Women May Need to Request Their Own Clinical Breast Examination (CBE)

Women may need to request a clinical breast examination (also called a CBE) if their physician or nurse practitioner does not do one.

In 1987, a survey in five parts of the United States found that 95 percent of women who had a mammogram also had a CBE. A repeat survey in the same five regions in 1992 found that only 87 percent of women had a CBE with their mammogram.

Surveys in other parts of the United States in the mid-1990’s found that only about 76 percent of women had a CBE with their mammogram; and a study just after 2000 found that in some regions only half of clinicians do a clinical breast exam in addition to ordering a mammogram!

Women who do not have a CBE are at risk to have a cancer missed if they have a negative mammogram.

Part of the reason that doctors do not do breast exams may be that they do not feel that they have the time — even 2 minutes. Other doctors claim that data do not support doing a CBE.

The argument based on data is somewhat complex, but it can be reduced to a simple value judgment of whether it is important for CBE to find breast cancers that other tests do not find.

CBE repeatedly finds breast cancers that are missed by mammograms, ultrasound, and/ or MRI (magnetic resonance imaging). Therefore, a decision not to do CBE is really a decision to ignore the fact that a breast cancer might be found by CBE — even after it has been missed by a mammogram, an ultrasound, or an MRI.

The United States Preventive Services Task Force is a group that rates various screening tests and advises physicians on whether each test should be used routinely. The USPSTF bases their recommendations on whether a test can be proven to save lives in specific types of studies called randomized trials.

There are different levels of statistics that doctors use to determine whether to do any test or give any medicine. The best way to determine which is the better test is a randomized trial. In a randomized trial similar women are, with their consent, randomized to receive or not receive a test of a drug. In randomized trials, only mammograms can be proven to save lives. If a test is moderately expensive like a mammogram it might be reasonable to choose only the one test that is most sensitive.

However, whether to have a CBE is not about choosing the better of two tests. It is about having a complete evaluation. CBE is inexpensive; and even though it is not the most sensitive test, it repeatedly finds breast cancers that are missed by other tests.

If a woman could only do one test, she would probably choose a mammogram, and skip the CBE. However, before women accept that they will not be offered a CBE, they should be informed that mammograms miss about one out of six breast cancers and it takes only 2 minutes to do a basic clinical breast exam.