Clinical breast exam controversy

A recent study discusses the “controversy about whether adding clinical breast examination (CBE) to mammography improves the accuracy of breast screening.” The study was published online on August 31, 2009 in the Journal of the National Cancer Institute.
The study of women in the Ontario Breast Screening Program (OBSP) discusses the rise in false positives when women have a clinical breast exam at the same time as the mammography exam. The conclusion of the study is that “women should be informed of the benefits and risks of having a CBE in addition to mammography for breast screening.”
This is an interesting study with a worthwhile conclusion. My concern with any controversy is that it adds to the confusion felt by some women, who may throw up their hands and stay away from screening altogether. I hope this won’t be the case as I believe that women, and men, should be tuned in to the importance of the early detection of cancer.

I understand the fear that women experience when they’re recalled for follow up after a mammogram or when a lump is found on a clinical exam. I was diagnosed with advanced breast cancer in 1986 because screening mammography was not available and my doctor refused to order a mammogram. This resulted in a greater load on the health care system than if it had been detected earlier since it involved surgery, chemotherapy, and longer follow up. There was also a much larger fear factor for my self and my family than if the cancer had been found sooner.

I think we need to do more to help women get through “false positives” without fear and anxiety. The point remains that it’s better to find cancer earlier than later, and to reassure women that it’s better to go through a false positive diagnostic process than to take a chance on letting an unfound cancer grow larger.

There are a couple of basic issues which contribute to false positive mammograms. As a mammographer, I have explained to many women about the challenges of reading mammograms. Breast tissue is formed in branches like grapes so that if the branches are on top of each other in the images, then it’s difficult to tell what’s there; women may be asked to return for further X-rays, either coned, a different angle, or ultrasound. This does not mean there is something wrong with the tissue, but that the radiologist needs more information to make an accurate diagnosis. Similarly, looking at images of dense breast tissue is more challenging as it’s like looking through a tree full of leaves in the summer. As women age, the dense tissue turns to fat and mammograms are much easier to read as they are more like looking through a tree in the winter.

If women are educated to know that the early stages of a mammography work up are a matter of gathering information, then it will relieve some anxiety. False positives from CBE’s are usually from feeling a lump or thickening. Since 80% of breast lumps are benign, it makes sense that they can be viewed calmly if they can be viewed as probable cysts or normal breast lumps, not cancerous growths.

Breast self examinations (BSE) are often not recommended due to the fear factor of false positives, and I hope that CBE’s will not be viewed in the same light. Mammograms are the gold standard in the detection of breast cancer; however, they are not perfect and I believe it’s in everyone’s best interest to continue to do both monthly BSE’s and annual CBE’s with a health professional.

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3 Responses to “Clinical breast exam controversy”

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