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Breast Cancer: Mary B. Barton, MD, MPP, discusses the clinical examination for breast cancer.
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Breast Cancer: Mary B. Barton, MD, MPP, discusses the clinical examination for breast cancer.
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Segment:0 .
>> I'm Joan Stephenson, Editor of "JAMA's Medical News and Perspectives" section. Today, I have the pleasure of speaking with Dr. Mary Barton on the clinical breast examination, which is discussed in chapter eight of the "Rational Clinical Exam". The chapter is co-authored by Dr. Barton. Dr. Barton, why don't you introduce yourself to our listeners? >> My name is Mary Barton, and I am an internist and am currently Vice President for Performance Measures at the National Committee for Quality Assurance. >> Dr. Barton, what is the incidence of breast cancer in the United States among different age groups?
And what factors increase a woman's risk for breast cancer? >> Well, the chief risk factor for breast cancer is increasing age and that pretty much trumps everything except for the relatively rare incidence of genetic predisposing factors. The incidence of breast cancer occurring within a year's time ranges from, for a woman in her 40s, about 1-in-800 to a woman in her 60s, 1-in-300, and a woman in her 80s, closer to 1-in-200.
So the rate does increase significantly with increasing age. The other known risk factors for breast cancer are relatively small in magnitude. So things that are related to estrogen levels in the body such as early menarche or late age at first live delivery are relatively small in magnitude. There are, as I mentioned, known genetic mutations, most famous of which are BRCA1 and 2, which confer a much higher risk of breast cancer in a woman who is affected by one of those inherited mutations but that is true of a relatively small number of people, thankfully.
And as it turns out, most people who have breast cancer were not known to be at high risk before they developed it. >> Dr. Barton, why is it important for primary care clinicians to perform clinical breast examinations? >> Well, it is important to know that whatever part of the examination we're doing, we're doing it in a way to maximize the information impact of the examination. Of course, that's what the "Rational Clinical Examination Series" is all about.
Clinical breast exam, I think is particularly important to know that we're doing it with the most effective technique because it is a sensitive examination. And many patients feel somewhat uncomfortable for this part of an exam. Because of that, it is even more important that clinicians know what they're doing when they do the exam. The best situation would be that they could convey their knowledge and their findings as they were doing the breast exam. Why is it important to know how to do a breast exam?
Well, it is part of a diagnostic examination. Someone who has any kind of a complaint or a symptom related to her breasts should have a clinical breast examination. It's important to communicate the findings of a clinical breast examination to the next professional who might be seeing a patient. If you're sending the referral to a surgeon or sending them for a diagnostic mammogram, it's useful to note where the location of any abnormality is. And it's only by doing a systematic clinical breast exam that one would be able to say, with confidence, where the findings were and that there were no findings anywhere else.
>> And I would also imagine, since many women who develop breast cancer have no known risk factors, it makes sense for this to be in the purview of a primary care clinician to do. >> Well, I think that's right. The role that the clinical breast exam plays in screening breast cancer has unfortunately not been definitively clarified by evidence. So I think there are many people for whom a clinical breast exam might be part of their screening sequence, people who don't have access to mammography or who decline mammography for one reason or another.
And, in addition, the other category that I already mentioned, that for a clinician to know how to do an appropriate diagnostic examination is without a doubt a reason for many clinicians to use the clinical breast exam. >> Have clinical trials demonstrated the effectiveness of screening for breast cancer with clinical breast examination? >> Not directly. So the inferential link between the value of a good clinical breast exam and improved outcomes for breast cancer comes from trials that used alternating years of doing mammography without the clinical breast exam and then years of doing screening with both techniques.
So the current state for the screening literature is that we know that screening mammography decreases breast cancer mortality rates. And it is possible that clinical breast exam could add some detection to mammography but that's somewhat hard to detect given that we already know that mammography is a good screening tool and so it's not as if somebody's going to fund another really big study in this area. >> What factors in the examiner and in the patient affect the accuracy of the clinical breast examination?
>> Well, I think in the examiner, the main things that impact the efficacy of the clinical breast exam are using the standard technique and that's outlined in the "Rational Clinical Exam" chapter on the breast exam using a search pattern that uses a vertical strips, making circular motion using the pads of the fingers, and spending adequate time on the exam to cover all of the breast tissue. So nobody has an exact figure on what's the right amount of time to spend, of course.
