The Clinical Breast Exam

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The Clinical Breast Exam

• Margaret Plumbo
• Catherine Juve
• University of Minnesota
• AIHA

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Effectiveness of Clinical Breast Exam (CBE)

• Meta-analyses demonstrated that CBE and/or
  screening mammography decreases breast cancer
  mortality rates by about one fourth in women from
  50 through 69 years and by 18 in women in their
  40s.
• Studies that compared a combination screening
  strategy with no screening are the strongest
  scientific evidence for an effect of screening
  CBE.

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Strength of Recommendation

• A Strongly recommends routine provision
• B Recommends routine provision
• C No recommendation for or against
• D Recommends against routine provision
• I Insufficient evidence to recommend for or
  against routine provision

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Breast Cancer Screening Guidelines
USPSTF 2002

• For women 40-49 years old
• Mammography w/wo CBE every year
• B - recommend routine provision
• Lower risk of breast cancer and higher rate of
  false positives makes mammography less beneficial
  if woman is lt 50
• Insufficient evidence for CBE alone
• I - cannot recommend for or against

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Breast Cancer Screening Guidelines
USPSTF
2002

• For women 50-69 years of age
• Mammography w/wo CBE q 1-2 yr
• B - recommend routine provision
• Insufficient evidence for CBE alone
• I - cannot recommend for or against

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Breast Cancer Screening Guidelines
USPSTF 2002

• For women 70 years and older
• Same benefit as younger women, if no concurrent
  disease
• Limited evidence regarding mammography and CBE in
  women over 75
• I - cannot recommend for or against

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Clinical Breast Exam

• Data show that sensitivity of CBE is far from
  perfect.
• Pooled data from human studies give an overall
  estimate for the sensitivity of the CBE of 54
• i.e. 46 masses missed
• 4 percent of women with an abnormal CBE will be
  subsequently diagnosed with cancer.

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Breast Self Exam

• A randomized trial in China
• No evidence of reduction in breast cancer
  mortality after long-term follow-up.
• 3 worldwide trials
• Failure to identify a reduction in breast cancer
  mortality or significant improvements in the
  number or stage of cancers detected

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Associations disagree about recommendations

• AMA, ACOG, American College of Radiology (ACR),
  ACS
• Age 40 - mammography and CBE
• Canadian Task Force on Preventive Health Care
  (CTFPHC), AAFP and the American College of
  Preventive Medicine (ACPM)
• Age 50 begin mammography for average-risk
• AAFP and ACPM
• Age 40 begin mammography in high-risk women
• AAFP
• Age 40-49 - counsel about risks and benefits of
  mammography before making decisions about
  screening.

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The Procedure

• Explain what you will be doing
• Ask if she does breast self exam
• Warm your hands
• Assure privacy
• Would someone else in the room be helpful?
• Assist patient to supine position

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Mammacare method

• Spoke model not sensitive
• Overlapping strip method has been validated in
  independent investigations of CBE technique.

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Palpation

• Variables important in palpating the breast
  correctly are
• patient position
• breast boundaries
• examination pattern
• finger position, movement, and pressure
• duration of the examination

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Patient Position

• Clinical breast examination requires flattening
  breast tissue against the patient's chest
• Client is supine during the examination

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Breast Boundaries

• Breast tissue extends laterally toward the axilla
  and superiorly toward the clavicle.
• Cover a rectangular area bordered by the clavicle
  superiorly, the midsternum medially, the
  midaxillary line laterally, and the bra line
  inferiorly.

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Examination Pattern

• Palpation begins in the axilla and extends in a
  straight line down the midaxillary line to the
  bra line
• The fingers move medially, and palpation
  continues up the chest in a straight line to the
  clavicle.
• Rows should be overlapping.

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Technique

• The 3 middle fingers are held together, with the
  metacarpal-phalangeal joint slightly flexed.
• Pads of the fingers are the examining surface.

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• Each area is palpated by making small circles
  using 3 different pressureslight, medium, and
  deep

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Duration

• 3 minutes recommended for each breast
• Average actual time spent is 1.8 minutes
• Discuss with patients the time needed to do a
  complete examination and discuss the procedure
  during the examination.

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Nipple

• Palpation of the nipple area is performed in the
  same manner as the rest of the breast.
• Squeezing for discharge not a useful prognostic
  sign for cancer.

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Inspection

• The importance of inspection is unproved.
• No adequate data support recommendations of some
  authorities to examine women in a variety of
  other positions

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Masses

• Normal breasts are often lumpy
• Cancers classically are characterized as hard,
  fixed, and irregular
• Benign breast lumps are soft or cystic, movable,
  and regular

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Masses

• Many cancers do not conform to the classic
  picture and benign masses can mimic cancer.

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• Because the characteristics of cancerous lumps
  overlap with those of noncancerous lumps,
  clinicians rarely diagnose breast cancer with
  CBE.
• Careful CBE can locate abnormalities. Further
  evaluation with other tests is then required.

