Effectiveness of clinical breast examination as a ‘stand-alone’ screening modality: an overview of systematic reviews

Abstract

Background There is uncertainty about the effectiveness of clinical breast examination (CBE) and conflicting recommendations regarding its usefulness as a screening tool for breast cancer. This paper provides an overview of systematic reviews that assessed the effectiveness of CBE as a ‘stand-alone’ screening modality for breast cancer compared to no screening and focused on its value in low- and middle-income countries (LMICs). Methods We searched MEDLINE, EMBASE, Scopus, Web of Science, and the Cochrane Database of Systematic Reviews for systematic reviews reporting the effectiveness of CBE published prior to October 29, 2019. The main outcomes assessed were mortality and down staging. The AMSTAR 2 checklist was used to assess the methodological quality of the reviews including risk of bias. Results Eleven systematic reviews published between 1993 and 2019 were identified. There was no direct evidence that CBE reduced breast cancer mortality. Indirect evidence suggested that a well-performed CBE achieved the same effect as mammography regarding mortality despite its apparently lower sensitivity (40–69% for CBE vs 77–95% for mammography). Greater sensitivity was recorded among younger and Asian women. Moreover, CBE contributed between 17 and 47% of the shift from advanced to early stage cancer. Conclusions CBE merits attention from health system and service planners in LMICs where a national screening programme based on mammography would be prohibitively expensive. In particular, it is likely that considerable value would be gained from conducting implementation scientific research in countries with large numbers of Asian women and/or where younger women are at higher risk. Registration PROSPERO, registration number CRD42019126798.

Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries

“…According to a report summarizing 83 studies across 17 sub‐Saharan African countries, 77% of all staged cases were stage III/IV at diagnosis 49 . Because organized, population‐based mammography screening programs may not be cost effective or feasible in low‐resource settings, 50 efforts to promote early detection through improved breast cancer awareness and clinical breast examination by skilled health providers, 51,52 followed by timely and appropriate treatment, are essential components to improving survival 53 . A recent study conducted in 5 sub‐Saharan African countries estimated that 28% to 37% of breast cancer deaths in these countries could be prevented through earlier diagnosis of symptomatic disease and adequate treatment, with a fairly equal contribution of each 54 .…”

Frecuencia de la mamografía, ecografía, examen clínico y autoexamen de mama en población general

“…La detección temprana sigue siendo la clave para el control de la morbimortalidad por cáncer de mama, y los métodos utilizados incluyen la mamografía, la ecografía, el ECM y el autoexamen. La mamografía tiene una sensibilidad entre 77% y 95%, y una especificidad entre 93% y 97%, y está asociada a una reducción del 20% de la mortalidad por cáncer de mama [8][9][10]. Es la prueba de tamización más ampliamente utilizada; no obstante, las diferentes asociaciones a nivel mundial sugieren pautas para su uso que difieren entre sí, como ocurre con la edad de inicio y de suspensión, y la frecuencia con que debe hacerse.…”

“…El ECM no ha sido evaluado de manera eficaz en estudios clínicos aleatorizados, pero mostró en un reporte de revisiones sistemáticas que tiene una sensibilidad del 54% (40% a 69%) y una especificidad >93% en la detección de cáncer de mama [8,15,16], sin demostrar reducción en la mortalidad [17,18]; ahora bien, en los países de bajos recursos juega un papel muy importante y puede ser la única alternativa como método de tamización. El mayor inconveniente del ECM son los falsos positivos, solo o en combinación con la mamografía, con tasas del 2,2% al 5% y del 3% al 8,7%, respectivamente [11].…”

“…De los métodos de tamización que se han discutido, el único que ha demostrado disminución de la mortalidad por cáncer de mama es la mamografía, en el grupo de edad de 50 a 69 años, con cifras que oscilan entre 19% y 25% [8,26]. La tasa de falsos positivos si se usa la mamografía como método de tamización anual iniciando a los 40 años de edad, se ha estimado en 61,3%, y si es bienal en 41,6%.…”

Cost-effectiveness of screening mammography in a low income country: a Markov simulation analysis

“…The first reason for the omission was its notoriously low sensitivity at 54% [ 31 ]. Second, to date there is no evidence of its effect on reducing breast cancer-related mortality [ 32 ]. To this effect clinical breast examination is not recommended as a routine screening protocol by the American Cancer Society [ 30 ].…”