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1 Present address: Kaiser Permanente Division of Research, 2000 Broadway,
Oakland, CA 94612.
2 Pharmaceutical Outcome Research and Policy Program, University of Washington
School of Pharmacy, Center for Cost & Outcomes Research, Seattle, WA
98195.
3 Department of Radiology, University of Washington Medical Center, Seattle
Cancer Care Alliance, Seattle WA 98195.
4 Center for Health Studies, Group Health Cooperative of Puget Sound, Seattle WA
98101.
5 Department of Epidemiology, University of Washington School of Public Health
and Community Medicine, Seattle, WA 98101.
6 Cancer Prevention Research Program, Fred Hutchinson Cancer Research Center,
Seattle, WA 98109-1024.
OBJECTIVE. The objective of this study was to determine the potential added contribution of clinical breast examination (CBE) to invasive breast cancer detection in a mammography screening program, by categories of age and breast density.
SUBJECTS AND METHODS. We prospectively followed 61,688 women aged 40 years or older who had undergone at least one screening examination with mammography and CBE between January 1, 1996, and December 31, 2000, for 1 year after their mammogram for invasive cancer. We computed the incremental sensitivity, specificity, and positive predictive value of CBE over mammography alone for combinations of age and breast density (predominantly fatty or dense).
RESULTS. Mammography sensitivity was 78% and combined mammography–CBE sensitivity was 82%, thus CBE detected an additional 4% of invasive cancers. CBE detected a minority of invasive cancers compared with mammography for all age groups and all breast densities. Sensitivity increased from adding CBE to screening mammography for all ages, from 6.8% in women ages 50–59 with dense breasts to 1.8% in women ages 60–69 years with fatty breasts. CBE generally added incrementally more to sensitivity among women with dense breasts. Specificity and positive predictive value declined when CBE was used in conjunction with mammography, and this decrement was more pronounced in women with dense breasts.
CONCLUSION. CBE had modest incremental benefit to invasive cancer detection over mammography alone in a screening program, but also led to greater risk of false-positive results. These risks and benefits were greater in women with dense breasts. The balance of risks and benefits must be weighed carefully when evaluating the inclusion of CBE in a screening examination.
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