Research Update May 2020: Most Breast Cancer is Detected by Hand

Annotated research reports: clinical breast exams (CBE) self breast exams (SBE)

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“Breast lump is the most common presenting symptom among women with breast cancer and has relatively high predictive value for malignancy….Evidence from a national audit of cancer diagnosis….A total of 56 presenting symptoms were described: breast lump was the most frequent (83%)…”

Cancer Epidemiol. 2017 Jun; 48: 140–146. doi:

“A significant number of women present with palpable breast cancer even with a normal mammogram within 1 year.”

Am J. Surg . Haakinson DJ, Stucky CC, Dueck AC, Gray RJ, Wasif N, Apsey HA, Pockaj B.

“A total 41 of 52 interns (79%) completed the curriculum. Their average MammaCare scores improved from 63% to 91%. Scores on a knowledge-based assessment improved from 47% on the pretest to 85% on the posttest (P < .001). Comparison PGY-2s who did not complete the curriculum averaged a score of 52% (P < .001).”

An Effective Multimodal Curriculum to Teach Internal Medicine Residents Evidence-Based Breast Health.J Grad Med Educ. 2014 Dec;6(4):721-5.

“Evaluation of Palpable Breast Lumps in Women 30 Years Old and Older….palpable breast lumps have a higher probability of breast cancer than all patients who undergo diagnostic breast imaging.”

Clinical Value of Mammography in the Evaluation of Palpable Breast Lumps in Women 30 Years Old and Older. American Journal of Roentgenology. 2017;209: 935-942. 10.2214/AJR.16.17088

“Annual mammography in women aged 40-59 does not reduce mortality from breast cancer beyond that of physical examination…”

BMJ . 2014 Feb 11;348:g366. doi: 10.1136/bmj.g366.

“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.

“Discovery of Breast Cancers Within 1 Year of a Normal Screening Mammogram: How Are They Found? ….“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

“Palpable presentation of breast cancer persists in the era of screening mammography.”

.https://pubmed.ncbi.nlm.nih.gov/20193894/

“…A Comparison of the Accuracy of Clinical Exam Versus MRI…. Post-NAC [neoadjuvant chemotherapy] MRI is no more accurate than clinical exam alone in predicting SLN [sentinel lymph node] pathology in patients…. ” [Both Clinical Exam + MRI reccommended in report ]

Ann Surg Oncol. 2019 Dec;26(13):4238-4243. doi: 10.1245/s10434-019-07867-x. Epub 2019 Oct 3.

“Most young women detect their own breast cancers…”

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.

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

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.

“New Palpable Breast Lump With Recent Negative Mammogram: …. A woman may present with a new palpable lump after having had a recent negative mammogram…”

New Palpable Breast Lump With Recent Negative Mammogram: Is Repeat Mammography Necessary?. American Journal of Roentgenology. 2016;207: 200-204. 10.2214/AJR.15.14799

“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”.

“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.”

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.

“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.”

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*

“Training in clinical breast examination as part of a general surgery core curriculum ….These data suggest significant improvement in CBE in students receiving formalized instruction.”

Shaghayegh Aliabadi‐Wahle MD , Maiko Ebersole , Ella U. Choe & Derrick J. Beech MDPages 10-13 | Published online: 01 Oct 2009

Additional Studies and Legacy Research Reports on CBE and SBE – 1979-2005

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.

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.

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.

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.

Benincasa T. A., King, E.S., Rimer, B. K., Bloom H. S., Balshem, A., James J., Engstrom, P. F. (1996). Results of an office-based training program in clinical breast examination for primary care physicians. Journal of Cancer Education. 11(1):25-31.

Bloom, H. S., Criswell, E. L., Pennypacker, H. S., Catania, A. C., & Adams, C. K. (1982). Major stimulus dimensions determining detection of simulated breast lesions. Perception and Psychophysics, 32(3), 251-260.

Campbell, H. S., Fletcher, S. W., Lin, S., Pilgrim, C. A., & Morgan, T. M. (1991). Improving physicians’ and nurses’ clinical breast examination: A randomized controlled trial. American Journal of Preventive Medicine, 7, 1-18.

Campbell, H. S., McBean, M., Mandin, H., & Bryant, H. (1994). Teaching medical students how to perform a clinical breast examination. Academic Medicine, 69(12), 993-995.