And it will depend a little bit on the size of the breasts of the patient being examined but more than a minute probably. I think in the Canadian study, the nurse examiners did 10-minute exams actually so it's hard to imagine many primary care clinicians spending that amount of time on a breast exam in this day and age but certainly several minutes would be appropriate. >> And what factors in the patient might affect the accuracy of the exam? >> Yeah. So the things that are related to the density of breasts, which again primarily means age, you know, pre-menopausal women versus post-menopausal women, just as mammography has an easier time looking through tissue that's post-menopausal, it's probably the case that an examining hand has an easier time distinguishing normal tissue from abnormal tissue in the relatively sparser breast tissue of a post-menopausal breast.
But, in other regards, there is not a lot of data about the things that might impact the sensitivity of the exam from the patient's point of view. So those are the factors that are related to a woman's breast that might influence the efficacy of the exam, the sensitivity and specificity. And then things about the examination that we've talked about before, the clinician's technique but also their positioning of the patient in a way to maximize access to all of the breast tissue would be an important part of improving the sensitivity of the exam.
>> Dr. Barton, does research support the use of both palpation and inspection during clinical breast examination? What method do you recommend? >> Well, the lack of evidence for something does not necessarily mean that it is not effective, but the bulk of the evidence on the sensitivity and specificity of the clinical breast exam involves the palpation technique and the use of a systematic approach to palpation. So I think given the press of time that generally is associated with most primary care practices, it would be sensible to limit the exam to palpation given that that's the part of the examination that we have the most data and information about.
>> Is there anything else you would like to tell our listeners about clinical breast examination? >> Clinical breast examination is an important part of a primary care clinician's toolbox of techniques. And at the times in one's clinical experience when a patient presents with a problem or has reason to be examined as part of screening, if their particular circumstances warrant that, it's very important to have a practiced hand and a clear sense of what one is doing and using the standardized search technique is a way to do that.
It also facilitates, as I've mentioned before, accurate record-keeping. For example, if one is following a lump over time in a young patient that you think is likely to be a cyst, you want to be sure, this year, that you're finding it in the same place where you found it last year and so having a standardized search technique will facilitate the kind of record-keeping that can assist in following of breast lesions that are known to be benign. So the case for doing the breast exam is without a question. If you're going to do one, you should do it right.
And the needs of one's patient will determine whether it is something that a primary care clinician offers to all patients or just to selected patients but is certainly an appropriate part of the exam to have, as I said, in one's toolbox. >> Thank you, Dr. Barton, for this helpful look at clinical breast examination. For additional information about this topic, "JAMAevidence" subscribers can consult chapter eight of the "Rational Clinical Exam". This has been Joan Stephenson of JAMA talking with Dr. Mary Barton for "JAMAevidence".
Segment:0 .
>> I'm Joan Stephenson, Editor of "JAMA's Medical News and Perspectives" section. Today, I have the pleasure of speaking with Dr. Mary Barton on the clinical breast examination, which is discussed in chapter eight of the "Rational Clinical Exam". The chapter is co-authored by Dr. Barton. Dr. Barton, why don't you introduce yourself to our listeners? >> My name is Mary Barton, and I am an internist and am currently Vice President for Performance Measures at the National Committee for Quality Assurance. >> Dr. Barton, what is the incidence of breast cancer in the United States among different age groups?
And what factors increase a woman's risk for breast cancer? >> Well, the chief risk factor for breast cancer is increasing age and that pretty much trumps everything except for the relatively rare incidence of genetic predisposing factors. The incidence of breast cancer occurring within a year's time ranges from, for a woman in her 40s, about 1-in-800 to a woman in her 60s, 1-in-300, and a woman in her 80s, closer to 1-in-200.
So the rate does increase significantly with increasing age. The other known risk factors for breast cancer are relatively small in magnitude. So things that are related to estrogen levels in the body such as early menarche or late age at first live delivery are relatively small in magnitude. There are, as I mentioned, known genetic mutations, most famous of which are BRCA1 and 2, which confer a much higher risk of breast cancer in a woman who is affected by one of those inherited mutations but that is true of a relatively small number of people, thankfully.
And as it turns out, most people who have breast cancer were not known to be at high risk before they developed it. >> Dr. Barton, why is it important for primary care clinicians to perform clinical breast examinations? >> Well, it is important to know that whatever part of the examination we're doing, we're doing it in a way to maximize the information impact of the examination. Of course, that's what the "Rational Clinical Examination Series" is all about.
Clinical breast exam, I think is particularly important to know that we're doing it with the most effective technique because it is a sensitive examination. And many patients feel somewhat uncomfortable for this part of an exam. Because of that, it is even more important that clinicians know what they're doing when they do the exam. The best situation would be that they could convey their knowledge and their findings as they were doing the breast exam. Why is it important to know how to do a breast exam?
