CBE FOR THE MAMMOGRAPHER - Part 3: Overcoming Barriers to Practice

OBJECTIVES:
With the constant changing of the expectations of DI personnel our scope of practice changes year on year, full patient assessment now often comes into our scope of practice. With that in mind, the mammographers responsibilities in regards to Clinical Breast exam broaden somewhat.

I will present recommendations in three areas, the clinical breast examination itself, interpretation/ report/follow-up, and overcoming barriers to performance. Some recommendations can be implemented immediately within clinical settings, and clinicians are encouraged to lead this effort. Others will require partnerships between the clinical community and health care organizations to establish systems, increase awareness, and gather necessary information to achieve outcomes.

CLINICAL BREAST EXAMINATION 

The premise underlying CBE is that visually inspecting and palpating of the breast and surrounding tissue can detect breast abnormalities. CBE is considered to include a continuum of integrally related components, from the examination itself, to interpretation and reporting of findings, to patient follow up. The recommendations for performance in this article represent general standards that can be immediately disseminated and adopted based on current evidence.

Neither CBE nor mammography is a substitute for the other as an independent examination for detecting breast abnormalities. When a suspicious mass is found on CBE, it must be evaluated and explained even if mammography examination does not show an abnormality.

Overcoming Barriers to Performing Clinical Breast Examinations

The recommendations to address barriers to proficient CBE focus on examiner training, public education, and research and quality improvement.

Examiner Training
Lead responsibility for implementation: health care organizations.

 Develop and promote training systems to improve and maintain the proficiency of those who perform CBE, and encourage the integration of such systems into basic and continuing education programs health care professionals.

CBE training should build on existing training programs designed to improve CBE proficiency and include the components described below. In addition, training programs should be made more available, and these programs integrated into medical, paramedical, radiological and nursing school curricula, programs for residents and fellows, and continuing medical and nursing education. Expanding the availability of training will require collaborative efforts among clinicians, health organizations, and the community.

 Training Components:

1. Didactic Presentation: Training should include a didactic presentation that:

• Provides basic information on the anatomy and physiology of the breast
• Provides the rationale for performing CBE through background information on breast health and disease
• Identifies and describes elements of standard CBE—clinical history, visual inspection, palpation, interpretation and reporting, and follow-up of abnormal results to resolution

2. Visual Presentation: Training also should include a visual, real-time CBE performance—either a video or demonstration—so that trainees can see correct CBE techniques
3. Practice and Feedback:

Finally, and no doubt most important, trainees should have an opportunity to practice CBE skills and to obtain feedback from experienced examiners. This skills-building element should involve the use of high-quality silicone models and, if possible, instructors posing as patients. Live models provide a more realistic clinical experience, allow training in components of CBE beyond palpation, provide palpation experience with breast tissue, and can provide valuable feedback about provider-patient interactions. If instructors are not available to pose as patients during the initial training, training programs should develop a plan for ensuring that trainees are given skills practice on live models with feedback in the near future. Training also must include measuring and demonstrating adequate levels of sensitivity and specificity of lump detection.

  
Training Characteristics:

1. Training Should Be Flexible to Accommodate Diverse Settings and Trainee Needs

Training programs should be tailored to suit a variety of settings, including basic medical education, residency, fellowship, nursing education, and continuing medical education. Training in all three components—the examination, interpretation and reporting, and follow up—may not be possible to complete in one session or a brief series of sessions. It may be more effective in some cases to divide training into phases so that examiners can improve their skills in each component through successive sessions.

2. Participation in Training Should Be Incentive Based

Training and retraining programs need to provide incentives for health care professionals to participate, such as continuing education units, information and skills for clinicians, and certification that might reduce the clinician’s risk of successful malpractice claims.

3. Training Should Offer General Guidance on Follow-Up That Focuses on Resolution of Finding

The level of detail in instruction about appropriate follow up may vary across the trainee’s profession and the setting. The fundamental training principle is that providers must follow the patient to resolution or refer her to another health care professional, depending on the complexity of the problem. Within established standards of care, algorithms that are appropriate to the examiner’s health care system/institution can direct specific actions.

Strategies to Increase the Number of Qualified Trainers:

As the demand for CBE training grows, we must ensure that a sufficient supply of qualified trainers is available. Furthermore, because CBE is a tactile skill and didactic instruction alone is insufficient, institutions will need to help potential instructors become skilled at behavioral and skill-based teaching techniques, including providing constructive and motivating feedback.

