breast cancer screening: benefits of BSE and CBE, and annual physicals

 A recent study found that there was efficacy for both clinical breast exams (CBE) performed by a clinician and patient breast self-exams (BSE): see breast ca screening CBE and BSE help Cureus2023 in dropbox, or doi: 10.7759/cureus.22464 

 

Details: 

-- retrospective cross-sectional study of 2019 medical records from the Epic medical record system of women with breast lumps, from 2 clinics in Galveston, Texas 

-- mean age 42yo (58 in those with cancer and 41 in those without), 23% with family history of breast cancer (12% in those with cancer and 23% without) 

-- primary outcomes: detection of cancer, and positive ultrasound findings 

 

Results: 

-- 462 breast masses were detected: 

    -- BSE: women found 391 (85%) themselves

        -- 69 had positive ultrasound findings, 26 had cancer 

            -- cancers detected: 10 of the cancers were early stage (stage 0 and 1) 

            -- overall, 96% of the cancers and 81% of the positive ultrasound results were detected by the women  

 

    -- CBE: 71 (15%) of the masses detected were by clinicians

        -- 100% of cancers and 92% of positive ultrasound findings were discovered by MDs (versus DOs or mid-level practitioners) 

            -- though pretty much all of them were picked up by physicians specializing in women’s health (eg breast surgeons and OB/GYN doctors)

        -- 1 of 13 positive ultrasound findings was detected by a mid-level practitioner 

 

--personal history of breast cancer or family history of breast or ovarian cancer were not associated with the outcome of lumps being cancer or having positive ultrasound findings 

-- No statistically significant difference in BSEs versus CBEs in identifying either cancers or positive ultrasound findings (though most of the palpable masses were identified by patients) 

-- of note, of the 26 patients with cancer, only 6 had received prior screening mammograms.... 

 

Commentary: 

-- breast cancer is the most common cancer in women, with one in 8 women in the US developing breast cancer over their lifetime 

-- breast cancer survival is dictated largely by the timing of diagnosis: those with localized breast cancers have a 99% 5-year survival versus , decreasing to 93% in stage 2, 72% in stage 3 and 22% in stage 4 

-- BSE and CBE had been promoted strongly in the past, though a Chinese study in Shanghai more than 30 years ago did not find that BSE led to decreased breast cancer mortality, and this led to much less BSE being promoted/done, and when done, without much guidance by clinicians (see https://pubmed.ncbi.nlm.nih.gov/12359854/ ). The evaluation of CBE also found no direct evidence that it reduced breast cancer mortality (see https://bmccancer.biomedcentral.com/articles/10.1186/s12885-020-07521-w ) [though mortality may not be the best marker to follow: the Shanghai study was only for 2 years; and all but one of the studies in the CBE meta-analysis did show a stage shift to less advanced tumors in those receiving CBE, and the researchers commented that "indirect evidence suggested that a well-performed CBE achieved the same effect as mammography regarding mortality despite its apparently lower sensitivity". short-term mortality would likely not be affected by BSE/CBE since those deaths were probably from advanced lesions; the goal here is prevention of early cancers from becoming advanced, which would yield mortality benefit many years later...]

    -- after these older studies, several medical societies subsequently reversed their recommendations for screening women of average risk (eg, the American Cancer Society and the US Preventive Services Task Force), though some continued to encourage CBEs (eg, the National Comprehensive Cancer Network, which recommends CBEs everyone to 3 years from age 25 to 39, and then annually after age 40). Also, based on the Shanghai study and some others, there has not been much pursuit on further research to evaluate CBE and BSE . 

-- however, I am not sure exactly what average risk means, given the quite high risk for all women in the United States, with one in 8 women developing breast cancer during their lifetime 

    -- and the risk of breast cancer varies quite dramatically in different countries: the global age-standardized rate of breast cancer globally is 47.8/100K women, but 10 resource-rich countries (including the US) are above 90/100K women (https://www.wcrf.org/cancer-trends/breast-cancer-statistics/ ). which means, of course, that many countries have well below the mean of 47.8/100K to offset those with much higher rates 

    -- which brings up questions as to why there is such a difference globally. I am very concerned about toxic exposures leading to breast cancer, with many chemicals in the air, water, and food supply having stimulatory phytoestrogens, etc (see https://www.sciencedirect.com/science/article/pii/S0013935117307971 for review of the many chemicals associated. also the high level of stress in our society does lead to higher cortisol levels, which are associated with fewer NK cells (natural killer cells) which are a main defense against cancer

 

-- the current Texas study did show benefit for both CBE and BSE in picking up breast cancers 

-- another study using a nationally representative survey (NHIS) in 2003 found that of 361 women who had survived breast cancer, 43% found it themselves (25% reported that they had found it by self-examination and 18% by accident), see Self-Detection Remains a Key Method of Breast Cancer Detection for U.S. Women | Journal of Women's Health (liebertpub.com

