Breast exams by a doctor or other healthcare professional are an important part of breast cancer screening. About 10% of breast cancers are found by clinical exams and about 33% of these cancers aren't seen in a mammogram.
When clinicians find a suspicious area, they usually refer a woman for another evaluation and/or a mammogram or other screening test. This is called a referral for an advanced breast exam. The small study reviewed here found that when professionals filled out a breast exam form, the number of referrals for advanced breast exams (the call rate) nearly doubled. This suggests that using a form to record breast exam results can improve the chances of finding suspicious areas during a clinical breast exam.
The researchers developed two breast exam forms (a simple form and a detailed form) for clinicians at a neighborhood medical center to use. The forms were filled out during the breast exam, but their purpose was to focus the clinician's attention on the breast exam while it was being done. Family doctors, general internists, nurse practitioners, and certified physician assistants all did breast exams in the study. The clinicians didn't have any special breast exam training during the study. The forms were used by the clinicians for 1 year.
The researchers compared the call rate during the year the forms were used to the call rate from the previous year. A higher call rate suggests that more suspicious findings were being noticed and referred for more evaluation, increasing the chances that breast cancer wouldn't be missed.
During the year the forms were used, the clinicians did 1,522 breast exams: 558 with the simple form and 964 with the detailed form. The clinicians referred 127 suspicious areas for evaluation, for a call rate of 8.3% when either form was used. In comparison, clinicians did 298 breast exams without using a form and 14 (4.7%) suspicious areas were referred for evaluation. So the call rate increased from 4.7% to 8.3% when a form was used.
It didn't seem to matter if the form was simple or detailed. Any type of form seemed to make the clinician doing the breast exam focus more intently on the exam.
It's important to know that even though the call rate increased, this study didn't find that using the forms improved the detection of early-stage breast cancer. This could be because the study was small. It's possible that if all clinicians who did breast exams used a form like the ones in this study, breast cancer detection would go up.
Using only one screening method for any disease is never perfect. This is why doctors recommend using several different screening tests. There are three screening methods for breast cancer. When all three are done consistently, chances go up that breast cancer will be diagnosed early, when it's most treatable.
The three breast cancer screening methods are:
If you have a higher-than-average risk of breast cancer, your screening plan may include more frequent tests and/or the use of other tests such as breast ultrasound and breast MRI.
Learn more breast cancer screening, including breast self-exams, in the Breastcancer.org Screening and Testing section.
Referrals for follow-up advanced breast examinations almost doubled after clinicians at a community health center started using a dedicated evaluation form following routine breast exams as part of a year-long study, researchers reported.
The proportion of breast examinations leading to referral increased from 4.7% in the year before the study to 8.3% during the study period, according to an article in the April 1 American Journal of Medicine. The increase was similar whether clinicians used a brief form or one with more detail.
The improvement in referrals, known as the call rate, occurred without retraining the practitioners in breast evaluation, researchers said.
"In larger series, clinicians are the first to identify one in 10 breast cancers, approximately one-third of which have negative mammograms," William H. Goodson III, MD, of California Pacific Medical Center Research Institute in San Francisco, and colleagues noted in their report.
"It would be difficult to abandon these opportunities to detect breast cancer and thus difficult to abandon breast examination. We believe a more effective approach is to retain clinical breast examination but to develop tools to focus clinician attention rather than to demand more clinician time for a more elaborate technique."
Mammography fails to detect 8% to 17% of breast cancers, which may require a clinical breast examination to evaluate, the authors wrote.
Despite the value of these evaluations in early breast cancer diagnosis, physicians are less likely to conduct clinical breast examinations today, the authors asserted, noting that poor application of breast examination skills is the leading cause of delayed breast cancer diagnosis.
The quality of clinical examination is difficult to assess, the authors noted. Routine breast examination is a low-yield procedure, and estimating quality by proctoring would require multiple examinations by an expert to determine whether a clinician's examination technique detected or missed clinically relevant areas, they wrote.
Moreover, even when experienced clinicians examine the same patients, they may disagree on the findings and their relevance.
So the authors argued in favor of examining the the call rate -- the percentage of routine breast examinations that result in referral of a woman for additional evaluation.
A normal breast has areas of asymmetry or other irregularities that cannot be diagnosed as malignant or benign on the basis of palpation, they wrote. Clinicians who do not have a low, but expected, rate of detecting such abnormalities are unlikely to be detecting all clinically relevant, palpable abnormalities.
"A low call rate indicates either inattention to detail or clinical judgment is being used to ignore some findings, even though the latter is the most common cause of delayed diagnosis of breast cancer," the authors wrote.
"Because any breast mass is cancer until proven otherwise, identification of all breast masses as reflected in the call rate, not identification of cancers specifically, is the appropriate quality measure for breast examination."
Goodson and colleagues conducted a study designed to determine whether an attention-focusing device -- the requirement to fill out a form -- would increase the call rate.
They developed two forms to focus clinician attention on the examination. The briefer of the two required physicians to record abnormal findings. The longer form required more detailed description of the breasts as well abnormal findings.
Clinicians (family practice physicians, general internists, nurse practitioners, and certified physician assistants) at a neighborhood health center were randomized to one of the forms, which were used for a year during clinical breast examinations. At the end of the study, call rates were compared with those from the year prior to the study. Expected breast cancer detection rates were derived from the NCI Surveillance, Epidemiology, and End Results (SEER) database.
During the study, clinicians at the health center performed 1,522 breast examinations, 558 using the short form and 964 with the long form. Patients in the two groups did not differ with respect to clinical or demographic variables.
Overall, the clinicians detected 127 masses that were referred for further evaluation. The resulting call rates did not differ between caregivers assigned to the short or long form.
By comparison, 14 masses were detected in a historical control group of 298 patients who received preventive gynecologic care at the clinic in the 12 months before the study.
Two invasive cancers were detected during the study, while SEER data had predicted 2.2. SEER had also predicted 0.6 noninvasive cancers would be found in the study groups -- and no such masses were detected.
In the control group, SEER data had predicted 0.5 invasive and 0.6 noninvasive cancers. In reality, one of each was detected, resulting in a total of four breast cancers for all patients included in the study, as compared with a prediction of 3.4.
The findings suggest the occurrence of a "Hawthorne effect in which altering conditions of data collection (use of the dedicated forms) functioned as an independent variable," the authors wrote.
The study did not report a breakdown of physicians versus nurse practitioners and physician assistants participating in the study, nor the experience levels of these clinicians.
Only 30% of the patients had an accompanying mammogram so it was not possible to correlate clinical exam findings with mammography.
The authors had no disclosures.
Primary source: American Journal of Medicine Source reference: Goodson WH, et al "Optimization of clinical breast examination" Am J Med 2010; DOI:10.1016/j.amjmed.2009.08.023.
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