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"The Canadian Cancer Society's decision to de-emphasize traditional breast self-exams is perplexing some breast-cancer survivors and doctors who say women should continue checking their breasts and reporting potential signs of cancer to their doctors," writes Rebecca Dube in Still a case for checking your breasts .

"So who's right? The answer is both, though it may be a confusing message for women to hear."

To help clear the confusion, Heather Logan, director of cancer control policy and information for the Canadian Cancer Society, and Dr. Nancy Baxter, assistant professor of surgery at the University of Toronto, answered your questions on the cancer society's decision and what women can and should do to be proactive about catching and fighting breast cancer.

Thank you to everyone who submitted questions before Monday's cutoff. Ms. Logan and Dr. Baxter's answers are now available below.

Dr. Baxter is an assistant professor of surgery at the Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto. During her surgical training she completed the Surgeon Scientist Program, specializing in clinical research, and published guidelines for the Canadian Taskforce on Preventive Health Care regarding the routine use of breast-self examination for prevention of deaths from breast cancer. She is an active health services researcher focusing on cancer screening and survivorship issues for cancer patients. She holds grants and awards from the Canadian Institutes of Health Research, the American Society of Clinical Oncology, the Lance Armstrong Foundation, and the Ontario Ministry of Research and Innovation, and has over 40 peer-reviewed publications.

Heather Logan is the director of cancer control policy at the Canadian Cancer Society (CCS) and the National Cancer Institute of Canada (NCIC). In this role, Mrs. Logan is responsible for evaluating scientific evidence, developing health policy and position statements about emerging scientific issues, including disease prevention and health promotion, working with committees that advise the CCS and NCIC Boards of Directors, overseeing the development of print and online cancer information materials.

Editor's Note: globeandmail.com editors will read and allow or reject each question. Questions may be edited for length, clarity or relevance. HTML is not allowed. We will not publish questions that include personal attacks on participants in these discussions, that make false or unsubstantiated allegations, that purport to quote people or reports where the purported quote or fact cannot be easily verified, or questions that include vulgar language or libellous statements. Preference will be given to readers who submit questions/comments using their full name and home town, rather than a pseudonym.

Rasha Mourtada, Globe Life web editor: Thank you, Ms. Logan and Dr. Baxter, for taking the time to answer reader questions on this important issue. I'll start by asking you each to address your views on the Canadian Cancer Society's announcement regarding breast self exams. How do you reconcile it with anecdotal evidence that seems to show that self exams serve a purpose? And can you explain what women should in fact be doing to be pro-active in combatting this disease?

Heather Logan: Many women have found their own breast cancer because they learned what was normal for them by looking at and feeling their breast tissue. By knowing what is normal, they were better able to feel or see changes more easily, and report these changes to a doctor. The Society is still strongly encouraging women to know what is normal for their breasts by using a hands-on approach that is comfortable for them and at whatever time is convenient. It just doesn't have to be done using a specific technique at the same time each month, which was the hallmark of breast self-examination.

The most effective ways to detect breast cancer are through mammograms and clinical breast exams. Women can be pro-active by following the Canadian Cancer Society's breast screening guidelines:

-For women aged 40-49, this means having a clinical breast examination by a trained healthcare professional at least every 2 years. Women in this age group should also talk to their doctor about their risk of breast cancer, along with the benefits and risks of mammography.

-Women aged 50-69 should have a mammogram every 2 years and a clinical breast examination by a trained healthcare professional at least every 2 years.

-Women over 70 should talk to their doctor about how often they should be tested for breast cancer.

We also encourage women to learn what is normal for your breasts by looking at and feeling your breast tissue.

Women who think they are at high risk for breast cancer should talk to their doctor to decide whether additional or more frequent screening is warranted.

Nancy Baxter: Thanks Rasha for giving me the opportunity to participate in this discussion.

Although the announcement of the Canadian Cancer Society -- that routine breast self-examination is no longer recommended -- may seem sudden to some, really this decision has been evolving over a long period of time. There has never been good evidence that breast self-examination is effective (i.e. leads to better survival from breast cancer) and over the past decade, a number of high quality studies have been performed and published to better evaluate the risks and benefits of this screening technique. These studies have found that while teaching breast self-examination to women results in an increased rate of physician visits for non-cancerous breast problems and a higher number of benign breast biopsies, unfortunately teaching breast self-examination does not help prevent deaths from breast cancer. So there appears to be a down side to this form of breast cancer screening and no upside, at least in terms of survival from breast cancer. At the end of the day, we can't ask healthy women to participate in any form of screening if we don't think there is a benefit and we know there is risk, so this has resulted in the change in recommendation.

