Regular Breast Exams-why dont OBgyns follow the USPSTF guidelines?

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Analyzethis

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I had a question-I am a 4th year student currently making up a 3rd year obgyn rotation and I did FP not too long ago and of course their whole message is prevention prevention prevention and I got very familiar with the U.S preventative health task force ( or something like that) but its the basically say all on preventative health and sets the guidelines for screening tests.

Well regarding breast cancer, I was taught and also it is backed up in the USPSTF-here is the exceprt from their breast cancer screening recomendations regarding CBE use for screening
.....
The USPSTF concludes that the evidence is insufficient to recommend for or against routine CBE alone to screen for breast cancer.
Rating: I recommendation.

Rationale: No screening trial has examined the benefits of CBE alone (without accompanying mammography) compared to no screening, and design characteristics limit the generalizability of studies that have examined CBE. The USPSTF could not determine the benefits of CBE alone or the incremental benefit of adding CBE to mammography. The USPSTF therefore could not determine whether potential benefits of routine CBE outweigh the potential harms.


Now I am not arguing one way or another, only curious why every single obgyn I work with does not regard this site has something to listen to (yet follows it for every other cancer screening guidelines!) but FP follow it a lot. Many FPs I know never did breast exams anymore unless the patient asked for it-providing they were getting year mamograms.

I dont think nobody is doubting that by doing clinical breast exams yearly-I am sure you do pick up more masses than had you not-but does picking up the mass equate to any increase in survival of the patient that would not have already been their had you not "caught it" by manual exam?

It is kind of similar to lung cancer-it is obvious that spiral CT used as screenin for lung cancer could undoubtly pick up masses that are smaller than ever picked up by the time they are symptomatic or via CXR yet this is not in place-because a VERY large study showed NO improvment in survival for the patients who had their mass picked up early-the fact is they ended up dying int he same time had they died anyway since the cancer was not curable.

Same thing for breaast-maybe you would pick up a mass a bit earlier but by the time you pick it up by hand-at that size it probably is too late to really affect outcome-

Now sorry this is long but I think its really interesting the views I have heard-I am more the type to like to follow the studies and recomendations based on data-not on old school views.

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I did a presentation on the topic of self breast exams and on the evidence to support whether or not they should be recommended. The basic message was that although guidelines such as USPSTF can't say one way or the other if it is helpful - it's still a risk/benefit thing. What is the risk in doing a clinical breast exam? The studies referenced by the USPSTF were mainly the Shanghii and the the Russian studies that had some fairly significant methodological flaws in them. These were for self breast exams. The big risk or harm they discussed was invasive surgery for something that probably wasn't breast cancer and the fears associated with it for the woman. The big difference in the US is that a patient would likely have a breast ultrasound and diagnostic mammogram prior to having a lumpectomy/needle biopsy which was the norm for the study populations in those countries. There is also a Thompson study that is a case control subsection of the large Canadian preventive services RCT that showed women who did monthly breast exams in a correct manner (measured by certain techniques used) had a better survival rate than those who didn't. Now, it's case controlled, but it is nested in a huge RCT.

The USPSTF, ACS, ACOG, AFP all say that women should be taught to be "aware of their breasts and report any changes in them", but don't say how to tell women to be breast aware, other than the tried and true self breast exam spiel we give. So what is the benefit - early awareness, possible early treatment in the setting of something a woman might not notice for some time? So why include it with the annual pelvic exam? My personal belief is it's kind of like requiring kids to be immunized at arbitrary times - so that they may be "caught" while they have to be there for another reason - like school.

As for the FP's not doing breast exams - I just did FP rotation in May/June, and they all asked "so does your Ob/gyn do your female exam, including your breast exam?" This also went for the medicine rotation in the winter.

Here is a link to the ACOG recommendations, in honor of October being National Breast Awareness month: http://www.acog.org/from_home/publications/press_releases/nr10-02-06.cfm
 
I had a question-I am a 4th year student currently making up a 3rd year obgyn rotation and I did FP not too long ago and of course their whole message is prevention prevention prevention and I got very familiar with the U.S preventative health task force ( or something like that) but its the basically say all on preventative health and sets the guidelines for screening tests.

Well regarding breast cancer, I was taught and also it is backed up in the USPSTF-here is the exceprt from their breast cancer screening recomendations regarding CBE use for screening
.....
The USPSTF concludes that the evidence is insufficient to recommend for or against routine CBE alone to screen for breast cancer.
Rating: I recommendation.

