Physicians can increase accuracy of clinical breast examinations using attention-focusing forms

Using a simple form to help focus their attention can help physicians increase the quality and accuracy of clinical breast examinations, increasing the likelihood of detecting cancers missed by mammograms. That's the finding of a new study coming out in the April 1st issue of The American Journal of Medicine.

Between 8 and 17 percent of breast cancers are not detected by mammograms, that's why a clinical breast examination remains an important method of ensuring breast health. However, because of time pressure many primary care physicians do not do regular or thorough breast exams, meaning that some breast cancers are not detected at an early stage when they would more readily respond to treatment.

"We wanted to see if using a simple attention-focusing device, such as a dedicated form, could help improve the practice of clinical breast examination," says William Goodson, M.D., of the California Pacific Medical Center Research Institute and the lead author of the study. "We found that not only did this method improve the physician's technical performance, improving their ability to spot potential problems, but that it did so without the need for any retraining."

The researchers randomized 21 physicians at a community health center to complete one of two dedicated forms after carrying out a routine breast examination: one form was a long version requiring the physician to list general breast descriptors as well as clinical information and breast examination findings; the second form was shorter, requiring only clinical information and examination findings. The two groups were then compared with an historical sample of 300 women from the same center.

From November 2004 to June 2005 the physicians recorded 1522 breast examinations with physicians filling out 558 short forms and 964 long forms. Researchers used the call rate - the percentage of examinations that led to further evaluation (but not usually a biopsy) - as a way of measuring the quality of the exams. [About 7 to 10 percent of women have some area in one breast that is either asymmetric or different from the average. There is usually no way to determine which of these areas are cancer on physical examination criteria alone. However, if a clinician does not observe these expected abnormalities - if their call rate is low - they are not doing adequate breast examinations.] At the end of the period the researchers found that physicians using the long and short form had similar overall call rates, and that rate was double that of the control group (7.7 to 8.7 percent call rate for the physicians using the forms versus 4.4 percent for the control group.) It did not make any difference which form was used. Since both forms improved the call rate, they realized that it was the form itself that focused attention and led to improved results.

"Many people consider a clinical breast examination a low-yield procedure because it doesn't find many cancers," says Dr. Goodson. "But that does not make it an unimportant one. Previous studies have shown that physicians are the first to spot one in ten breast cancers, around one third of which did not show up on a mammogram. If a simple dedicated form can help focus a physician's attention on the exam and make it more accurate, then clearly that has enormous potential benefit for women."

"In this day when we are promised better health care by a system or an electronic record, the best health care still depends on the personal relationship between the patient and the doctor. Machines may help us, but obtaining the information for diagnosis always requires the interface of touch, and giving the best care always requires undistracted attention and time with a patient."