Women do find breast cancer themselves, so it seems paradoxical that breast self-examination does not work. However, most women who find breast cancer themselves do not find the cancer during breast-self examination. They find a lump during casual palpation. Many people equate self detection (finding cancer yourself) with breast self-examination but it is very important to make the distinction. Breast self-examination involves a systematic search of the breasts for lumps or changes. Breast self-examination requires teaching and reinforcement and should be done regularly, in a rigorous fashion (there are well described techniques that most of us are familiar with — a description may be hanging in your shower at this very moment) Conversely casual palpation is just that, feeling the breasts during showering, changing, sexual relations or whenever. There is no specific technique and it is not done on any particular schedule. Seems vague, but also seems to work; women find breast lumps all the time this way, and overall this approach seems to be as effective as performing regular, structured breast self-examination. Certainly, and I suspect Heather will emphasize this point as well, the change in recommendations should not discourage women from being pro-active about their health; if you find a lump in your breast (or anything that you are worried about) you need to report this to your physician. But making women search their breasts for cancer each month just doesn't seem to make a difference.

Ann Bishop, Regina: Hello Ms. Logan and Dr. Baxter. I think one of the statements made when this latest study was publicized was that one could discontinue regular self breast examinations. On the other hand it also stressed that one should 'get to know' one's breasts. How can one get to know one's breasts if one does not self-examine regularly? It would seem to me that changes in one's breasts would only be apparent if one knew what 'normal' felt like. Any thoughts?

Nancy Baxter: Hi Ann — this is a great point. Sometimes the language used to promote breast awareness can be a bit vague - "get to know your breasts" doesn't really give any specific direction and that can be confusing. However, we really don't have any evidence that any systematic approach is beneficial, and in fact for some women focusing on this can cause a lot of anxiety. Knowing what feels abnormal or worrisome seems to be a lot easier and a lot more important than knowing what feels "normal."

Heather Logan: We'd like to emphasize that the Society is still encouraging women to learn what is normal for their breasts by looking at and feeling their breast tissue. It just doesn't have to be done using a specific technique at the same time each month, which was the hallmark of breast self-examination. Use a hands-on approach that is comfortable for you and at whatever time is convenient.

Bry Land, Canada: Hi there, if women checking their breasts monthly is now debatable, what can be said about doctor exams? Are doctor exams still dependable and to be relied upon? Can doctor exams feel lumps not seen in mammograms?

Nancy Baxter: Bry you are right, although we think clinical breast examination (examination by a health professional on a yearly basis) is a better screening test than breast self-examination, we don't have great evidence that this form of screening actually works. In fact, no form of breast cancer screening is even close to perfect. The evidence for screening with mammography is the strongest while the evidence for clinical breast examination is weaker. I know this seems counterintuitive — these techniques, particularly mammography, can find cancers when they are tiny, and smaller must be better, right? But not all breast cancers are the same — some cancers are very aggressive, and even if they are detected when they are small they will still spread, while some large cancers are slow growing and even if you find these cancers later, women can be still cured with treatment, so early detection of cancer will not benefit everyone.

Cancers detected during breast self-examination are larger than those found with mammography or clinical breast examination, and this is likely why this technique does not result in any benefit when it is widely applied. In fact, the only thing the studies of breast self-examination have clearly demonstrated is that teaching this technique will result in an increase in physician visits for breast problems that are not cancer, and an increase in breast biopsies for non-cancerous breast lumps.

Heather Logan: The most effective ways to detect breast cancer are through mammograms and clinical breast exams. Clinical breast exams by a healthcare professional trained to feel tumours, helps find potentially cancerous breast changes at an earlier stage than if a women was checking her breasts herself. For women 40 and older, we recommend they have a clinical breast exam at least every 2 years.

Eugene Moreau, Candiac, Canada: What case controlled studies are there that shows that screening of any sort is of any use at all?

