Bad medicine: clinical breast examinationBMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e6789 (Published 11 October 2012) Cite this as: BMJ 2012;345:e6789
- Des Spence, general practitioner, Glasgow
To question clinical examination is to open a rich vein of debate. Clinical examinations are unquestioned, given disproportionate weight, and considered “must do.” Not doing a full examination implies you are a bad doctor. But much of examination is mere ritualistic dogma passed down through the ages. Examination would never pass modern assessments of predictive value. Is this so for clinical breast examination (CBE)?⇑
For CBE, I was taught that the patient should be exposed from the chest down, examined in various positions, and palpated with the three central fingers in the various quadrants, and to always examine the axilla. This examination takes about 5-10 minutes and can be particularly unpleasant for women. In some countries CBE is promoted to screen for breast cancer; indeed the American Cancer Society still recommends examination in women from the early 20s onwards.1 But the truth is that many practising doctors in the UK ignore this teaching and conduct limited examinations. So who is right? Does traditional examination really have any value?
There is no evidence that clinician based screening or teaching self examination reduce mortality in breast cancer,2 3 but they do cause harm through overinvestigation or missing potential cancers.4 CBE, therefore, has no role in asymptomatic screening. The current advice in the UK is to promote breast screening to detect impalpable masses and for all other women “to be breast aware.”5
As for those women presenting with breast lumps, the National Institute for Health and Clinical Excellence (NICE) recommends that all women be considered for referral (perhaps temporising for a month in younger women).5 The prevalence of breast cancer in women under 40 years old is very low, but missing a tumour is not acceptable, and general practitioners have been pilloried for late diagnosis. In reality most GPs refer anyone who is concerned. This “no risk” situation, with its high referral rates, is not set to change. So of these urgent cancer referrals by GPs, only 12% are malignant, and clinical examination seems to have limited diagnostic accuracy or impact on management.4 The usual solution is to bemoan the generalist and promote “better” teaching of examination technique, but this won’t work because it is the limitations of CBE that are the core problem. And I wonder in specialist centres how often clinicians make decisions, except in young patients, without definitive investigations like mammography, ultrasound, or magnetic resonance imaging and biopsy?
Is it time for a complete rethink? To teach students something different? To acknowledge the limitations of CBE? Perhaps we should instead teach inspection, a limited version of palpation, timely referral, and the prevalence of cancer by age. Or we could even explore the use of cheap portable ultrasound machines in examinations.6 Traditional CBE is bad medicine.
Cite this as: BMJ 2012;345:e6789
Provenance and peer review: Commissioned: externally peer reviewed.
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