Click here for YNHH home page.


Sign up for HealthLINK.

Can we help?

Follow up on this month's He@lthLINK

 

He@lthLINKs

Site Contents


Phone Numbers

Directory assistance
(203) 688-4242

Patient information
(203) 688-4177

Adult emergency
(203) 688-2222

Children's emergency
(203) 688-3333

Admitting
(203) 688-2221

Children's admitting
(203) 688-3331

Psychiatric admitting
(203) 688-9907



Mailing address:
Yale-New Haven Hospital
20 York Street
New Haven, CT
06510-3202




Site Contents


 Yale-New Haven Hospital, New Haven, Connecticut, USA HealthLINK: Cancer

August 1, 2000

News this month
The role of clinical breast exams

Clinical breast exams (CBEs) are at best forgettable for the woman involved and at worst slightly embarrassing. But are they of value in detecting breast cancer? Yes, according to new data from the National Breast and Cervical Cancer Early Detection program. The study, published in the June 20 issue of the Journal of the National Cancer Institute, found that manual exams detected very small cancers and sometimes even found cancers that were not picked up by mammogram. It should be stressed that mammogram, a detailed X-ray of the breast, is still the best way to detect breast cancer an average of 1.7 years before a woman can feel the lump. Mammography also locates cancers too small to be felt during a clinical breast examination.

Manual exams detected very small cancers and sometimes even found cancers that were not picked up by mammogram.

Determining the value of CBEs
Since 1991, the National Breast and Cervical Cancer Early Detection program has provided free mammograms, Pap smears and clinical breast exams to more than 2.2 million low income women across the country. This program has provided useful data for a number of studies, but to date very little has been published on the value of clinical breast exams. The researchers, led by Janet Bobo of the U.S. Centers for Disease Control and Prevention, wanted to find out if CBEs done in the community setting were as valuable as CBEs done during clinical trials.

Results from more than 750,000 women
The researchers analyzed data collected from 752,081 CBEs performed from 1995 through 1998. In all, the researchers determined that about 7 percent of all CBEs were suspicious for cancer. Overall, five cancers were detected per 1,000 examinations. They also found that the values observed for sensitivity (58.8 %) and specificity for cancer (93.4 %) were comparable to those reported for the CBE component of clinical trials. That meant that the exams being done in the community setting were turning up results similar to those done during clinical trials, which was good news.

CBEs were detecting cancers in a small percentage of women who had had normal mammograms. However, …CBEs did not come close to detecting all the cancers.

Finding cancers after normal mammograms
What was very interesting was that the CBEs were detecting cancers in a small percentage (seven cancers per 1,000 records) of women who had had normal mammograms. However, it’s important to note that the CBEs did not come close to detecting all the cancers.

When the CBE was normal but the mammography was abnormal, the rate of detection was 42 cancers per 1,000 records. When both CBE and mammography results were abnormal, the rate of detection was 170.3 cancers per 1,000 records. Cancer detection could not be attributed entirely to CBE or mammography on about a third of this last group because the tests were performed on the same day.

Breast cancer screening schedule
Women under age 40 should perform monthly breast self exams and receive an annual breast exam by a physician. In addition to self exams and clinical exams, women age 40 to 49 should have mammography every one to two years and an annual mammography from age 50 and older, according to the National Cancer Institute. The researchers concluded that community-based CBEs detected breast cancers as effectively as CBEs performed in clinical trials and might make slight improvements in early detection programs.

JAMA study sheds light on CBEs
A study published in the Journal of the American Medical Association last fall suggested that properly performed CBEs can detect at least 50 percent of cancers where symptoms are not yet present and may help save lives in women screened. However, they also noted there was wide variation among physicians in how they performed CBEs. The study recommended that a clinical breast exam take at least three minutes per side and offered a detailed description of how the exam should be done.


Physician Referral Online

A free and confidential service
of Yale-New Haven Hospital.

