Author Affiliations: Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School, Boston, Mass (Drs Barton and Fletcher); and Department of Medicine, University of North Carolina, Chapel Hill (Dr Harris).
The Rational Clinical Examination Section
Editors: David L. Simel, MD, MHS, Durham Veterans Affairs Medical
Center and Duke University Medical Center, Durham, NC;
Drummond Rennie, MD, Deputy Editor (West), JAMA .
Context The clinical breast examination (CBE) is widely recommended and practiced
as a tool for breast cancer screening; however, its effectiveness is dependent
on its precision and accuracy.
Objective To collect evidence on the effectiveness of CBE in screening for breast
cancer and information on the best technique to use.
Data Sources We searched the English-language literature using the MEDLINE database
(1966-1997) and manual review of all reference lists, as well as contacting
investigators of several published studies for clarifications and unpublished
Study Selection and Data Extraction To study CBE effectiveness, we included all controlled trials and case-control
studies in which CBE was at least part of the screening modality; for technique,
we included both clinical studies and those that used silicone breast models.
All 3 authors reviewed and agreed on the studies selected for inclusion in
the pooled analyses.
Data Synthesis Randomized clinical trials demonstrated reduced breast cancer mortality
rates among women screened by both CBE and mammography. Evidence of CBE's
independent contribution was less direct; CBE alone detected between 3% and
45%of breast cancers found that screening mammography missed. The precision
of CBE was difficult to determine because of the lack of consistent and standardized
examination techniques. Studies on CBE precision reported fair agreement (κ=0.22-0.59).
Pooling trial data, we estimated CBE sensitivity at 54% and specificity at
94%. The likelihood ratio of a positive CBE result is 10.6 (95% confidence
interval [CI], 5.8-19.2), while the likelihood ratio of a negative test result
is 0.47 (95% CI, 0.40-0.56). Longer duration of CBE and a higher number of
specific techniques used were associated with greater accuracy. The preferred
technique for CBE includes proper positioning of the patient, thoroughness
of search, use of a vertical-strip search pattern, proper position and movement
of the fingers, and a CBE duration of at least 3 minutes per breast. The value
of inspection is unproved. Professional and lay examiners improved their sensitivity
on silicone breast models after being taught this technique.
Conclusions Indirect evidence supports the effectiveness of CBE in screening for
breast cancer. Although the screening clinical examination by itself does
not rule out disease, the high specificity of certain abnormal findings greatly
increases the probability of breast cancer.
Barton MB, Harris R, Fletcher SW. Does This Patient Have Breast Cancer? The Screening Clinical Breast Examination: Should It Be Done? How? JAMA. 1999;282(13):1270–1280. doi:10.1001/jama.282.13.1270
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