Well, it is part of a diagnostic examination. Someone who has any kind of a complaint or a symptom related to her breasts should have a clinical breast examination. It's important to communicate the findings of a clinical breast examination to the next professional who might be seeing a patient. If you're sending the referral to a surgeon or sending them for a diagnostic mammogram, it's useful to note where the location of any abnormality is. And it's only by doing a systematic clinical breast exam that one would be able to say, with confidence, where the findings were and that there were no findings anywhere else.
>> And I would also imagine, since many women who develop breast cancer have no known risk factors, it makes sense for this to be in the purview of a primary care clinician to do. >> Well, I think that's right. The role that the clinical breast exam plays in screening breast cancer has unfortunately not been definitively clarified by evidence. So I think there are many people for whom a clinical breast exam might be part of their screening sequence, people who don't have access to mammography or who decline mammography for one reason or another.
And, in addition, the other category that I already mentioned, that for a clinician to know how to do an appropriate diagnostic examination is without a doubt a reason for many clinicians to use the clinical breast exam. >> Have clinical trials demonstrated the effectiveness of screening for breast cancer with clinical breast examination? >> Not directly. So the inferential link between the value of a good clinical breast exam and improved outcomes for breast cancer comes from trials that used alternating years of doing mammography without the clinical breast exam and then years of doing screening with both techniques.
So the current state for the screening literature is that we know that screening mammography decreases breast cancer mortality rates. And it is possible that clinical breast exam could add some detection to mammography but that's somewhat hard to detect given that we already know that mammography is a good screening tool and so it's not as if somebody's going to fund another really big study in this area. >> What factors in the examiner and in the patient affect the accuracy of the clinical breast examination?
>> Well, I think in the examiner, the main things that impact the efficacy of the clinical breast exam are using the standard technique and that's outlined in the "Rational Clinical Exam" chapter on the breast exam using a search pattern that uses a vertical strips, making circular motion using the pads of the fingers, and spending adequate time on the exam to cover all of the breast tissue. So nobody has an exact figure on what's the right amount of time to spend, of course.
And it will depend a little bit on the size of the breasts of the patient being examined but more than a minute probably. I think in the Canadian study, the nurse examiners did 10-minute exams actually so it's hard to imagine many primary care clinicians spending that amount of time on a breast exam in this day and age but certainly several minutes would be appropriate. >> And what factors in the patient might affect the accuracy of the exam? >> Yeah. So the things that are related to the density of breasts, which again primarily means age, you know, pre-menopausal women versus post-menopausal women, just as mammography has an easier time looking through tissue that's post-menopausal, it's probably the case that an examining hand has an easier time distinguishing normal tissue from abnormal tissue in the relatively sparser breast tissue of a post-menopausal breast.
But, in other regards, there is not a lot of data about the things that might impact the sensitivity of the exam from the patient's point of view. So those are the factors that are related to a woman's breast that might influence the efficacy of the exam, the sensitivity and specificity. And then things about the examination that we've talked about before, the clinician's technique but also their positioning of the patient in a way to maximize access to all of the breast tissue would be an important part of improving the sensitivity of the exam.
>> Dr. Barton, does research support the use of both palpation and inspection during clinical breast examination? What method do you recommend? >> Well, the lack of evidence for something does not necessarily mean that it is not effective, but the bulk of the evidence on the sensitivity and specificity of the clinical breast exam involves the palpation technique and the use of a systematic approach to palpation. So I think given the press of time that generally is associated with most primary care practices, it would be sensible to limit the exam to palpation given that that's the part of the examination that we have the most data and information about.
>> Is there anything else you would like to tell our listeners about clinical breast examination? >> Clinical breast examination is an important part of a primary care clinician's toolbox of techniques. And at the times in one's clinical experience when a patient presents with a problem or has reason to be examined as part of screening, if their particular circumstances warrant that, it's very important to have a practiced hand and a clear sense of what one is doing and using the standardized search technique is a way to do that.
It also facilitates, as I've mentioned before, accurate record-keeping. For example, if one is following a lump over time in a young patient that you think is likely to be a cyst, you want to be sure, this year, that you're finding it in the same place where you found it last year and so having a standardized search technique will facilitate the kind of record-keeping that can assist in following of breast lesions that are known to be benign. So the case for doing the breast exam is without a question. If you're going to do one, you should do it right.
And the needs of one's patient will determine whether it is something that a primary care clinician offers to all patients or just to selected patients but is certainly an appropriate part of the exam to have, as I said, in one's toolbox. >> Thank you, Dr. Barton, for this helpful look at clinical breast examination. For additional information about this topic, "JAMAevidence" subscribers can consult chapter eight of the "Rational Clinical Exam". This has been Joan Stephenson of JAMA talking with Dr. Mary Barton for "JAMAevidence".
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