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Clinical Case Breast mass in 64 year old

• The discovery conveys an increased risk of
  cancer.
• Probability of invasive cancer in the coming year
  is 0.35 (347 cases per 100,000 women).
• Finding the mass on CBE gives a probability of
  0.73
• If the mass is greater than 2 cm and has all the
  other malignant characteristics the probability
  of cancer increases to 8.8

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42 year old

• No breast symptoms - pretest probability of
  breast cancer is 0.12, or 119 per 100,000.
• A normal CBE would decrease her risk of breast
  cancer to 0.11
• The psychological reassurance she may gain from a
  CBE could increase the value of this maneuver.

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Mammography
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Women aged 50-69

• If facilities are available, screening by
  mammography alone (with or without CBE) plus
  follow-up of individuals with positive or
  suspicious findings, will reduce mortality from
  breast cancer by up to one-third.

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Sensitivity of mammography

• In one large study
• Mammography detected 77 to 95 of cancers
  diagnosed over the current year, but only 56 to
  86 of cancers diagnosed over the next 2 years.
• Sensitivity is lower among women who are younger
  than 50, have denser breasts, or are taking
  hormone replacement therapy.

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False positive rates

• In screening trials
• False-positive rate of mammography is 3 to 6
• Better detection with a shorter screening
  interval and the availability of prior
  mammograms.
• Rate of false-positive mammograms higher in women
  aged 40-59 (7-8) than in women aged 60-79
  (4-5).

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Predictive value

• The probability that an abnormal mammogram is due
  to cancer increases with age.
• 2 to 4 among women aged 40-49
• 5 to 9 among women aged 50-59
• 7 to 19 among women aged 60 and older
• Positive predictive values were also higher among
  women with a family history of breast cancer in
  two studies.

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Practical tips for getting a group going and
running smoothly- Group dynamics
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Self-reflection

• Ask yourself how comfortable you are with the
  material.
• Consider practicing in front of a mirror or with
  a trusted friend or family member before the
  workshop.

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• You may have to handle issues such as grieving a
  loss of someone to breast cancer, personal
  stories of breast cancer, sexuality,
  disfigurement.
• Have resources at hand for such members.

What would you do or say if someone did confide
such things during the workshop?
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Publicize the event

• Your advertisement or flyer for the workshop
  should be posted in numerous areas of the city or
  facility from which you hope to draw
  participants.
• Provide brief overview of content and sponsoring
  agency. Provide details of time, date, place, and
  any future presentations in case they cannot come
  to this one.

• Breast Health
• Come to learn -
• how to protect your health
• how to increase your awareness
• St. Nicholass Church
• Saturday, Nov. 27, 2004
• 2 pm - 4 pm
• Bring a friend or family member
• Tea will be served

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Establishing group cohesion

• In group work, it is important to foster
  interactions between group members to create a
  positive learning environment.
• While members are coming in, welcome members and
  help them get seated or get tea. Shake hands or
  use touch to show your pleasure that they have
  come to the workshop.

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Before participants arrive

• Have tea and snacks ready.
• Take note of comfort of environment
• temperature
• seating arrangement in circle if possible

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• Make certain that your models are at hand.
• Make sure handouts are ready.
• Make sure audio-visual equipment is ready and
  working.

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Initiation of the workshop

• Within the first few minutes, the leader must
  establish credentials
• introduce yourself
• why are you the leader, what can you offer
• show your enthusiasm for the topic of breast
  health
• share a story about what stimulated your interest
  in this topic

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Establish a welcoming presence

• Directions to beverages, snacks. restrooms
• Introduce other experts (no more than 2)
• Ask members to introduce themselves -
  ice-breaker
• Tell us a little about your knowledge of this
  topic, your job or family or why you are here
  today.
• Provide members with a brief overview of content
  to be covered.

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At start of content discussion

• Acknowledge that this may be a review for some
• Ask if there are any initial questions or
  concerns
• Give participants permission to ask questions any
  time
• Make sure your language and use of terminology is
  appropriate for the groups level including
  materials and audio-visual content

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Use of models and resources

• Have your Resource Kit at hand
• video for each participant
• models
• handouts
• shower cards
• Pass around several breast models. Give members
  time to get comfortable with them. If possible,
  have one model for 1-3 participants.

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• Experts circulate in room, briefly working with
  each group, provide suggestions and give positive
  feedback.
• Ask them to feel to see if they can find any
  masses.
• Explain how to determine consistency, mobility,
  location, size so this can be communicated to
  their care provider.
• Emphasize that a lump is most often NOT cancer.

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After content is presented

• Provide participants with summary
  3 Take Home messages
• Evaluation
• At the end of the session, ask participants to
  evaluate various components of the session. Ask
  for verbal feedback and provide a written
  evaluation form.