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Abstract & commentary
Synopsis: A thorough clinical breast examination can detect cancers missed by mammography.
Source: Barton MB, et al. JAMA 1999;282:1270-1280.
Barton and colleagues conducted a pooled analysis of the English literature on the effectiveness and techniques of clinical breast examination. Clinical breast examination screening was compared to a combination of clinical examination and mammography. The reduction in breast cancer mortality rate was similar. This is a strong argument that clinical breast examination alone can have a beneficial effect on the risk of breast cancer mortality. Importantly, all studies have reported a proportion of breast cancers detected by clinical examination alone (3-45% of breast cancers missed by screening mammographies). In other words, a clinical breast examination can detect cancers missed by mammography. The literature on clinical breast examination is plagued by variability. To a significant degree, this is due to the lack of an unstandardized method of clinical breast examination. The accuracy of clinical breast examination is further reduced by not spending sufficent time at the examination, reduced sensitivity in younger more dense breasts, large breasts, and lumpy breasts. Barton et al concluded that there is sufficient evidence to warrant screening clinical breast examination in every woman older than 40 years of age, and that approximately 50% of asymptomatic breast cancers can be detected by a well-performed breast examination.
Comment by Leon Speroff, MD
This is an article that every clinician who cares for adult women should read. I have always taken pride in my technique for breast examination and, I suspect, this is true for most clinicians. However, this article revealed to me that my technique is not good enough. After making a convincing argument that the literature supports the value of clinical breast examination for the detection of breast cancer, Barton et al provide a detailed description of a technique based upon the research literature, especially that regarding the development and standardization of the clinical examination. There are five vital parts to the correct technique for clinical breast examination:
• A systematic search pattern
• Thoroughness with adequate duration
• Varying palpation pressure
• The use of three fingers and the pads of the fingers
• A circular motion of the finger pads
In excellent diagrams, this article describes the best patient position to achieve flattening of the lateral and medial parts of the breast, a requirement that is essential for adequate examination. A circular boundary for the examination is inadequate. A complete examination requires covering a rectangular area, bordered by the clavicle, the mid-sternum, the bra line, and the mid-axillary line. The most effective examination pattern is not the circular pattern I have used but, in fact, a vertical strip pattern or lawn mower technique, beginning in the axilla, moving to the bra line, and then back and forth, overlapping rows. The three middle fingers are held together. Palpation is performed by the pads of the fingers, rotating in small dime-sized circles. Most important, at each position, three levels of pressure should be exerted (light, medium, and deep) to complete palpation of all levels of tissue. The duration of examination affects the accuracy. Studies have demostrated that a careful examination of an average size breast requires at least three minutes. I know I have not been spending six minutes examining both breasts of patients. In one study, it was documented that the average time equaled 1.8 minutes. Of note is the lack of data supporting inspection in various positions. Thus, it is recommended that careful breast palpation should be combined with careful visual examination simultaneously.
Because of this article, I have already changed the technique of my breast examination, especially changing the pattern of palpation and the duration of examination. I urge you to obtain a copy of this article. Not only are the numbers important, but the description of technique with the excellent diagrams will affect your practice. The numbers tell us that doing it right makes clinical breast examination effective and important. The pictures show us the right way to do it. (Dr. Speroff is Professor of Obstetrics and Gynecology, Oregon Health Sciences University, Portland, Ore.)