Coleman, E. A.. (1991). Practice and effictiveness of breast self-examination: A selective review of the literature. Journal of Cancer Education, 6(2), 83-92.

Coleman, E. A., & Pennypacker, H. S. (1991). Measuring breast self-examination proficiency. Cancer Nursing, 14(4), 211-217.

Coleman, E. A., & Pennypacker, H. S. (1991). Nursing research to define outcomes of care: Evaluating breast self-examination performance. Journal of Nursing Quality Assurance, 5(3), 65-69.

Coleman, E. A., Riley, M. B., Fields, F., & Prior, B. (1991). Efficacy of breast self-examination teaching methods among older women. Oncology Nursing Forum, 18(3), 561-566.

Coleman, E. A., Lord, J. E., Bowie, M., & Worley, M. J. (1993). A statewide breast cancer screening project. Cancer Nursing, 16(5), 347-353.

Duer, J. D. (1984). Group dissemination of group breast self-examination training technology. Patient Education Counseling, 7(6), 98-116.

Fletcher, S. W., O’Malley, M. S., & Bunce, L. A. (1985). Physicians’ abilities to detect lumps in silicone breast models. Journal of the American Medical Association, 253, 2224-2228.

Fletcher, S. W., O’Malley, M. S., Earp, J. L., Morgan, T. M., Lin, S., & Degnan, D. (1990). How best to teach women breast self-examination. Annals of Internal Medicine, 112(10), 772-779.

Fletcher, S. W., O’Malley, M. S., Pilgrim, C. A., & Gonzalez, J. J. (1989). How do women compare with internal medicine residents in breast lump detection? Journal of General Internal Medicine, 4, 277-283.

Goldstein, M. K., Stein, G. H., & Pennypacker, H. S. (1982). Efficient technology of training breast self-examination. Technical Bulletin, World Health Organization, England.

Goldstein, M. K., Stein, G. H., & Pennypacker, H. S. (1982). On subordination of BSE. American Journal of Public Health, 5(72), 498-499.

Hall, D. C., Adams, C. K., Stein, G. H., Goldstein, M. K., Stephenson, H. S., & Pennypacker, H. S. (1980). Improved detection of human breast lesions following experimental training. Cancer, 46, 408-414.

Hall, D. C., Goldstein, M. K., & Stein, G. H. (1977). Progress in manual breast examination. Cancer, 40, 364-370.

Hilt, G. (1990). Selbstuntersuchung der brust: So nehmen sie den frauen dïe angst. Arztliche Praxis, 75(18), 20-21.

Hilt, G. (2005). Bessere infos, mehr früherkennung. Ärztliche Praxis Gynäkologie, 6, 22.

Hilt, G. (2006). Frauen zur Selbstkontrolle motivieren. Ärztliche Praxis Gynäkologie, 5, 24.

Jacob T.C., Penn N.E., Giebink J., & Bastien R. (1994). A comparison of breast self-examination and clinical examination. Journal of the National Medical Association, 86(1), 40-45.

Kotke, T. E., & Trapp, M. A. (1998). Implementing nurse-based systems to provide American Indian women with breast and cervical cancer screening. Mayo Clinic Proceedings, 73(9), 815-823.

Leight, S. B., Deiriggi, P., Hursh, D., Miller, D., & Leight, V. (2000). The effect of structured training on breast self-examination search behaviors as measured using biomedical instrumentation. Nursing Research, 49(5), 283-289.

Madden, M. C., Hench, L. L., Hall, D. C., Pennypacker, H. S., Adams, C. K., Goldstein, M. K., & Stein, G. H. (1978). Development of a model human breast with tumors for use in teaching breast examination. Journal of Bioengineering, 2, 427-435.

McDermott, M. M., Dolan, N. C., Huang, J., Reitler, D., & Rademaker, A. W. (1996). Lump detection is enhanced in silicone breast models simulating postmenopausal breast tissue. Journal of General Internal Medicine, 11, 112-114.

McDermott, M. M., Dolan, N. C., & Rademaker, A. W. (1996). Effect of breast-tissue characteristics on the outcome of clinical breast examination training. Academic Medicine, 71, 505-507.

