ContextThe clinical breast examination (CBE) is widely recommended and practiced
as a tool for breast cancer screening; however, its effectiveness is dependent
on its precision and accuracy.ObjectiveTo collect evidence on the effectiveness of CBE in screening for breast
cancer and information on the best technique to use.Data SourcesWe searched the English-language literature using the MEDLINE database
(1966-1997) and manual review of all reference lists, as well as contacting
investigators of several published studies for clarifications and unpublished
data.Study Selection and Data ExtractionTo study CBE effectiveness, we included all controlled trials and case-control
studies in which CBE was at least part of the screening modality; for technique,
we included both clinical studies and those that used silicone breast models.
All 3 authors reviewed and agreed on the studies selected for inclusion in
the pooled analyses.Data SynthesisRandomized clinical trials demonstrated reduced breast cancer mortality
rates among women screened by both CBE and mammography. Evidence of CBE's
independent contribution was less direct; CBE alone detected between 3% and
45%of breast cancers found that screening mammography missed. The precision
of CBE was difficult to determine because of the lack of consistent and standardized
examination techniques. Studies on CBE precision reported fair agreement (κ=0.22-0.59).
Pooling trial data, we estimated CBE sensitivity at 54% and specificity at
94%. The likelihood ratio of a positive CBE result is 10.6 (95% confidence
interval [CI], 5.8-19.2), while the likelihood ratio of a negative test result
is 0.47 (95% CI, 0.40-0.56). Longer duration of CBE and a higher number of
specific techniques used were associated with greater accuracy. The preferred
technique for CBE includes proper positioning of the patient, thoroughness
of search, use of a vertical-strip search pattern, proper position and movement
of the fingers, and a CBE duration of at least 3 minutes per breast. The value
of inspection is unproved. Professional and lay examiners improved their sensitivity
on silicone breast models after being taught this technique.ConclusionsIndirect evidence supports the effectiveness of CBE in screening for
breast cancer. Although the screening clinical examination by itself does
not rule out disease, the high specificity of certain abnormal findings greatly
increases the probability of breast cancer.

Does This Patient Have Breast Cancer?: The Screening Clinical Breast Examination: Should It Be Done? How?

Little is known about how well physicians detect breast lumps in clinical breast examinations. We studied 80 general medicine, family medicine, general surgery, and obstetrics/gynecology physicians to determine their abilities to detect lumps in manufactured breast models. The mean number of lumps detected was 8.0 (44%), with a range of three (17%) to 15 (83%). Detection varied significantly by size (87% of 1.0-cm and 14% of 0.3-cm lumps) and hardness (56% of hard and 40% of soft lumps), but not depth; by specialty (from 50% for general internists to 40% for obstetricians), but not by level of training or experience; and by search duration (r=.59). On multiple regression analysis, only search duration was consistently associated with increased detection. Modest detection rates and wide variation suggest breast lump detection can be improved among physicians. Adequate search duration may be important for high detection rates. (JAMA1985;253:2224-2228)

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=jama&articleId=397970&pdfFileName=jama_253_15_027.pdf

Physicians' abilities to detect lumps in silicone breast models.

CANCER of the breast is newly diagnosed in about 180,000 women per year in the United States.1 In the majority of these cases the cancer presents as a palpable mass, usually found by the patient. With intensive public education about breast cancer and the growing acceptance of routine self-examination of the breasts, particularly by young women, an increasing number of women can be expected to seek consultation for the evaluation of breast masses. A study by the Physician Insurers Association of America in 1990 found that failure to diagnose breast cancer was the second most frequent reason for claims brought . . .

Evaluation of a Palpable Breast Mass

In an attempt to reduce the number of breast biopsies done for benign breast disease in patients with breast lumps, we evaluated prospectively the sensitivity and specificity of the combination of three diagnostic modalities: clinical examination, mammography, and fine-needle aspiration cytologic examination (FNA). A total of 234 patients with a breast mass had a physical examination, a mammogram, and FNA, and were listed as malignant/suspicious or benign. All patients underwent a subsequent biopsy: 110 were found to have breast cancer, and 124 had a benign lesion. The sensitivity and specificity of the individual tests were as follows: 89% and 73%, respectively, for mammographic examination; 93% and 97% for FNA cytologic examination; and 89% and 60% for physical examination. For the combined triad of tests, the sensitivity was 100% and specificity 57%. All patients who had breast cancer had positive findings for malignancy in one or more of the diagnostic tests, i.e., 100% sensitively. All patients who had negative findings for malignancy in all three diagnostic tests had benign lesions, i.e., a negative predictive value of 100%. We conclude that breast masses can be diagnosed with a high degree of accuracy by combined physical, mammographic, and fine-needle aspiration cytologic examination. Patients in whom physical examination, mammography, and FNA were negative for malignancy can be safely observed, obviating the need for an open biopsy.

Triple approach in the diagnosis of dominant breast masses: Combined physical examination, mammography, and fine‐needle aspiration

Although often recommended as an important component in screening for breast cancer, physical examination of the breasts (PE) by medical professionals has not been well evaluated. The Canadian National Breast Screening Study (NBSS) permits estimation of sensitivity, specificity, and positive predictive value (PPV) of PE alone as performed by screen-examiners because 50% of the 89,835 NBSS participants did not receive mammography. There were 19,965 women aged from 50 to 59 years who were eligible to receive four or five annual PEs from 77 nurse-examiners, in 12 screen centers outside Quebec province and 58 physician-examiners in three screen centers in Quebec. The gold standard was histologically proven breast cancer. When a test was positive the participant was referred to the study surgeon for review. For screens one to five, sensitivity was 83, 71, 57, 83, and 77; specificity was 88, 94, 96, 96, and 96; and PPV was 3, 3, 4, 3, and 4, respectively. For 25,620 women aged 40 to 49 years who were eligible to receive only one PE, sensitivity was 71, specificity 84, and PPV 1.5. Using a binomial regression model, X2 for heterogeneity suggested there was no difference between nurse and physician examiners (P = 0.6879). Similar estimates made for the surgeons who performed 8914 reviews showed that sensitivity and PPV were higher than for the screen examiners and specificity was lower. These results support the conclusion that physical examination of the breasts by trained nurses is a useful component in screening for breast cancer.

Physical examination. Its role as a single screening modality in the Canadian National Breast Screening Study.

The reliability of physical examination of the breast was evaluated by determining the extent of agreement among four experienced breast surgeons who examined the same 100 patients. The consequences of disagreements among surgeons were assessed by determining the diagnostic accuracy of each examiner. Despite differences in the frequency with which each surgeon found abnormalities or masses, or recommended mammography or biopsy, the diagnostic accuracy of the surgeons was very similar, and most disagreements concerned the findings in patients who did not have breast cancer. Breast examination carried out by more than one surgeon may reduce the frequency with which biopsy is performed in patients who do not have breast cancer.

Virginia E. Maurer

Papers

Prospective evaluation of physical examination of the breast