Training of Trainers Should Have Four Core Elements

• Teaching all components of CBE
• Encouraging consistent performance of a standardized exam as necessary for providing a quality CBE
• Providing the necessary information for interpreting CBE findings
• Teaching new skills and improving existing skills

Public Education: Lead responsibility for implementation: health care organizations

• Promote and encourage public education about CBE so that women
• Know what to expect in the performance of CBE and follow-up care
• Understand the benefits, limitations, and potential harms associated with CBE
• Become familiar with their own breast characteristics as well as health practices that might increase the likelihood of identifying breast abnormalities

Many women are not aware that many health organizations recommend CBE in addition to regular mammograms, and most do not know what to expect in a CBE. Being informed and educated will help women become active partners with their provider in their own health care decisions. Professional organizations play a valuable role in influencing their members to follow current guidelines as a component of comprehensive breast cancer screening. Public education messages about CBE should be part of a wider effort to promote informed health care decision-making among women. Messages should be simple, clear, and tailored to different groups of women, if possible. CBE is an opportunity for dialogue between women and their providers and should parallel education about the importance of women understanding their own normal breast characteristics

Public education efforts should convey the following messages:

1. Why CBE can be important?

• It contributes to the detection of palpable breast cancers and other breast abnormalities
• It offers a test for detecting palpable breast cancers at an earlier stage of progression
• It adds to, but does not replace, mammography
• Its contribution to the detection of breast cancer among asymptomatic women is relatively small. Not all organizations recommend CBE

2. What should be expected in a proficient CBE?

• Components should include careful visual inspection and palpation of the breast and lymph nodes
• It must provide a trained examination and an opportunity for patient/provider interaction about breast health

3. What should happen if an abnormality is identified?

• Follow up should be conducted to an appropriate resolution
• Follow up is required for an abnormal CBE regardless of the results from the mammogram

4. What a woman can do to improve the quality of her CBE

• Provide a complete history
• Adhere to a schedule of appointments

5. When screening CBE should be performed.

• Premenopausal women.

These women should be screened as part of a periodic health examination according to screening guidelines.

If possible, screening should be a week or two after a woman’s period to avoid breast tenderness and shortly before her mammogram.

• Postmenopausal women.

These women should be screened as part of a periodic health examination according to screening guidelines.

If possible, screening should be shortly before a woman’s mammogram.

• Pregnant and breastfeeding women.

These women should be screened as part of a periodic health examination according to screening guidelines.

These women might expect increased breast tenderness and nodularity.

Research and Quality Improvement
Lead responsibility for implementation: health care organizations and research sponsoring organizations.

Support and encourage research in key aspects of CBE, particularly questions related to characteristics of abnormalities found by CBE, the timing of the exam, training of examiners (clinicians), reporting systems, and CBE’s contributions to early detection of breast cancer and the reduction of morbidity and mortality from the disease.

The evidence regarding many aspects of CBE is insufficient. Standardized performance, reporting, and follow up, combined with reporting and surveillance systems, could provide the foundation for assessing the relative contributions of CBE to the earlier detection of breast cancer. Such information may enable more accurate estimates of sensitivity and specificity of CBE in clinical practice settings. Information about the number of cancers first identified by CBE, particularly as a function of age and other population characteristics, could help clarify the role of this examination as a component of early detection and the most effective use of CBE relative to other screening modalities. Such data might also be used to assess the costs and benefits of CBE as an early detection test. This type of information is essential to resolving the confusion engendered by having disparate practice guidelines across organizations. Furthermore, such data could provide the basis for further enhancements in training providers to be proficient in CBE.

Research Needs:

1. CBE characteristics.

• Sensitivity and specificity
• In clinical practice
• Among women at different ages (premenopausal, perimenopausal, postmenopausal)

2. Method of initial detection of abnormalities.

• CBE, mammography, BSE
• By woman, partner, provider

3. Characteristics of masses identified.

• Size
• Shape
• Consistency
• Mobility
• External texture

4. Timing

• Effect of examination performance at different times of the menstrual cycle on sensitivity and specificity
• Effect of dissociating CBE from other screening modalities for breast cancer

5. CBE training

• Components of optimal training
• Optimal frequency
• Systems for integrating CBE training with other medical/health care training
• Characteristics of effective trainers
• Measurement of training effectiveness

6. CBE reporting systems

• Acceptability of using a uniform or standardized lexicon for reporting
• Feasibility of expanding medical records or registry databases to include information about detection of breast abnormalities by CBE
• Contribution to the earlier detection of breast cancer and reductions in breast cancer mortality

SUMMARY:
As laws change, medical teams form and shift, multi disciplinary education becomes normal and hybrid and fusion imaging becomes standard practice our responsibilities as clinicians expand and evolve. As professionals we are expected to rise to the challenges presented to us.
With education, practice and experience we can embrace these new proficiencies and continue to serve our patients with skill and renewed efficacy. Knowledge is power!