening all work together.
“The earlier we identify breast cancer, the smaller the tumour is likely to be and the greater the chance that we can offer cure rather than simply control the disease.”