McDonald, S., Saslow, D., & Alciati, M. H.. (2004). Performance and Reporting of Clinical Breast Examination: A review of the literature. CA: A Cancer Journal for Clinicians, 54(6): 345-361. Retrieved June 2, 2005 from http://caonline.amcancersoc.org/cgi/content/abstract/54/6/345

Mehn, M. A., Goldstein, M. K., & Pennypacker, H. S. (2001). Women with disabilities learn proficient breast self-examination using Adaptive MammaCare. Proceedings of the Conference Promoting the Health and Wellness of Women with Disabilities. San Antonio, TX, August 2-5, 1999. Atlanta, GA: Centers for Disease Control and Prevention.

Mehn, M. A., Goldstein, M. K., Pennypacker, H. S., Kanuck, K. T., & Thomas, S. J. (2002). Women age 50 and older who are blind or visually impaired learn proficient skill-based breast self-examination. Proceedings of the Fourth Meeting of National Leaders in Women’s Health Research [Successful Aging: Women’s Health and Well-being in the Second 50 Years], University of Florida, Health Science Center, March 9-11, 2001, Gainesville, Florida.

O’Malley, M. S. (1993). Cost-effectiveness of two nurse-led programs to teach breast self-examination. American Journal of Preventive Medicine, 9(3), 139-145.

Pennypacker, H. S. (1991). Perspective on manual breast examination. Administrative Radiology Journal, 10(7), 33-36.

Pennypacker, H. S., Bloom, H. S., Criswell, E. L., Neelakantan, P., Goldstein, M. K., & Stein, G. H. (1982). Toward an effective technology of instruction in breast self-examination. International Journal of Mental Health, 11(3), 98-116 [Reprinted in: Public education about cancer (1982). UICC Technical Report Series, 72(5), 498-499].

Pennypacker, H. S., & Iwata, M. (1990). MammaCare: A case history in behavioural medicine. In D. Blackman & H. Lejeune (Eds.), Behavior analysis in theory and practice: Contributions and controversies (pp. 259-288). Hillsdale, NJ: Lawrence Erlbaum & Associates.

Pennypacker, H. S., Naylor, L., Sander, A. A., & Goldstein, M. K. (1999). Why can’t we do better breast examinations? Nurse Practitioner Forum, 10(3), 122-128.

Pennypacker, H. S., & Pilgrim, C. A. (1993). Achieving competence in clinical breast examination. Nurse Practitioner Forum, 4(2), 85-90.

Pilgrim, C. A., Lannon, C., Harris, R. P., Cogburn, W., & Fletcher, S. W. (1993). Improving clinical breast examination training in a medical school: A randomized controlled trial. Journal of General Internal Medicine, 8, 685-688.

Pinto, B. M. (1993). Training and maintenance of breast self-examination skills. American Journal of Preventive Medicine, 9(6), 353-358.

Pinto, B., & Fuqua, W. (1991). Training breast self-examination: A research review and critique. Health Education Quarterly, 18(4), 495-516.

Saslow, D., Hannan, J., Osuch, J., Alciati, M. H., Baines, C., Barton, M., Bobo, J. K., Coleman, C., Dolan, M., Gaumer, G., Kopans, D, Kutner, S., Lane, D., Lawson, H., Meissner, H., Moorman, C., Pennypacker, H., Pierce, P., Sciandra, E., Smith, R., & Coates, R. (2004) Clinical breast examination: Practical recommendations for optimizing performance and reporting. CA: A Cancer Journal for Clinicians, 54(6), 327 -344. Retrieved February 22, 2005 from http://caonline.amcancersoc.org/cgi/content/abstract/54/6/327?etoc

Saunders, K. J., Pilgrim, C. A., & Pennypacker, H. S. (1986). Increased proficiency of search in breast self-examination. Cancer, 58, 2531-2537.

Smith, R. L., Hanchak, N. A., Bloom, H., Leibfreid, D., Xuan, S., & Schlackman, N. (1996). The effectiveness of postgraduate education on the clinical breast examination skills of primary care physicians. American Journal of Managed Care, 2, 989-995.

Somkin, C.P. (1993). Improving the effectiveness of breast self-examination in the early detection of breast cancer. Nurse Practitioner Forum, 4(2), 76-84.

