Is it time to abandon clinical breast examination?

Despite limits to its clinical value, the potential benefits for women should not be overlooked

Women with mutations in breast cancer predisposition genes have a very high risk of developing breast cancer and are offered risk‐reducing strategies and intensified surveillance; many are referred to specialist risk management clinics. Because magnetic resonance imaging (MRI) is more sensitive for detecting breast cancer at an early stage than mammography,1 it is part of most high risk breast cancer screening programs, and in Australia is covered by Medicare for women at high risk under 50 years of age.2

In this issue of the MJA, Hettipathirana and colleagues question the utility of clinical breast examination in high risk breast cancer screening programs.3 Their analysis included 414 women with BRCA1 or BRCA2 mutations who underwent clinical breast examination every 6 to 12 months at a Melbourne risk management clinic in addition to annual mammography and, from 2009, annual MRI screening (until age 50). Overall, 35 women were diagnosed with breast cancer, including three for whom abnormal clinical breast examinations were recorded. One of these women (aged 51 years) had a concurrent abnormal mammogram, while two women (aged 36 and 65 years) had imaging occult cancers (mammography and ultrasound); none of the three had been screened by MRI. Hettipathirana and her colleagues conclude that clinical breast examination could be safely omitted from a high risk screening program that includes MRI for all women, regardless of age.3

Before abandoning clinical breast examination, we should review its role in more detail. Its advantages include the facts that it is non‐invasive, does not expose women to radiation or gadolinium, and it is inexpensive. It provides women with reassurance and the opportunity to discuss concerns with their clinicians. Practitioners have the opportunity to educate women about breast awareness and self‐examination, and the consultation facilitates discussion of other risk mitigation strategies, such as salpingo‐oophorectomy and the management of menopausal symptoms. Disadvantages include the need for clinician time and availability, and for women to travel to a specialist clinic for a face‐to‐face consultation. As clinical breast examination is difficult to standardise, technique and quality of examination vary markedly between clinicians, particularly outside the controlled environment of a clinical trial. There is also the potential for false positive clinical breast examination findings leading to unnecessary imaging and biopsy.

Clinical breast examination has an important role in assessing women with symptoms and in surveillance after treatment of early breast cancer, when it is recommended to help detect local recurrences and new primary cancers.4 In the context of breast cancer screening, clinical breast examination is most useful in countries without national screening mammography programs.5 For example, a cluster randomised trial in India found that a program of two‐yearly clinical breast examination combined with cancer awareness education was associated with significant down‐staging of breast cancer at diagnosis, and it reduced mortality among women aged 50 years or more by almost 30% compared with women who received a single health education session and no clinical breast examination.6 In countries with mammography screening programs, however, the evidence does not support regular clinical breast examination as part of a screening program for women at average risk.7

In the Dutch MRI Screening Study, 2157 women at high risk (including 599 with predisposition mutations) underwent biennial clinical breast examination as well as annual MRI and mammography screening. Of 97 breast cancers, 78 were detected by imaging, three were detected by clinical breast examination with normal concurrent mammography and MRI, 13 were interval cancers, and six were chance findings at risk‐reducing mastectomy.8 Similar studies of women with BRCA mutations undergoing MRI and mammography screening reported that no cancers were detected by clinical breast examination alone.9,10

Hettipathirana and colleagues reported that seven of the 35 women diagnosed with cancer presented with self‐detected lumps between clinic visits.3 Given the high rates of incident cancers, particularly in women with BRCA1 mutations,3,8 educating those at high risk to be breast‐aware and to report any symptoms promptly is probably more useful than performing regular clinical breast examinations.

The evidence favours removing annual clinical breast examination from high risk breast cancer screening programs, provided women remain breast‐aware and have access to annual MRI breast screening. Removing clinical breast examination would allow screening consultations to be conducted via telehealth, with less impact on work and other commitments for women. It may be difficult to convince women that clinical breast examination can be safely omitted because, even when educated about its limited value, many still want regular breast examinations and are reassured by normal results.11 Knowing that it provides an opportunity for clinicians to educate and counsel women, and that cancers are detected by clinical breast examination alone (if only very occasionally), is there any harm in retaining clinical breast examination as an optional component of a high risk screening program?