Breast Cancer Screening Guidelines

While there are wide differences of opinion among prominent organizations about preferred breast cancer screening guidelines, most breast cancer is first detected by the hands of women or their health care providers. The American College of Obstetricians and Gynecologists (ACOG) notes that self-exams are effective in detecting breast cancer for a majority of women although this finding conflicts with  the United States Preventive Services Task Force (USPSTF), and the American Cancer Society (ACS) . These two organizations jointly recommend against teaching women how to perform self-exams of their breast and discourage screening by the hands of nurses and physicians.

In their current “Practice Bulletin” the American College of Obstetricians and Gynecologists states:

“Although breast-self examination is no longer recommended [by USPSTF ], evidence of the frequency of self-detection of breast cancer provides strong rationale for breast self -awareness in the detection of breast cancer. Approximately 50% of cases of breast cancer in women 50 years and older and 71% of cases of breast cancer in women younger than 50 years are detected by women themselves. (40, 41). For example, 43% of the 361 breast cancer survivors who participated in the 2003 National Health Interview Survey reported detecting their cancer themselves (42). Additional evidence of the important role of breast cancer self- detection comes from a study of low-income women who received breast cancer care through California’s Breast and Cervical Cancer Treatment Program. Of the 921 women in the cohort, 64% detected their breast cancer (43) ”.

Although well-intentioned, organizations differ in their opinions and the data selected to support them, issuing press releases may be a disservice to women worldwide. More than 500,000 women die each year from breast cancer and there is little disagreement that most women find their own cancer and at a late stage. Discouraging women and their healthcare providers from learning to perform a thorough, skilled breast exam has a global impact that is unlikely to improve the outcomes for the vast majority of women.

Progress in BSE and CBE

Many of the studies that inspired criticism of breast self-examination (BSE) and clinical breast exams (CBE) were conducted before it was known how to perform the exam effectively and before the advent of advanced breast cancer treatment options.  Women and researchers relied on pamphlets and video demonstrations as teaching devices that failed to address the central question of the tactile sense: what does a lump actually feel like?  To improve tactile  breast exam skills, the National Science Foundation supported development and validation of  a hands-on computer- guided training technology that is now in use teaching students in colleges of medicine and nursing as well as obgyn residents and advanced practice nurses. The platform trains hands to perform accurate clinical breast exams and validates acquisition of the requisite skills. The results of training are reported in terms of sensitivity,  specificity and percent of tissue examined as trainees advance through a series of increasingly complex palpation modules.

Annotated bibliography: Physical Examination of the Breast

A significant number of women present with palpable breast cancer even with a normal mammogram within 1 year. Am J. Surg 2010 Dec;200(6):712-7. Haakinson DJ, Stucky CC, Dueck AC, Gray RJ, Wasif N, Apsey HA, Pockaj B. “Patients presenting with palpable masses on SBE or CBE even with a normal mammogram within 1 year tended to have more aggressive tumors… resulting in more aggressive therapy ”

Palpable presentation of breast cancer persists in the era of screening mammography. J Am Coll Surg. 2010 Mar;210(3):314-8. Mathis KL, Hoskin TL, Boughey JC, Crownhart BS, Brandt KR, Vachon CM, Grant CS, Degnim AAC. “Patients with palpable presentation were younger than those with screen-detected cancer (mean age 57 versus 62 years…” abstract  p1

Discovery of breast cancers within 1 year of a normal screening mammogram: how are they found? Ann Fam Med. 2006 Nov-Dec;4(6):512-8. Carney PA, Steiner E, Goodrich ME, Dietrich AJ, Kasales CJ, Weiss JE, MacKenzie, T. “Having a lump and both a personal and a family history of breast cancer was the most common reason why women initiated a health care visit.”

Self-Detection Remains a Key Method of Breast Cancer Detection for U.S. Women. J Womens Health 2011 Jun 15. [Epub ahead of print] Roth MY, Elmore JG, Yi-Frazier JP, Reisch LM, Oster NV, Miglioretti DL. “Most women survivors  (57%) reported a detection method other than mammographic examination.”

Measuring performance in clinical breast examination. Br J Surg. 2010 Aug;97(8):1246-52.  Wishart GC, Warwick J, Pitsinis V, Duffy S, Britton, PD. “performance measures…could help to identify clinicians who have a lower sensitivity for CBE and who may therefore require feedback and further training.”

Tumor Characteristics Associated With Mammographic Detection of Breast Cancer in the Ontario Breast Screening Program.  J Natl Cancer Inst 2011.Jun 22;103(12):942-50. Epub 2011 May 3 Kirsh VA, Chiarelli AM, Edwards SA, O’Malley FP, Shumak RS , Yaffe MJ, Boyd, NF  “…77% of these were true interval cancers, detected clinically in the 1–2 year interval between screening examinations…” p4

Improved Clinical Breast Examination Competencies Via Intelligent Simulator Training, July 7, 2012   Meeting of the German Society for Senologie, Stuttgart Goldstein M.K.*, Mehn M.A.*, Pennypacker H.S.*, Brost B.C.** Petersen W.O.**, Nicometo A.M.**,  MammaCare* and Mayo Clinic** “Two independent trials found that the CBE Simulator produced significant gains in clinical breast examination skills suggesting that this technology may improve the accuracy and quality of breast cancer screening.”

Barton, M. B., Harris, R., & Fletcher, S. W. (1999). Does this patient have breast cancer? The screening clinical breast examination: Should it be done? How? Journal of the American Medical Association, 282(13), 1270-1280. ” “Our recommendation incorporates practices from the Mammacare method, because its components have been validated in independent investigations of CBE technique”

Artmann, A., Heyne, M., Kiechle, M., & Harbeck, N. (2005, June 20 Suppl.). Breast self-examination training and counseling as motivation strategies for breast awareness and participation in breast cancer screening programs (ASCO Annual Meeting Proceedings, Part 1). Journal of Clinical Oncology, 24(18S), 1027.

Narod, S.A. (2014). Reflections on screening mammography and the early detection of breast cancer. Current Oncology, 21(5), 210-214.

Vaz-Luis, I., et al. (2014). Outcomes by tumor subtype and treatment pattern in women with small, node-negative breast cancer: a multi-institutional study. Journal of Clinical Oncology, 32(20), 2142-2150.

Adams, C. K., Hall, D. C., Pennypacker, H. S., Goldstein, M. K., Hench, L. L., Madden, M. C., Stein, G. H., & Catania, A. C. (1976). Lump detection in simulated human breasts. Perception and Psychophysics, 20, 163-176.

Atkins, E., Solomon, L. J., Worden, J. K., & Foster, R. (1991). Relative effectiveness of methods of breast self-examination. Preventive Medicine, 14(4), 357-367.

———————