Breast Cancer Screening (PDQ®)–Health Professional Version

Nonimaging Screening Modalities

Clinical Breast Examination

The effect of screening clinical breast examination (CBE) on breast cancer mortality has not been fully established. The Canadian National Breast Screening Study (CNBSS) compared high-quality CBE plus mammography with CBE alone in women aged 50 to 59 years. CBE, lasting 5 to 10 minutes per breast, was conducted by trained health professionals, with periodic evaluations of performance quality. The frequency of cancer diagnosis, stage, interval cancers, and breast cancer mortality were similar in the two groups and similar to outcomes with mammography alone.[1] With a mean follow-up of 13 years, breast cancer mortality was similar in the two groups (mortality rate ratio, 1.02 [95% confidence interval [CI], 0.78–1.33]).[2] The investigators estimated the operating characteristics for CBE alone; for 19,965 women aged 50 to 59 years, sensitivity was 83%, 71%, 57%, 83%, and 77% for years 1, 2, 3, 4, and 5 of the trial, respectively; specificity ranged between 88% and 96%. Positive predictive value (PPV), which is the proportion of cancers detected per abnormal examination, was estimated to be 3% to 4%. For 25,620 women aged 40 to 49 years who were examined only at entry, the estimated sensitivity was 71%, specificity was 84%, and PPV was 1.5%.[3]

In clinical trials involving community clinicians, CBE-type screening had higher specificity (97%–99%) [4] and lower sensitivity (22%–36%) than that experienced by examiners.[5-8] A study of screening in women with a positive family history of breast cancer showed that, after a normal initial evaluation, the patient herself, or her clinician performing a CBE, identified more cancers than did mammography.[9]

Another study examined the usefulness of adding CBE to screening mammography; among 61,688 women older than 40 years and screened by mammography and CBE, sensitivity for mammography was 78%, and combined mammography-CBE sensitivity was 82%. Specificity was lower for women undergoing both screening modalities than it was for women undergoing mammography alone (97% vs. 99%).[10] Other international trials of CBE are under way, two in India and one in Egypt.

Breast Self-Examination (BSE)

Monthly BSE has been promoted, but there is no evidence that it reduces breast cancer mortality.[11,12] The only large, randomized clinical trial of BSE assigned 266,064 female Shanghai factory workers to either BSE instruction with reinforcement and encouragement, or instruction on the prevention of lower back pain. Neither group underwent any other breast cancer screening. After 10 to 11 years of follow-up, 135 breast cancer deaths occurred in the instruction group, and 131 cancer deaths occurred in the control group (relative risk [RR], 1.04; 95% CI, 0.82–1.33). Although the number of invasive breast cancers diagnosed in the two groups was about the same, women in the instruction group had more breast biopsies and more benign lesions diagnosed than did women in the control group.[13]

Other research results on BSE come from three trials. First, more than 100,000 Leningrad women were assigned to BSE training or control by cluster randomization; the BSE group training had more breast biopsies without improved breast cancer mortality.[14] Second, in the United Kingdom Trial of Early Detection of Breast Cancer, more than 63,500 women aged 45 to 64 years were invited to educational sessions about BSE. After 10 years of follow-up, breast cancer mortality rates were similar to the rates in centers without organized BSE education (RR, 1.07; 95% CI, 0.93–1.22).[15] Thirdly, in contrast, a case-control study nested within the CNBSS compared self-reported BSE frequency before enrollment with breast cancer mortality. Women who examined their breasts visually, used their finger pads for palpation, and used their three middle fingers had a lower breast cancer mortality rate.[16]

Tissue sampling (fine-needle aspiration, nipple aspirate, ductal lavage)

Various methods to analyze breast tissue for malignancy have been proposed to screen for breast cancer, but none have been shown to be associated with mortality reduction.

References

Baines CJ: The Canadian National Breast Screening Study: a perspective on criticisms. Ann Intern Med 120 (4): 326-34, 1994. [PUBMED Abstract]
Miller AB, To T, Baines CJ, et al.: Canadian National Breast Screening Study-2: 13-year results of a randomized trial in women aged 50-59 years. J Natl Cancer Inst 92 (18): 1490-9, 2000. [PUBMED Abstract]
Baines CJ, Miller AB, Bassett AA: Physical examination. Its role as a single screening modality in the Canadian National Breast Screening Study. Cancer 63 (9): 1816-22, 1989. [PUBMED Abstract]
Fenton JJ, Rolnick SJ, Harris EL, et al.: Specificity of clinical breast examination in community practice. J Gen Intern Med 22 (3): 332-7, 2007. [PUBMED Abstract]
Fenton JJ, Barton MB, Geiger AM, et al.: Screening clinical breast examination: how often does it miss lethal breast cancer? J Natl Cancer Inst Monogr (35): 67-71, 2005. [PUBMED Abstract]
Bobo JK, Lee NC, Thames SF: Findings from 752,081 clinical breast examinations reported to a national screening program from 1995 through 1998. J Natl Cancer Inst 92 (12): 971-6, 2000. [PUBMED Abstract]
Oestreicher N, White E, Lehman CD, et al.: Predictors of sensitivity of clinical breast examination (CBE). Breast Cancer Res Treat 76 (1): 73-81, 2002. [PUBMED Abstract]
Kolb TM, Lichy J, Newhouse JH: Comparison of the performance of screening mammography, physical examination, and breast US and evaluation of factors that influence them: an analysis of 27,825 patient evaluations. Radiology 225 (1): 165-75, 2002. [PUBMED Abstract]
Gui GP, Hogben RK, Walsh G, et al.: The incidence of breast cancer from screening women according to predicted family history risk: Does annual clinical examination add to mammography? Eur J Cancer 37 (13): 1668-73, 2001. [PUBMED Abstract]
Oestreicher N, Lehman CD, Seger DJ, et al.: The incremental contribution of clinical breast examination to invasive cancer detection in a mammography screening program. AJR Am J Roentgenol 184 (2): 428-32, 2005. [PUBMED Abstract]
Baxter N; Canadian Task Force on Preventive Health Care: Preventive health care, 2001 update: should women be routinely taught breast self-examination to screen for breast cancer? CMAJ 164 (13): 1837-46, 2001. [PUBMED Abstract]
Humphrey LL, Helfand M, Chan BK, et al.: Breast cancer screening: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 137 (5 Part 1): 347-60, 2002. [PUBMED Abstract]
Thomas DB, Gao DL, Ray RM, et al.: Randomized trial of breast self-examination in Shanghai: final results. J Natl Cancer Inst 94 (19): 1445-57, 2002. [PUBMED Abstract]
Semiglazov VF, Moiseyenko VM, Bavli JL, et al.: The role of breast self-examination in early breast cancer detection (results of the 5-years USSR/WHO randomized study in Leningrad). Eur J Epidemiol 8 (4): 498-502, 1992. [PUBMED Abstract]
Ellman R, Moss SM, Coleman D, et al.: Breast cancer mortality after 10 years in the UK trial of early detection of breast cancer. UK Trial of Early Detection of Breast Cancer Group. The Breast 2 (1): 13-20, 1993.
Harvey BJ, Miller AB, Baines CJ, et al.: Effect of breast self-examination techniques on the risk of death from breast cancer. CMAJ 157 (9): 1205-12, 1997. [PUBMED Abstract]