Stephenson, H. S., Adams, C. K., Hall, D. C., & Pennypacker, H. S. (1979). Effects of certain training parameters on detection of simulated breast cancer. Journal of Behavioral Medicine, 2(3), 239-250.

Stratton, B. F., Nicholson, M. E., Olsen, L. K., Mahoney, B. S., & Warland, R. H. (1994). Breast self-examination proficiency: Attitudinal, demographic and behavioral characteristics. Journal of Women’s Health, 3(3), 185-195.

Thomas, R.G., et al. (1981). Computer aided instruction of breast self-examination. Annals of the World Association for Medical Informatics, 1, 19-22.

Trapp, M.A., Kottke, T.E., Viekrant, R.A., Kaur, J.S., & Sellers, T.A. (1999). The ability of trained nurses to detect lumps in a test set of silicone breast models. Cancer, 86, 1750-6.

Worden, J. K., Solomon, L. J., Flynn, B. S., Costanza, M. C., Foster, R. S., Jr., Dorwaldt, A. L., & Weaver, S. O. (1990). A community-wide program in breast self-examination training and maintenance. Preventive Medicine, 19(3), 254-269.

Yang, Jui-Chen. (2007). The effects of a breast self-examination education program in Taiwanese women: A triangulation study. Unpublished doctoral dissertation. National Taiwan University.

J Chalabian 1 , S Formenti, C Russell, J Pearce, G Dunnington Comprehensive needs assessment of clinical breast evaluation skills of primary care residents Ann Surg Oncol1998 Mar;5(2):166-72.

Fletcher, S. W., O’Malley, M. S., & Bunce, L. A. (1985). Physicians’ abilities to detect lumps in silicone breast models. Journal of the American Medical Association, 253, 2224-2228.

Fletcher, S. W., O’Malley, M. S., Earp, J. L., Morgan, T. M., Lin, S., & Degnan, D. (1990). How best to teach women breast self-examination. Annals of Internal Medicine, 112(10), 772-779.

Pennypacker, H. S., Naylor, L., Sander, A. A., & Goldstein, M. K. (1999). Why can’t we do better breast examinations? Nurse Practitioner Forum, 10(3), 122-128.

Foster, R. S., Lang, S. P., Costanza, M. C., Worden, J. K., Haines, C. R., & Yates, J. W. (1978). Breast self-examination practices and breast cancer stage. The New England Journal of Medicine, 299, 265-270.

Feldman, J. G., Carter, A. C., Nicastri, A. D., & Hosat, S. T. (1981). Breast self-examination: Relationship to stage of breast cancer at diagnosis. Cancer, 47, 2740-2745.

Foster, R. S., Lang, S. P., Costanza, M. C., Worden, J. K., Haines, C. R., & Yates, J. W. (1978). Breast self-examination practices and breast cancer stage. New England Journal of Medicine, 299, 265-270.

Greenwald, P., Nasca, P. C., Lawrence, C. E., Horton, J., McGarrah, R. P., Gabriele, T., & Carlton, L. (1978). Estimated effect of breast self-examination and routine examinations on breast cancer mortality. New England Journal of Medicine, 299, 272-273.

Feldman, J. G., Carter, A. C., Nicastri, A. D., & Hosat, S. T. (1981). Breast self-examination: Relationship to stage of breast cancer at diagnosis. Cancer, 47, 2740-2745.

Foster, R. S., Jr., & Worden, J. K. (1992, October 11-13). Clinical breast examination and breast self-examination. Past and present effect on breast cancer survival. Paper presented at the American Cancer Society Workshop on Guidelines and Screening for Breast Cancer, Pasadena, California.

Hicks, M. J., Davis, J. R., Layton, J. M., et al. (1979). Sensitivity of mammography and physical examination of the breast for detecting breast cancer. Journal of the American Medical Association, 242, 2080-2083.

Bloom, H. S., Criswell, E. L., Pennypacker, H. S., Catania, A. C., & Adams, C. K. (1982). Major stimulus dimensions determining detection of simulated breast lesions. Journal of Perception and Psychophysics, 32, 251-260.

Toth, N. (1987). 3mm breast cancer Pathology report. Pennsylvania State University Medical Center, Hershey, PA

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