In this study we tested the framing hypothesis that a pamphlet stressing the negative consequences of not performing breast self-examination (BSE) would be more persuasive than a pamphlet emphasizing BSE's positive consequences. College-aged female subjects were exposed to a loss-frame pamphlet, a gain-frame pamphlet, or a no-arguments pamphlet, or they received no pamphlet describing the importance of and the techniques for performing BSE. Attitudes toward BSE and intentions to perform BSE were assessed immediately after this intervention and again 4 months later. The follow-up also assessed subjects' postexperimental BSE behavior. Consistent with predictions, subjects who read a pamphlet with arguments framed in loss language manifested more positive BSE attitudes, intentions, and behaviors than did subjects in the other three conditions. The greater impact of the loss pamphlet could not be attributed to greater fear arousal, better memory for pamphlet content, greater perceived susceptibility to breast cancer, or stronger beliefs in BSE's efficacy on the part of the loss subjects. Only measures of perceived self-efficacy in performing BSE were differentially affected by the framing manipulation, with loss subjects reporting the greatest levels of self-confidence. The results are discussed in terms of prospect theory's framing postulate and a simpler negativity-bias conceptualization, and underlying mechanisms such as differential salience and vividness are considered. Clinical implications of the findings are also explored.

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The effect of message framing on breast self-examination attitudes, intentions, and behavior.

Background Among women who practice breast self-examination (BSE), breast cancers may be detected when they are at an earlier stage and are smaller than in women who do not practice BSE. However, the efficacy of breast self-examination for decreasing breast cancer mortality is unproven. This study was conducted to determine whether an intensive program of BSE instruction will reduce the number of women dying of breast cancer. Methods From October 1989 through October 1991, 266,064 women associated with 519 factories in Shanghai were randomly assigned to a BSE instruction group (132,979 women) or a control group (133,085 women). Initial instruction in BSE was followed by reinforcement sessions 1 and 3 years later, by BSE practice under medical supervision at least every 6 months for 5 years, and by ongoing reminders to practice BSE monthly. The women were followed through December 2000 for mortality from breast cancer. Cumulative risk ratios of dying from breast cancer were estimated using Cox proportional hazards models. All statistical tests were two-sided. Results There were 135 (0.10%) breast cancer deaths in the instruction group and 131 (0.10%) in the control group. The cumulative breast cancer mortality rates through 10 to 11 years of follow-up were similar (cumulative risk ratio for women in the instruction group relative to that in the control group = 1.04, 95% confidence interval = 0.82 to 1.33; P =.72). However, more benign breast lesions were diagnosed in the instruction group than in the control group. Conclusions Intensive instruction in BSE did not reduce mortality from breast cancer. Programs to encourage BSE in the absence of mammography would be unlikely to reduce mortality from breast cancer. Women who choose to practice BSE should be informed that its efficacy is unproven and that it may increase their chances of having a benign breast biopsy.

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Randomized Trial of Breast Self-Examination in Shanghai: Final Results

Background: The efficacy of breast self-examination in helping to reduce mortality from breast cancer has not been rigorously demonstrated. Purpose: To assess efficacy, a large, randomized trial was initiated in Shanghai, China. Methods: From October 1989 to October 1991, 267 040 current and retired female employees associated with 520 factories in the Shanghai Textile Industry Bureau were randomly assigned on the basis of factory to either a selfexamination instruction group (133 375 women) or a control group (133 665 women). The women were born within the period from 1925 through 1958. Women in the instruction group were given intensive training in breast self-examination, including the use of silicone breast models and personalized instruction, plus two subsequent reinforcement sessions and multiple reminders to practice the technique. Women in the control group were asked to attend training sessions on the prevention of low back pain. All women have been followed for the development of breast diseases and for death from breast cancer. Results: A high level of participation during the first 4-5 years of the trial was documented among women in the instruction group. Randomly sampled women in this group demonstrated greater proficiency in detecting lumps in breast models than did randomly sampled women in the control group. Approximately equal numbers of breast cancers were detected in the two groups (331 in the instruction group and 322 in the control group) through 1994, which is the last year for which case-finding efforts have been completed. The breast cancers detected in the instruction group were not diagnosed at an appreciably earlier stage or smaller size than those in the control group. More benign breast lesions were detected in the instruction group than in the control group (1457 versus 623, respectively), suggesting a higher index of suspicion for women who received training. Cumulative breast cancer mortality rates through 5 years from entry into the study were nearly equivalent for the two groups. Conclusions: Breast selfexamination has not led to a reduction in mortality from breast cancer in this study cohort in the first several years since the trial began. A shift toward the diagnosis of disease at a less advanced stage in women given instruction has also not been demonstrated. Longer follow-up of participants in this trial is required before final assessment can be made of the efficacy of breast self-examination. Implications: At this time, there is insufficient evidence to recommend for or against the teaching of breast self-examination. [J Natl Cancer Inst 1997;89:355-65]

Randomized Trial of Breast self-examination in Shanghai: Methodology and Preliminary Results

We reviewed evidence regarding breast self-examination (BSE) and screening for breast cancer. To our knowledge, no controlled prospective trial links BSE to lives saved from breast cancer. Compared with clinical breast examination and mammography, the estimated sensitivity of BSE is low (20% to 30%) and is lower among older women. The potential sensitivity of BSE should be higher because women can detect small lumps (0.3 cm) in silicone models. Instruction increases BSE frequency over the short term. Sensitivity also increases, but specificity decreases. The psychological effects of teaching and performing BSE are not yet clear. The cost of screening by BSE is unknown but depends on the accuracy of the test as well as the training method used. Breast self-examination has potential as a screening test for breast cancer, but many questions require scientific examination before this procedure can be advocated as a screening test for breast cancer. ( JAMA 1987;257:2196-2203)

US Preventive Services Task Force. Screening for breast cancer with breast self-examination. A critical review.

A comparison was made of the incidence rates of localized, regional, and remote breast cancer between Black and White women by age at diagnosis. The analysis is based on 17,361 cases of breast cancer, newly diagnosed between 1973 and 1982, in Black and White female residents of the Detroit metropolitan area. Cases with breast cancer classified as local, regional, or remote were drawn from the Metropolitan Detroit Cancer Surveillance System of the Division of Epidemiology at the Michigan Cancer Foundation, a participant in the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute. The findings indicate that older women, particularly Black women, are at elevated risk for being diagnosed with the most advanced form of breast cancer.

J. Chamberlain

Papers

Self-examination in the early detection of breast cancer. A review of the evidence, with recommendations for further research.