Women and Clinicians Learn Breast Exams Skills Despite “Prohibition”

Antique US Government policies continue to resist safe, low-cost breast cancer screening leaving women and their healthcare providers in a confusing and costly screening fog.

Informed clinicians and women are constrained by an influential US agency recommendation against teaching women how to perform breast self exams and against breast cancer screening exams by the hands of trained healthcare providers. Although the recommendations are based on outdated reports, poorly trained hands and limited treatment options, the agency’s position exerts a strong, international influence over healthcare policy and practices. Their  curious edict to not  teach or learn breast exam skill was first issued in 2002 and is repeated to the present day, The plain take-home for the half million women who die every year is that they would be better off not being taught by their provider to correctly perform a self-exam or even receive screening by skilled clinicians. 

Naturally, without learning, exams performed by women and their providers will generate higher rates of false positives and more missed tumors. Yet the agency, in reissuing their recommendation, ignores strong evidence that the standards for proficient performance of clinical and personal breast exams are known, free and safe alternatives to the practice of mass, x-ray mammograms.

Equally troubling is the exclusion or insubstantial consideration of landmark evidence that contradicts the agency’s reports and media releases. Although their edict has had mass impact in effectively discouraging women and their practitioners from learning and teaching how to perform skilled exams, independent regional and national evidence indicates that the long hiatus is lifting or should be despite USPSTF discouragements. 

For example:

Physicians and scientists at the University of Washington’s Department of Global Health reported this year that most women receiving care at an urban clinic in Peru detected their own breast cancer finding nearly half of the cancers at early stages. Published in May, in the American Medical Association journal JAMA Onclology,  women who received a previous clinical breast exam by the hands of  trained practitioners were the most likely to find their own breast cancer in its earliest stages. These results add support to the recent, massive Canadian National Health Service study of 89,000 women reporting that physical (clinical) examination by trained nurses coupled with self-exam instruction detects the same number of breast cancers as do mammograms. This twenty five year study of 89,000 Canadian women was reported in the prestigious British Medical Journal.  

The annotated findings below provide additional, compelling evidence in support of a change in US policy  for teaching women and for training clinicians how to perform skilled exams and how to teach women.

Breast cancer presentation and diagnostic delays in young women. Cancer. 2014 Jan 1;120(1):20-5. doi: 10.1002/cncr.28287. Nov 11. 2014  Ruddy KJ, Gelber S, Tamimi RM, Schapira L, Come SE, Meyer ME, Winer EP, Partridge AH

Most young women detect their own breast cancers…

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 A

Patients with palpable presentation were younger than those with screen-detected cancer (mean age 57 versus 62 years…

Self-Detection Remains a Key Method of Breast Cancer Detection for U.S. Women. J Womens Health. 2011Aug; 20(8): 1135-9. Roth MY, Elmore JG, Yi-Frazier JP, Reisch LM, Oster NV, Miglioretti DL

Conclusion: Most women survivors (57%) reported a detection method other than mammographic examination.

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.

Results: 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.”

Twenty-five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial. BMJ. 2014 Feb 11;348:g366. doi: 10.1136/bmj.g366. Miller, A. B., Wall, C., Baines, C. J., Sun, P., To, T., & Narod, S. A.

Upon finding that most cancers were palpable at mammography screening visits, Miller et; al. concluded:

From this we infer that if there is benefit from a mammography only screening programme, it is derived through cancers detectable by a thorough breast physical examination.

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.

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 {clinical breast exams} in the 1–2 year interval between screening examinations…

Excessive resections in breast-conserving surgery: a retrospective multicentre study. Breast J. 2011 Nov-Dec; 17(6): 602-9. Krekel N, Zonderhuis B, Muller S, Bril H, van Slooten HJ, de Lange de Klerk E, van den Tol P, Meijer S.

Of all tumors, 72% (525/726) were palpable, and 28% (201/726) were nonpalpable. The tumor stage was T1 in 492 patients (67.8%) and T2 in 234 patients (32.2%).

Does This Patient Have Breast Cancer? The Screening Clinical Breast Examination: Should It Be Done? How? Journal of the American Medical Association, 1999 Oct, 6: 283(13), 1687-9.  Barton, M.B., Harris, R. & Fletcher, S.W.

…MammaCare’s standards for teaching and practicing effective CBE emerged from an extensive series of laboratory studies measuring lump detection and breast examination skills using tactually accurate breast models embedded with small, simulated lesions.

How best to teach women breast self-examination. A randomized controlled trial. Annals Intern Med. 1990 May 15;112(10):772-9. Fletcher SW, O’Malley MS, Earp JL, Morgan TM, Lin S, Degnan D.

Mammacare instruction resulted in more long-term improved lump detection and examination technique use than did traditional instruction or physician encouragement. Breast self-examination instruction should emphasize lump detection skills.

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.

M.K. Goldstein, Ph.D.

Senior Scientist and Director

The MammaCare® Foundation

Lab: (352) 375-0607

markgoldstein@mammacare.org

Supported in part by:

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Does This Patient Have Breast Cancer? The Screening Clinical Breast Examination: Should It Be Done? How? “Our recommendation incorporates practices from the Mammacare method, because its components have been validated in independent investigations of CBE technique” JAMA 283(13), (p. 1276), Barton, M.B., Harris, & Fletcher, S.W.