Physician Referral Online
Using your own criteria, you can request information from a database of 900 area physicians who have registered to participate.

Request an appointment
We would be happy to assist you in scheduling an appointment with a member of the hospital's medical staff. Use the link above or call:

203-688-2000
or toll free
1-888-700-6543
to talk with a referral coordinator.
Barbara Ward, MD

Why women need clinical breast exams

When discussing breast cancer detection, I first want to make sure all women know that mammography is still our best screening tool. But because mammography is not perfect, there is still great value in performing monthly breast examinations, as well as going for an annual clinical breast exam (CBE) with your primary care provider. The question of how valuable clinical breast exams are in saving lives has generated some controversy. I’m of the mindset that I want to do everything possible to detect breast cancer, even if there is doubt remaining in some people’s minds.

Clinical breast exams or self exams are particularly valuable in detecting types of breast cancers that usually do not show up on mammograms. These types of cancers do not tend to calcify (form round, hard balls) like most breast cancers so they don’t show up on mammogram.

"Mammography is still our best screening tool. But… there is still great value in performing monthly breast examinations, as well as going for an annual clinical breast exam (CBE)…"

Don’t forget self exams
An example is invasive lobular cancer. I’ve treated women with this type of cancer who needed mastectomies–even though they had regular mammograms–because they were not doing self exams. Any diffuse changes you find should be brought to your doctor’s attention right away. By diffuse I mean a generalized thickening or marked change in the texture of the breast that does not go away. This can change the way the breast looks–either you see dimpling or retraction or a difference in appearance between the two breasts.

Who should perform CBEs?
As a surgeon, I do a lot of clinical breast exams, but ideally a woman should be having this done by her regular primary care provider or gynecologist. Doctors learn how to perform breast self exams during their training in medical school. I review the procedure with our own medical students. The JAMA study suggests that a CBE take five to 10 minutes. In reality, I think that’s too long and is not practical. Instead, I recommend our med students come up with a shorter technique they can perform on everyone.

Self exams
It’s easier to feel lumps in the breast after menopause because of changes in the breast itself. The absence of estrogen causes the amount of ductal tissue to diminish and it is replaced by fat. Women who have fibrocystic breasts are harder to exam because they naturally have lumpier breasts. But that’s why it’s doubly important for these women to do self exams so that they know what’s normal and what is not. If a patient tells me she feels a change, she is the expert–even more so than another doctor.

"If you find something, …remember the vast majority of lumps are not cancerous."

Performing a clinical breast exam on a patient is an excellent time for me to teach the patient how to perform a self exam. I tell women that feeling a lump has a three-dimensional aspect to it. Cancers tend to have rough edges–not smooth edges like an M&M candy does. The menstrual cycle also influences how the breasts feel. The best time to examine the breasts is about a week after your period ends. If you are past menopause, try to come up with one date each month that you always do the exam. If you find something, try not to panic but remember the vast majority of lumps are not cancerous.

The take-home message is that all of these tools—mammography, clinical breast exams and self exams—have their own important role in detecting breast cancer. Use everything you’ve got—from shower cards that show how to do a breast self exam to a buddy system of calling a friend every month as a reminder.

Dr. Ward is director of the Yale Comprehensive Breast Care Center and is a surgical oncologist affiliated with Yale-New Haven Hospital.

2002 Best Hospital--U.S. News Online

Yale-New Haven was recognized this year by U.S. News & World Report for its cancer services.


Spacer.
Subscribe to HealthLink.

 

Other related links.

Copyright 1999-2008.
Top of Page. Y-NHH. YNHHS. Site Editor.

Home page
Staff directory
Directions and parking
Online resources
Yale New Haven Health System		   Need a doctor?
Search
Comments
Top of page
Yale-New Haven Medical Center

Home page URL: http://www.ynhh.org

All information is intended for your general knowledge and is not a substitute for medical advice or treatment for specific medical conditions. You should seek prompt medical care for any specific health issues and consult your physician before starting a new fitness regimen.