The Clinical Breast Exam

1. The Clinical Breast Exam Margaret Plumbo Catherine Juve University of Minnesota AIHA

2. Effectiveness of Clinical Breast Exam (CBE) Meta-analyses demonstrated that CBE and/or screening mammography decreases breast cancer mortality rates by about one fourth in women from 50 through 69 years and by 18% in women in their 40s. Studies that compared a combination screening strategy with no screening are the strongest scientific evidence for an effect of screening CBE.

3. Strength of Recommendation A Strongly recommends routine provision B Recommends routine provision C No recommendation for or against D Recommends against routine provision I Insufficient evidence to recommend for or against routine provision

4. Breast Cancer Screening Guidelines USPSTF 2002 For women 40-49 years old Mammography w/wo CBE every year [B - recommend routine provision] Lower risk of breast cancer and higher rate of false positives makes mammography less beneficial if woman is < 50 Insufficient evidence for CBE alone [I - cannot recommend for or against]

6. Breast Cancer Screening Guidelines  USPSTF 2002 For women 70 years and older Same benefit as younger women, if no concurrent disease Limited evidence regarding mammography and CBE in women over 75 [I - cannot recommend for or against]

7. Clinical Breast Exam Data show that sensitivity of CBE is far from perfect. Pooled data from human studies give an overall estimate for the sensitivity of the CBE of 54% i.e. 46% masses missed 4 percent of women with an abnormal CBE will be subsequently diagnosed with cancer.

8. Breast Self Exam A randomized trial in China No evidence of reduction in breast cancer mortality after long-term follow-up. 3 worldwide trials Failure to identify a reduction in breast cancer mortality or significant improvements in the number or stage of cancers detected

9. Associations disagree about recommendations AMA, ACOG, American College of Radiology (ACR), ACS: Age 40 - mammography and CBE Canadian Task Force on Preventive Health Care (CTFPHC), AAFP and the American College of Preventive Medicine (ACPM): Age 50 � begin mammography for average-risk AAFP and ACPM: Age 40 � begin mammography in high-risk women AAFP: Age 40-49 - counsel about risks and benefits of mammography before making decisions about screening.

10. The Procedure Explain what you will be doing Ask if she does breast self exam Warm your hands Assure privacy Would someone else in the room be helpful? Assist patient to supine position

11. Mammacare method Spoke model not sensitive Overlapping strip method has been validated in independent investigations of CBE technique.

12. Palpation Variables important in palpating the breast correctly are patient position breast boundaries examination pattern finger position, movement, and pressure duration of the examination

13. Patient Position Clinical breast examination requires flattening breast tissue against the patient's chest Client is supine during the examination

14. Breast Boundaries Breast tissue extends laterally toward the axilla and superiorly toward the clavicle. Cover a rectangular area bordered by the clavicle superiorly, the midsternum medially, the midaxillary line laterally, and the bra line inferiorly.

15. Examination Pattern Palpation begins in the axilla and extends in a straight line down the midaxillary line to the bra line The fingers move medially, and palpation continues up the chest in a straight line to the clavicle. Rows should be overlapping.

16. Technique The 3 middle fingers are held together, with the metacarpal-phalangeal joint slightly flexed. Pads of the fingers are the examining surface.

17. Each area is palpated by making small circles using 3 different pressures�light, medium, and deep

18. Duration 3 minutes recommended for each breast Average actual time spent is 1.8 minutes Discuss with patients the time needed to do a complete examination and discuss the procedure during the examination.

19. Nipple Palpation of the nipple area is performed in the same manner as the rest of the breast. Squeezing for discharge not a useful prognostic sign for cancer.

20. Inspection The importance of inspection is unproved. No adequate data support recommendations of some authorities to examine women in a variety of other positions

21. Masses Normal breasts are often lumpy Cancers classically are characterized as hard, fixed, and irregular Benign breast lumps are soft or cystic, movable, and regular

22. Masses Many cancers do not conform to the classic picture and benign masses can mimic cancer.

23. Because the characteristics of cancerous lumps overlap with those of noncancerous lumps, clinicians rarely diagnose breast cancer with CBE. Careful CBE can locate abnormalities. Further evaluation with other tests is then required.