Nancy Baxter: Eugene, the most important studies in this area are randomized controlled trials, where half the women get some form of screening while the other half get another form, or no screening at all. Who gets what is basically decided by the flip of a coin. These studies generally need to be very large and are conducted over a long period of time. They are therefore a real challenge to complete. We are fortunate to have information from a number of trials of mammography which, in total, have randomized over half a million women. For women age 50 to 69, the studies demonstrate that about 20% of breast cancer deaths could be prevented with regular screening mammography. So screening mammography is certainly of use, and that's why mammography is a major focus of the breast cancer screening recommendations of the Canadian Cancer Society.

Heather Logan: So far research, including case controlled studies and randomized control clinical trials, have led to information about effective screening tests for breast, colorectal and cervical cancers. There are several studies that have shown screening by mammography is effective at reducing the number of deaths from breast cancer. This website describes the evidence from 4 randomized control trials (considered the "gold standard") for breast cancer.

Our hope is that continued research in screening will uncover more answers about screening for other types of cancers.

John Owen, Victoria: On Sept. 6 my wife had a diagnostic mammogram (she is a breast cancer patient). There was nothing found. On Sept. 17 she found a lump. An ultrasound showed this to be of no concern. I think it's better to find a benign lump, with all its attendant worries, than not find a malignant one.

Nancy Baxter: Hi John, thanks for sharing your wife's story. First I would like to remind all our readers that the Canadian Cancer Society recommendations are for women at an average risk of breast cancer. Your wife is a breast cancer survivor, so these recommendations do not apply - follow up strategies should be tailored to her needs. Even so, there are no studies demonstrating a benefit of breast self-examination in breast cancer survivors.

Your wife's experience is common — when a breast lump is investigated and found not to be cancer (in medical terms this is called a false-positive result) it is a relief. I've heard people describe this experience as a "small price to pay" or "better safe than sorry" and if at the end of the day breast self-examination saved lives, they would be right. Unfortunately, although teaching a woman breast self examination increases the chance that she will require investigations and even a breast biopsy for breast problems that are not cancer, performance of breast self-examination will not reduce her chance of developing or dying from breast cancer. And that's no bargain at any price.

Having said this, I would like to again stress than women do find breast cancers themselves, in some cases this can happen even after a recent mammogram or examination by a medical professional. Certainly, the recommendations of the Canadian Cancer Society should not be interpreted as discouraging women from being aware of their bodies, or reporting anything worrisome to their physician.

Heather Logan: We're glad to hear that your wife is doing well. In general, the Canadian Cancer Society's recommendations are for women who are at average risk of developing breast cancer. A woman who has already been diagnosed with breast cancer would not ordinarily fall into the "average risk" category. What is best for your wife should be determined in consultation with her doctor.

Rasha Mourtada, Globe Life web editor: Thank you for your time. Are there any last thoughts you'd like to leave us with?

Nancy Baxter: You mentioned anecdotes in your introduction, Rasha, and whenever the subject of breast self-examination comes up I hear the narratives of breast cancer survivors who found their cancers through self-examination and attribute their survival to the fact that they found cancer early. These anecdotes are extremely powerful, and while I cannot (and do not) say that breast self-examination has never helped anyone, I can say that on average breast self-examination does not result in an improvement in breast cancer survival for women who are taught the technique. Before we had screening programs or any treatment for breast cancer other than surgery, half of women who developed breast cancer survived. It is therefore impossible to pinpoint for any breast cancer survivor what aspect of diagnosis or care resulted in her survival. While it may be hard to accept evidence when it is inconsistent with one's personal beliefs, it is essential that we base breast cancer screening recommendations for Canadian women not on anecdotes, but on the best evidence available. Breast self-examination is not effective and is therefore no longer recommended.

Heather Logan: The Canadian Cancer Society cares deeply about the health of Canadian women. We appreciate this opportunity to address important questions about breast awareness. We want to be clear that our message to women is that knowing your breasts is still a hands-on approach. By knowing what is normal for you will mean you can spot changes more easily and report them to your doctor. We encourage women to be proactive with their breast health — it could save your life. For more information about breast health we invite you to visit our website ( www.cancer.ca ) or to call our Cancer Information Service at 1 888 939-3333.