Clinical breast exam (CBE)

• Sensitivity of CBE is approximately 54% and the specificity is approximately 94%.
• Duration of CBE correlated with lump detection accuracy in experiments using silicone models.
• Highest recorded sensitivity was 69% for examiners who spent 5-10 minutes in examining both breasts.
• Using careful technique was also correlated with increased sensitivity in models.
• Careful technique: systematic search pattern, thoroughness, varying palpation pressure, use of three fingers, finger pads, circular motion.
• Clinicians observed using vertical strip method were more thorough than those using concentric circles or a random spoke pattern--most important factor was that the examiner has a consistent method.
• Careful examination of average-sized breasts takes at least 3 minutes per breast.
• Provider experience was also correlated with increased sensitivity.
• Patient characteristics that are associated with lower sensitivity of CBE: age (younger women have denser breasts, making CBE less sensitive) and size (CBE sensitivity is lower in women with large breasts).

USPSTF I recommendation - insufficient evidence to recommend for or against routine CBE alone to screen for breast cancer.

• CBE likely contributes minimally to early detection.
• Study in Canada reviewed contributions of mammograms and CBE to early detection of breast cancers.

• CBE increased the rate of detection of small invasive cancers by 2-6% over rates if mammogram were used alone.
• Without CBE, three cancers would be missed for every 10,000 screens and 3-10 small invasive cancers would be missed for every 100,000 screens.

5 P's of Clinical Breast Exam (Saslow, et. al., 2004)
Position	The patient is positioned to flatten the breast tissue; alternative positions such as standing, sitting, or lying down are used to palpate various tissue areas.
Palpation	Finger pads are used to detect a mass because these are the most sensitive parts of one's hands to distinguish textural changes.
Pressure	Adequate and varied pressure (mild, moderate, firm) is exerted to enable lump detection in multiple planes of the breast.
Pattern	Consistent use of a certain pattern is the most important to cover all areas of breast tissue, including the axillae.
Practice	Practitioner experience is correlated with increased detection of lumps.

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Size of tumors found by mammography and breast self-exam
	Average-size lump detected with routine mammogram (0.43 inches / 1.1 cm)
	Average-size lump detected with first mammogram (0.59 inches / 1.5 cm)
	Average-size lump found by regularly practicing breast self-exam (0.83 inches / 2.1 cm)
	Average-size lump found accidentally (1.42 inches / 3.6 cm)
Note: The actual size of the tumor detected can vary depending upon multiple factors, including the tumor type, the density of the woman's glandular tissue, the presence of exogenous hormone replacement therapy, and the existence of prior exams for comparison, which increase the imagers' ability to detect subtle changes. (Pamela A. Propeck, MD; Associate Professor of Radiology, University of Wisconsin)

Shall we teach breast self-examination (BSE) to all women?

Researchers have studied mortality rates due to breast cancer among women who do or do not do BSE. There is no evidence to support health practitioners' time in teaching BSE, if their goal is to reduce mortality from breast cancer.

How can we explain this? Simply put, BSE in the hands of lay women varies greatly. (In other words, BSE does not equal BSE, does not equal BSE.) If many women do BSE poorly, then there can be no significant gain in survival rates.

However, one research team demonstrated that, among women who did BSE thoroughly--based on a number of steps included in the exam--smaller tumors were found than among women who did not do BSE thoroughly.

In addition, from a women-centered perspective, we recognize that some women want to learn BSE, can learn BSE, and may be more comfortable with their bodies as result of BSE. Thus, there could be benefits to learning and doing BSE rather than just to decrease mortality.

We could tailor our approach to teaching BSE by asking women if they want to learn it or not.

If they do, then we could teach them to do it thoroughly.
If not, then we could omit this teaching at this visit.

For further information about breast and cervical cancer screening for low income women, see: National Breast and Cervical Cancer Early Detection Program, Centers for Disease Control and Prevention.