Journal of the National Cancer Institute Advance Access originally published online on August 31, 2009
JNCI Journal of the National Cancer Institute 2009 101(18):1236-1243; doi:10.1093/jnci/djp241
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© The Author 2009. Published by Oxford University Press.
ARTICLES |
The Contribution of Clinical Breast Examination to the Accuracy of Breast Screening
Affiliations of authors: Population Studies and Surveillance Division (AMC, PB), Prevention and Screening Division (ViM, VeM, RS), and Informatics Division (MT), Cancer Care Ontario, Toronto, ON, Canada; Dalla Lana School of Public Health, Division of Epidemiology (AMC, VeM) and Division of Biostatistics (PB, MT), University of Toronto, Toronto, ON, Canada
Correspondence to: Anna M. Chiarelli, PhD, Population Studies and Surveillance Division, Cancer Care Ontario, 620 University Ave, Toronto, ON, Canada M5G 2L7 (e-mail: anna.chiarelli{at}cancercare.on.ca).
Background: There is controversy about whether adding clinical breast examination (CBE) to mammography improves the accuracy of breast screening. We compared the accuracy of screening among centers that offered CBE in addition to mammography with that among centers that offered only mammography.
Methods: The cohort included 290 230 women aged 50–69 years who were screened at regional cancer centers or affiliated centers within the Ontario Breast Screening Program between January 1, 2002, and December 31, 2003, and were followed up for 12 months. The regional cancer centers offer screening mammography and CBE performed by a nurse. All affiliated centers provide mammography but not all provide CBE. Performance measures for 232 515 women who were screened by mammography and CBE at the nine regional cancer centers or 59 affiliated centers that provided CBE were compared with those for 57 715 women who were screened by mammography alone at 34 affiliated centers that did not provide CBE.
Results: Sensitivity of referrals was higher for women who were screened at regional cancer centers or affiliated centers that offered CBE in addition to mammography than for women screened at affiliated centers that did not offer CBE (initial screen: 94.9% and 94.6%, respectively, vs 88.6%; subsequent screen: 94.9% and 91.7%, respectively, vs 85.3%). Mammography sensitivity was similar between centers that offered CBE and those that did not. However, women without cancer who were screened at regional cancer centers or affiliated centers that offered CBE had a higher false-positive rate than women screened at affiliated centers that offered only mammography (initial screen: 12.5% and 12.4%, respectively, vs 7.4%; subsequent screen: 6.3% and 8.3%, respectively, vs 5.4%).
Conclusions: Women should be informed of the benefits and risks of having a CBE in addition to mammography for breast screening.
| CONTEXT AND CAVEATS Prior knowledge Although clinical breast examination (CBE) can detect cancers that are missed by mammography, controversy exists about whether adding CBE to mammography improves the accuracy of breast screening. Study design A comparison of the accuracy of screening among centers within the Ontario Breast Screening Program that offered CBE performed by a nurse in addition to mammography with that among centers that offered only mammography. Contribution Cancer detection rates and sensitivity were higher, as were the abnormal call rates and false-positive rates, among centers that offered CBE in addition to mammography than among centers that offered only mammography. Implications The benefit in increased sensitivity from adding CBE to mammography needs to be weighed against the potential risks and costs of further follow-up due to false-positive results as well as the anxiety associated with additional diagnostic evaluations. Limitations Comparison of performance measures across center types in a nonrandomized study design is subject to confounding. The findings may not be generalizable to CBE use in clinical practice or for women outside of the age range of this study. From the Editors
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Manuscript received June 16, 2009; revised June 16, 2009; accepted June 29, 2009.
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J Natl Cancer Inst 2009 101: 1221.
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