-- though mammography is the best tool we have for early detection of breast cancer, it is important to remember that it is hardly perfect. Studies have found that up to 30% of cancers are missed by mammography, and this may be partly related to mammography suboptimal sensitivity in women with asymmetric breasts or in women with denser breast tissue (see https://pubmed.ncbi.nlm.nih.gov/22700555/ or https://www.cancer.gov/types/breast/mammograms-fact-sheet#:~:text=False%2Dnegative%20results%20occur%20when,of%20security%20for%20affected%20women or https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2767742 ). Several older studies have found that 10% of women with palpable breast masses have normal mammograms, with the lesson being that a negative mammogram should not dissuade further workup 

-- one issue often raised is that breast self-exams by women may have the untoward effect of creating anxiety. However, for many women BSE may provide more self-awareness and empowerment to understand and control their health. Seems like promoting BSE should probably be assessed on a case-by-case basis. 

-- also, it is important to remember that in many resource-poor countries without access to routine mammograms, CBE and BSE are even more important and should not be underutilized because those of us in wealthy countries seem to have forgone them 

 

Limitations: 

-- This was a retrospective assessment through chart review and not a prospective randomized trial, limiting our ability to assume causation: ie, there could have been important unidentified confounders that might have altered the results. Were the women doing BSE doing it for some important reason that differentiated them from those not doing it? Was there more breast cancer in their families not reported (eg second degree relatives)? were they at higher risk for other reasons?

-- there was not any granular data about the training and competence of the clinicians doing the CBEs. it is noteworthy that the cancer pickups were limited to MDs trained in women's health 

    -- what was the content of the BSE or CBE. How did the women and clinicians do the exams? We do know that certain specific approaches to breast evaluations have higher yield 

-- these women were at 2 specific clinics connected to a tertiary center, so may not be generalizable to other areas of the country or internationally 

 

So, the study does bring up a few issues: 

-- it reinforces the utility of BSE and CBE 

    -- the numbers of women with breast cancer detected by CBE was a small minority in this study, but was not statistically significantly from BSE . In addition, one big advantage of doing CBE is that it does provide a reinforcement to the female patients for doing their own breast exams, as well as perhaps having some value in helping women improve their technique 

-- clinicians, however, did not do a good job in clinical breast screening in this study

    -- though MDs did outperform other clinicians, in fact we clinicians did not do very well. only CBEs done by physicians specializing in women’s health (eg, breast surgeons and OB/GYN doctors) actually picked up the cancers

        -- so the real issue here is that all clinicians other than those specializing in women’s health, whether other MDs, DOs, or NPs/PAs, need to have education on how to do optimal clinical breast exams (and enough time to actually do them). seems like yet another public health imperative....

 

-- i would like to highlight another related issue: what is the utility of annual physical exams, which have been pretty marginalized in the medical press for many years though i think there are several reasons to keep them around: 

    -- I personally have picked up some very important and occasionally perhaps life-saving but unsuspected clinical problems by doing physicals (valvular heart disease, hepatosplenomegaly, even a case of early ovarian cancer).  And this certainly reinforced my desire to continue with these exams

    -- especially in patients with multiple medical problems (which, of course, is increasing as the amount of overweight/obesity is increasing, along with diabetes), the annual exam gives us and patients a chance to look at the big picture: how are things going for the patients overall? How are things at home/work/in the community? What are their stressors? What about domestic violence? Depression? Anxiety? How are they dealing emotionally with their array of medical problems? Are they now drinking alcohol or smoking or using drugs? How did covid affect them and people close to them? These types of very important issues may be missed by addressing one medical problem and then another. and asking these questions may not only improve the clinician/patient relationship but may uncover really important issues to address 

    -- at least for some patients, they expect these exams to be done in order for them to feel satisfied that their clinician is being thorough. And they may feel that the clinician is not doing a great job by not touching them. And the therapeutic relationship may be less therapeutic...

    -- and, not doing these exams routinely leads to us clinicians to be less comfortable and competent doing specific clinical exams. 

        -- How comfortable are clinicians doing pelvic exams on women, as the requirements for doing cervical cancer screening is less frequent (and we may be moving to doing even less as women become able to do their own vaginal swabs for both vaginitis and HPV??): that is a great thing for many women to be able to do self-care, but how good will we be at picking up abnormal findings in women who come in with at vaginal complaint and get an exam?

        -- Are we competent to do accurate heart exams to pick up important but more subtle abnormalities?

        -- What about eye exams? How good are we at doing retinal exams, or picking up abnormalities in the optic nerve? many people do not see eye doctors regularly.

        -- which brings us to the clinical breast exam: and why were the clinicians doing women's health really the only ones finding abnormal breast findings? Are we other clinicians (MDs, DOs, NP/PA's) doing patients a service by missing early breast cancers with their 99% 5-year survival? we know that mammograms are far from perfect

    -- I think all of these (and other) evaluations do require a lot of experience for us to be comfortable with them and competent in the exams. 

-- And having patients see us specifically for an annual physical does give us the opportunity to get more comfortable with our abilities to do thorough exams. And the patients may well benefit from our having this experience... 

geoff

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