For years your doctor has extolled the virtues of breast self-examination — along with clinical breast exams and mammograms — as your front-line defense in the early detection of breast cancer. But in May 2003, the American Cancer Society changed its recommendations on breast self-examination, stating that the procedure should be optional rather than mandatory.

The new guidelines emphasize breast health awareness instead of a strict series of monthly self-exams. Although the guidelines don't say you shouldn't perform the exams, the importance of self-exams has been superceded by a more pressing need to become more familiar with your breasts. This familiarity will make it easier for you to notice any differences later on.

Breast familiarity refers to monitoring the way your breasts look and feel. You can do this by paying attention to changes in or on your breasts, such as:

• The development of a lump
• Irregular thickening of breast tissue
• Nipple discharge
• Skin changes, such as dimpling or retraction of the nipple

See your doctor if you notice any changes.

The change in guidelines comes on the heels of a large, randomized clinical study in Shanghai, China, that concluded that breast self-exams don't actually reduce the number of deaths from breast cancer.

In addition, the study found that women who perform regular breast self-exams (BSE) may be more likely to undergo biopsies after finding breast lumps. Because many such biopsies — about 75 percent — are noncancerous (benign), many women may undergo unnecessary surgery and anxiety.

Strong evidence still remains that detection of breast cancer at an early stage improves breast cancer survival rates. So if you're at average or increased risk of breast cancer, you may still choose to do BSE. To gain the greatest benefit from regular BSE, have your technique reviewed by your doctor at your next checkup.

If you choose not to perform BSE on a regular basis, you might discover a breast abnormality incidentally — while bathing or changing clothes, for instance. This reinforces the concept that increasing your familiarity with your breasts may help you notice when something isn't right. If you detect a breast lump or any other change at any time, schedule an appointment with your doctor to have it checked out.

The American Cancer Society (ACS) recommends that women be told at age 20 about the benefits and limitations of BSE. Breast self-exams should be supplemented with a clinical breast exam by a health professional every three years until age 40. After age 40, women should have a clinical breast exam and a mammogram every year.

If you're at high risk of breast cancer due to a family history of the disease, the ACS recommends that you think about starting your screening earlier, shortening the time interval between screening tests, or adding complementary imaging methods to mammography, such as ultrasound and magnetic resonance imaging (MRI). High risk women are advised to begin having yearly mammograms and clinical breast exams 10 years before the age a first-degree relative received the diagnosis of cancer, or no later than age 40.

Note that these are recommendations — not rules. Further research is needed to justify that this approach will be more effective than past approaches in screening for breast cancer.

Women experience changes in their breast tissue every month. This tissue is responding to the changes in hormone levels that occur during the menstrual cycle — the span of time from the start of one period to the start of the next. These changes in hormone levels cause your breasts to swell. With your menstrual flow, the swelling decreases and your breasts return to their normal size. Because of this cycle, the best time for you to examine your breasts is about one week after the start of your period. That's when your breasts are less likely to be tender or swollen.

During pregnancy and nursing, your breasts may feel lumpier than usual. If you have any questions about how your breasts look or feel, talk to your doctor.

A breast self-exam involves three steps:

1. Visual examination in front of a mirror
2. Examination while standing in the shower
3. Examination while lying down

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Breast self-exam Use your eyes and hands to search for lumps, thickened areas or swelling ... << ENLARGE

Visual examination
Stand in front of a mirror with your arms elevated and placed behind your neck. Thoroughly examine your breasts for any signs of puckering, dimples or changes in size, shape or symmetry. Check to see if your nipples are turned in (inverted). Look for these same signs with your hands on your hips.

Standing in the shower
Soap and water can make your breasts slicker and easier to examine. Once in the shower, place your left hand behind your head and examine your left breast with your right hand. Think of your breast as the face of a clock. Place your right hand at 12 o'clock at the top of your breast. Using the pads of your three middle fingers, press firmly in a slight circling, massaging motion. Feel for lumps as you move your hand down to 1 o'clock then 2 o'clock, continuing until you return to 12 o'clock. Slide your fingers closer to the nipple and repeat the circling motion around the clock face. Continue in increasingly smaller circles until you reach the nipple. Check the tissue under the nipple and look for discharge. Also check the tissue under your armpit, as well as tissue surrounding the breast, using the same firm, circling motion.

Place your right hand behind your head and repeat the examination on the right breast using your left hand.

Lying down
Lie down on a bed or flat surface, place your left hand under your head and examine your left breast with your right hand. Using the same firm, circling motion as you did in the shower, start examining your breasts at 12 o'clock at the top of your breast, moving in concentric circles around the clock face until you've examined the tissue under the nipple. Again, check the nipple for any discharge and be sure to examine the tissue under your armpit and surrounding the breast.

Repeat the procedure with your right hand under your head and your left hand examining the right breast.

If you do find a change or a lump, see your doctor. Also note that touching or gently pressing a breast lump may sometimes cause temporary discomfort.

Many women have lumpy (fibrocystic) breasts. This condition most frequently results from the changes in hormone levels that occur during menstruation or with perimenopause and menopause. Fibrocystic breasts are extremely common, occurring in at least half of all women. Having fibrocystic breasts doesn't mean you're more likely to develop breast cancer. If your breasts are very lumpy, performing BSE is more challenging. Becoming familiar with what's normal for you through regular self-examination will help make detecting any new lumps or changes easier.

Studies to date have shown that BSE alone doesn't reduce the number of deaths from breast cancer. However, BSE combined with mammography and clinical breast exams can reduce breast cancer mortality.

Early detection of breast cancer is crucial to beating the disease. One benefit of BSE lies in the potential to recognize, identify and treat a cancerous breast lump while it's still small and in an early stage of development. A potential risk, however, is that you might need a biopsy to evaluate the area of concern. If the biopsy results are noncancerous (benign), you might feel that the biopsy was unnecessary — but at least you'll know that you don't have cancer.

The bottom line is, if you notice any changes in your breasts, see your doctor as soon as possible. Taking the time to increase self-awareness of your breasts is important, but know that BSE can miss tumors, as can other methods. Don't rely on just one test to screen for breast cancer. Having regular clinical breast exams and yearly screening mammograms — in conjunction with increasing your self-awareness — may save your life.