Rationale: No screening trial has examined the benefits of CBE alone (without accompanying mammography) compared to no screening, and design characteristics limit the generalizability of studies that have examined CBE. The USPSTF could not determine the benefits of CBE alone or the incremental benefit of adding CBE to mammography. The USPSTF therefore could not determine whether potential benefits of routine CBE outweigh the potential harms.


Now I am not arguing one way or another, only curious why every single obgyn I work with does not regard this site has something to listen to (yet follows it for every other cancer screening guidelines!) but FP follow it a lot. Many FPs I know never did breast exams anymore unless the patient asked for it-providing they were getting year mamograms.

I dont think nobody is doubting that by doing clinical breast exams yearly-I am sure you do pick up more masses than had you not-but does picking up the mass equate to any increase in survival of the patient that would not have already been their had you not "caught it" by manual exam?

It is kind of similar to lung cancer-it is obvious that spiral CT used as screenin for lung cancer could undoubtly pick up masses that are smaller than ever picked up by the time they are symptomatic or via CXR yet this is not in place-because a VERY large study showed NO improvment in survival for the patients who had their mass picked up early-the fact is they ended up dying int he same time had they died anyway since the cancer was not curable.

Same thing for breaast-maybe you would pick up a mass a bit earlier but by the time you pick it up by hand-at that size it probably is too late to really affect outcome-

Now sorry this is long but I think its really interesting the views I have heard-I am more the type to like to follow the studies and recomendations based on data-not on old school views.

I'm just a second year, but they told us in our breast exam lecture that 1) They could never DO a study comparing CBE alone, because given the effectiveness of mammography, it would be unethical. 2) that we should eventually after years of practice be able to pick up lumps that are small enough to actually increase survival, and 3) the mammogram can't see just posterior to the nipple. So they said that we should go ahead and do it since we'll never be able to determine one way or the other if they increase survival, and as the previous poster said, the possible benefit outweighs the risk to the patient of performing the exam.
 
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Thanks guys-I agree with both of your points and I also obviously see no harm in doing it-however I always looked a little less favorably on the "shotgun" approach to medicine. I mean running PSA's on people has no "downside", doing spril CT's for screening Lung CA has no downside (if pt is willing to front the money-which a large number are in the right population) however while many of the so called "downsides" to picking breast lumps by manual exams include more than the small risk of the procedure but from my understanding from lectures and people in person-the risk comes from the emotional trauma inflicted and "scare" each time you pick up alump by exam which frankly happens a TON over the life span of a woman.

With lung it is different-a needle biopsy of a lung mass picked up on CT has tons of risks and the odds of it being cancer are low, just like breast-yet if it is caught well than great!-esp. lung since 99 percent of time its caught with symptoms and are too late.

Anyway-I do understand your points but also have to politely disagree to the shotgun metho of medicine-I prefer to follow hard data but if it was my patient with lawsuits these days-i WOULD definetly do it-I was just talking theoretically I wish I didnt but I totally understand ya guys if ou do! thanks guys for the input!
 
I'm not sure I fully agree. The downside to screening with a CT chest for lung cancer is a fairly significant radiation dose. And the downside to checking a PSA is what do you do with the results? PSA's are horrible for not being easy to interpret. You can have prostate cancer with a good PSA, and not have prostate cancer with a horrible PSA.

The step after finding a lump is to sit down and talk with the patient about what the possibilities are, with numbers related to her age and family history. Then, you schedule a diagnostic mammogram and ultrasound. Many times, if the ultrasound is really benign looking, they will give the woman the option of having it biopsied or not. Whatever she decides, she should know it's there to be able to monitor it for changes. If you handle it properly, she shouldn't be terrified leaving your office, should see you back shortly after the sono/mammo, and feel like you are really taking care of her.

Another thing to consider is a good portion of the women we see and do CBE on are women under 40, who are at more risk of having an aggressive breast cancer if it is a breast cancer found. These are the women who are not getting yearly mammograms. They aren't more likely to have breast cancer, in contrast, it's much more likely to be benign, and you tell them so. But it just doesn't seem right to not talk about it and check, regardless of if there's a study saying to do or not to do. I think evidenced based medicine is great, but I also think that there is a common sense component.
 
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