Rationale and Technique of Clinical Breast Examination

Karen M. Freund, MD, MPH

Disclosures
In This Article

Abstract and Introduction

Abstract

Despite the advances in breast imaging, there are clear indications for the need of clinical breast examination as part of breast cancer screening for all women. The article reviews the technique for clinical breast examination and assessment of its results. The main goal of the clinical breast examination is to differentiate normal physiologic nodularity from a discrete breast mass. If a discrete mass is identified, evaluation is mandatory in all cases to exclude breast cancer. This evaluation is guided by the features of the clinical findings, the age of the woman, and her personal risk for breast cancer.

Introduction

The rapid expansion of new technologies in screening and early detection of breast cancer would seem to diminish the value of clinical breast examination. Certainly, we have improved technology and demonstrated the benefits of mammography in early breast cancer detection,[1,2,3,4,5,6] and new technologies, including computed tomography and magnetic resonance imaging, are in development.[7] New markers for mutations in the BRCA1 and BRCA2 genes have enabled stratification of certain high-risk women.[8] Despite these advances, there continues to be a real need for expertise in clinical breast examination. This article will outline the rationale for this need and review the data on the technique of clinical breast examination and the management of women with abnormal clinical findings.

Despite the improvements in technology, early detection of breast cancer is not always straightforward. Mammography at its best has a sensitivity of about 85% to 90% in women older than 50 years of age; for women between the ages of 40 and 50, sensitivity is about 75% and is probably lower in women younger than age 40.[9] This means that mammography will miss 1 in every 4 breast cancers in women between the ages of 40 and 50. Clinical breast examination is required to address these gaps in screening sensitivity.

Second, false-positive results can occur with mammography. That is, an abnormality found on screening examination may later be determined to be either an artifact of the technique or a benign finding. With annual screening over 10 years, the chances of a false-positive result, depending on the lesion and a woman's risk, may be over 50%.[10] Given the controversy around the efficacy of mammography before age 50 and this high potential for a false-positive result, some patients, and some providers, are electing to wait to begin mammography screening until the patient is 50 years old.[11] This underscores the need for clinical breast examination.

Skill in conducting and interpreting clinical breast examination findings is essential, especially in the context of a mammogram without abnormalities. The most common reason for litigation for failure to diagnose breast cancer occurs in the setting of a young woman with a finding on clinical or self breast examination and a negative mammogram.[12] Most practicing physicians, when surveyed, acknowledge a need to increase their competence in clinical breast examination.[13]

Lastly, with the increasing use of mammography, there is evidence that providers are more likely to omit the clinical breast examination, perhaps because they believe that the mammographic examination is sufficient.[14,15] In addition, some studies have shown that rates of clinical breast examination decrease with patient age, as a woman's risk increases.[16]

Physicians trained in internal medicine and family medicine perform clinical breast examination at lower rates than gynecologists,[17] although most women older than age 40 seek their primary care from providers within these 2 specialties. These data underscore the need for these providers to conduct clinical breast examinations in their female patients.

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