24. Clinical Case Breast mass in 64 year old The discovery conveys an increased risk of cancer. Probability of invasive cancer in the coming year is 0.35% (347 cases per 100,000 women). Finding the mass on CBE gives a probability of 0.73% If the mass is greater than 2 cm and has all the other malignant characteristics the probability of cancer increases to 8.8%

25. 42 year old No breast symptoms - pretest probability of breast cancer is 0.12%, or 119 per 100,000. A normal CBE would decrease her risk of breast cancer to 0.11% The psychological reassurance she may gain from a CBE could increase the value of this maneuver.

26. Mammography

27. Women aged 50-69 If facilities are available, screening by mammography alone (with or without CBE) plus follow-up of individuals with positive or suspicious findings, will reduce mortality from breast cancer by up to one-third.

28. Sensitivity of mammography In one large study Mammography detected 77% to 95% of cancers diagnosed over the current year, but only 56% to 86% of cancers diagnosed over the next 2 years. Sensitivity is lower among women who are younger than 50, have denser breasts, or are taking hormone replacement therapy.

29. False positive rates In screening trials False-positive rate of mammography is 3% to 6% Better detection with a shorter screening interval and the availability of prior mammograms. Rate of false-positive mammograms higher in women aged 40-59 (7-8%) than in women aged 60-79 (4-5%).

30. Predictive value The probability that an abnormal mammogram is due to cancer increases with age. 2 to 4 % among women aged 40-49 5 to 9 % among women aged 50-59 7 to 19 % among women aged 60 and older Positive predictive values were also higher among women with a family history of breast cancer in two studies.

31. Practical tips for getting a group going and running smoothly- Group dynamics

32. Self-reflection Ask yourself how comfortable you are with the material. Consider practicing in front of a mirror or with a trusted friend or family member before the workshop.

33. You may have to handle issues such as: grieving a loss of someone to breast cancer, personal stories of breast cancer, sexuality, disfigurement. Have resources at hand for such members.

34. Publicize the event Your advertisement or flyer for the workshop should be posted in numerous areas of the city or facility from which you hope to draw participants. Provide brief overview of content and sponsoring agency. Provide details of time, date, place, and any future presentations in case they cannot come to this one. Breast Health Come to learn - how to protect your health how to increase your awareness St. Nicholas�s Church Saturday, Nov. 27, 2004 2 pm - 4 pm Bring a friend or family member Tea will be served

35. Establishing group cohesion In group work, it is important to foster interactions between group members to create a positive learning environment. While members are coming in, welcome members and help them get seated or get tea. Shake hands or use touch to show your pleasure that they have come to the workshop.

36. Before participants arrive Have tea and snacks ready. Take note of comfort of environment temperature seating arrangement in circle if possible

37. Make certain that your models are at hand. Make sure handouts are ready. Make sure audio-visual equipment is ready and working.

38. Initiation of the workshop Within the first few minutes, the leader must establish credentials introduce yourself why are you the leader, what can you offer show your enthusiasm for the topic of breast health share a story about what stimulated your interest in this topic

39. Establish a welcoming presence Directions to beverages, snacks. restrooms Introduce other �experts� (no more than 2) Ask members to introduce themselves - �ice-breaker� �Tell us a little about your knowledge of this topic, your job or family or why you are here today.� Provide members with a brief overview of content to be covered.

41. At start of content discussion Acknowledge that this may be a review for some Ask if there are any initial questions or concerns Give participants permission to ask questions any time Make sure your language and use of terminology is appropriate for the group�s level including materials and audio-visual content

42. Use of models and resources Have your �Resource Kit� at hand video for each participant models handouts shower cards Pass around several breast models. Give members time to get comfortable with them. If possible, have one model for 1-3 participants.

43. �Experts� circulate in room, briefly working with each group, provide suggestions and give positive feedback. Ask them to feel to see if they can find any masses. Explain how to determine consistency, mobility, location, size so this can be communicated to their care provider. Emphasize that a lump is most often NOT cancer.

44. After content is presented Provide participants with summary: 3 �Take Home� messages Evaluation At the end of the session, ask participants to evaluate various components of the session. Ask for verbal feedback and provide a written evaluation form.