Report from RSNA: Clinical breast exams paired with screening pick up additional cancers

Adding a clinical breast exam to routine mammography screenings can pick up additional cancers, but at a cost. At Memorial Sloan-Kettering Cancer Center, adding CBE to screening helped identify an additional eight cancers at a cost of $106,280 each, said Dr. Kimberly Feigin, a radiologist at the New York medical center.

"Annual clinical breast exams are recommended by several national organizations, including the American College of Radiology," Feigin said. "And the state of New York now requires that clinics have documentation on hand to prove they are providing CBEs annually to patients. But there is little data on the effectiveness of CBEs."

In a retrospective study, Feigin reviewed the cases of 33,084 women who presented for screening mammography between January 1997 and Dec. 31, 1998. All patients underwent clinical breast exam (CBE) by a nurse practitioner.

Patients with positive CBEs - typically, a palpable mass - were converted from screening to diagnostic workups. The team tracked the number of cancers arising from this population and reviewed reports and mammograms to determine how many would have been likely to undergo diagnostic imaging on the basis of mammography alone.

Of the 33,084 patients, 286 positive findings were reported with CBE. Of these, 25 cancers were identified in 23 patients. Seventeen of those cancers would have been diagnosed by screening mammography alone, but eight were mammographically occult, Feigin said.

Costs were derived by factoring in expense of diagnostic workup ($34,746) plus employment costs for five nurse practitioners over a two-year period ($815,490). These costs were divided by the eight cancers found, for a resulting cost per cancer of $106,280.

The cancers found by CBE alone account for approximately 3% of all cancers detected at MSKCC during the study's time frame, Feigin said.

Moreover, an evaluation of costs for providing clinical breast exams must take into account the intangibles such as the opportunity for patient education, the value of direct contact with a medical caregiver during the screening exam, and possible downstream cost savings for earlier detection, she said.

"It's also important to consider that excluding CBEs necessarily lowers breast screening sensitivity," Feigin said. "There are also legal repercussions of missed cancers."

According to the Physicians Insurers Association of America, the average settlement for a missed breast cancer malpractice claim in 2002 was $329,000. For cases in which a radiologist was named, the average payout was $346,000.