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Detection of breast cancerClinical breast examination is not an acceptable alternative to mammographyMammography should be availableSelf examination contributes to reduction in mortality

BMJ 2001; 322 doi: http://dx.doi.org/10.1136/bmj.322.7289.792/a (Published 31 March 2001) Cite this as: BMJ 2001;322:792

Clinical breast examination is not an acceptable alternative to mammography

  1. C J M de Wolf, consultant public health
  1. University of Geneva, Institut de Médecine Sociale et Préventive, CH-1205 Geneva, Switzerland
  2. Royal Marsden Hospital, Sutton, Surrey SM2 5PT
  3. Addenbrooke's Hospital, Cambridge CB2 2QQ
  4. Division of Clinical Epidemiology, Deutsches Krebsforschungszentrum, D-69120 Heidelberg, Germany
  5. Department of Public Health Sciences, University of Toronto, Toronto, Ontario, Canada M5S 1A8

    EDITOR—Clinical breast examination is not an acceptable alternative to mammographic screening, as Mittra et al say in their article.1 Screening for breast cancer is a public health intervention and needs objective criteria for evaluation and quality control. Clinical breast examination is a subjective method with variable interpersonal interpretation. For a public health screening intervention, the sensitivity and specificity of clinical breast examination are too low and variable to accept as a screening test. Clinical breast examination is a detection method acceptable in a doctor-patient relationship where the doctor has the full responsibility for the diagnosis.

    The estimate that only 22% of the cancers are detected by mammography remains a hypothetical calculation. Bobo and Lee analysed in a retrospective study all the cancers found by mammography and clinical breast examination in the national programme for early detection of breast cancer in the United States.2 Of the 3780 cancers reported, on 2224 (59%) records the clinical breast examination was suspicious for cancer. On 1556 (41%) records, the clinical breast examination was normal. In other words, this examination “missed” 41% of cancers. This is almost twice the reported assumption.

    Furthermore, it is a misconception that tumours grow exponentially. This is a mathematical projection of cells in virtual circumstances. The initial stage of solid tumour growth is limited by the ability of externally supplied nutrients to diffuse into the tumour. In a later stage the limiting factor for growth is the neovascularisation in the tumour tissue. The exponential growth of a …

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