clinical breast examination (cbe) - Breast Health Global Initiative

CLINICAL BREASTEXAMINATION (CBE)Benjamin O. Anderson, M.D.Director, Breast Health ClinicProfessor of Surgery and Global Health, University of WashingtonJoint Member, Fred Hutchinson Cancer Research CenterSeattle, Washington

CLINICAL BREAST EXAMINATIONOutline•CBE Technique•CBE Findings•Clinical Trials

CLINICAL BREAST EXAMINATIONOutline•CBE Technique•CBE Findings•Clinical Trials

BREAST CANCER DETECTION

CLINICAL BREAST EXAMINATION:Areas to examine• VISUAL FINDINGS: Asymmetries,puckering, dimpling, skin and nipple findings• LYMPH NODES: Palpable adenopathy insupraclavicular and axillary nodes• BREAST FINDINGS: Dominant or focalfindings based upon homogeneity andsymmetry of fibroglandular architecture

Barton, MB, Harris, R, Fletcher, S. JAMA 1999;282:1270-80.

Barton, MB, Harris, R, Fletcher, S. JAMA 1999;282:1270-80.

Barton, MB, Harris, R, Fletcher, S. JAMA 1999;282:1270-80.

CLINICAL BREAST EXAMINATIONOutline•CBE Technique•CBE Findings•Clinical Trials

CLINICAL BREAST EXAMINATIONOutline•CBE Technique•CBE Findings•Clinical Trials

COMMON BREAST PROBLEMSBenign Breast Masses• Normal “lumpy” breast tissue• Simple (gross) cysts• Fibroadenomas• Pseudoangiomatous stromal hyperplasia (PASH)• Lipomas (palpable subcutaneous fat lumps)• Tubular and lactating adenomas• Granular cell tumors, benign vascular lesions,leiomyomas, neurofibromas (all rare)

COMMON BREAST PROBLEMS“Fibrocystic disease”• Not a distinct entity• Kitchen sink phenomenon• NOT a risk factor for breast cancer• Gross Cystic Disease:– real entity– hormonal pathophysiology– may predispose to breast cancer

COMMON BREAST PROBLEMSBreast Pain• Very common problem• Rarely a symptom of breast cancer• Cystic pain may be more responsible tohormone therapy• Pain usually improves or resolves atmenopause

COMMON BREAST PROBLEMSMastitis• Inflammation or infection of the breast• Lactational vs. non-lactational mastitis• Treated with antibiotics• If abscess evolves, surgical drainage required• Must be distinguished from inflammatorybreast cancer

CLINICAL BREAST EXAMINATIONOutline•CBE Technique•CBE Findings•Clinical Trials

CLINICAL BREAST EXAMINATIONOutline•CBE Technique•CBE Findings•Clinical Trials

CLINICAL BREAST EXAMINATION:What do we know?• CBE detects about 60% ofmammo detected cancers• CBE finds some cancers notseen on mammography• No randomized trials comparemortality between womenoffered vs. not offered CBE

CLINICAL BREAST EXAMINATION:What do we know?• CBE detects about 60% ofmammo detected cancers• CBE finds some cancers notseen on mammography• No randomized trials comparemortality between womenoffered vs. not offered CBEBREAST CANCERSSBE / CBEDETECTABLEMAMMODETECTABLE

CLINICAL BREAST EXAMINATION:Randomized controlled trialsStudy Years # CancersMethod of detection, %Both Mammography CBE onlyHIP (N.Y.) 1963-66 132 22% 33% 45%Edinburgh 1978-81 88 71% 26% 3%Canadian(NBSS 1)Canadian(NBSS 2)1980-88(40-49y.o.)1980-88(50-59y.o.)255 36% 40% 24%325 35% 53% 12%Barton, MB, Harris, R, Fletcher, S. JAMA 1999;282:1270-80.

CLINICAL BREAST EXAMINATION:Randomized controlled trialsStudy Years # CancersMethod of detection, %Both Mammography CBE onlyHIP (N.Y.) 1963-66 132 22% 33% 45%Edinburgh 1978-81 88 71% 26% 3%Canadian(NBSS 1)Canadian(NBSS 2)1980-88(40-49y.o.)1980-88(50-59y.o.)255 36% 40% 24%325 35% 53% 12%Barton, MB, Harris, R, Fletcher, S. JAMA 1999;282:1270-80.

CLINICAL BREAST EXAMINATION:Limitation of StudiesDetermining the effectiveness ofscreening CBE is difficult, because noclinical trial has compared CBE aloneversus no screening

CLINICAL BREAST EXAMINATION:Canadian NBSS-2 Trial• 39,405 womenrandomized• age 50-59Mammography+CBE• All pts taught SBE• CBE vs.CBE+mammography(2 view)CBE onlyMiller, To, Baines, Wall. JNCI 2000;92:1490-9.

CLINICAL BREAST EXAMINATION:Canadian NBSS-2 Trial• 39,405 womenrandomized• age 50-59• All pts taught SBE• CBE vs.CBE+mammography(2 view)Subjects CBE+Mammography CBE AloneNumber ofWomenNumber ofBC deathsat 13 years19,711 19,694107 105Miller, To, Baines, Wall. JNCI 2000;92:1490-9.

CLINICAL BREAST EXAMINATION:Canadian NBSS-2 Trial• 39,405 womenrandomized• age 50-59• All pts taught SBE1801601401201008060• CBE vs.40CBE+mammography 20(2 view) 0# INVASIVE CANCERS, study years 1 through 9=4.0Miller, To, Baines, Wall. JNCI 2000;92:1490-9.

CLINICAL BREAST EXAMINATION:Canadian NBSS-2 Trial• 39,405 womenrandomized• age 50-59• All pts taught SBE• CBE vs.CBE+mammography(2 view)200180160140120100806040200# INVASIVE CANCERS, study years 1 through 570%62%21%24%None1 to 3CBE aloneMammo+CBE14% 9%>=4Miller, To, Baines, Wall. JNCI 2000;92:1490-9.

Mumbai Trial:Study Design• Tata Memorial Hospital, cluster randomized trial– CBE + cervical inspection in intervention group– Health education only in the control group• > 75,000 women in each arm• Screening in intervention arm every 2 years for 4cycles followed by 8 years of monitoring• Interval report after three rounds of screeningMittra et al. Int J Cancer 2010;126:976-84.

Mumbai Trial:Interim ResultsIntervention Group:Clinical breast examControl Group:Education onlyMittra et al. Int J Cancer 2010;126:976-84.

CONCLUSIONS• Clinical breast examination is one of the most importantmethods for breast cancer detection, especially in countriesthat lack screening mammography.• CBE technique involves a complete evaluation of the breastincluding visual inspection, examination of the lymph nodesand palpation of the breast.• CBE detects 60% of cancers seen on screening mammographyand may improve breast cancer survival, especially incountries that lack screening mammography.

SEATTLE CANCER CARE ALLIANCEUNIVERSITY OF WASHINGTONFRED HUTCHINSON CANCER CENTERCHILDREN’S HOSPITAL