Clinical Breast Examination For Breast Cancer Screening — Dr Nirmala Bhoo-Pathy, et al.

Clinical breast examination is not only cheap, but also accessible, since it can be easily performed by any trained health care worker at any location.

October is here, and we can once again see the pink ribbon being displayed in various places and events, on social media, and even in the sports scene, where it has gained huge media attention. 

So, what does the pink ribbon denote? The pink ribbon is the international symbol of breast cancer.

It is worn to raise awareness on the disease among the public and to express moral support towards those who are living with breast cancer. Since 1985, the month of October has been dedicated as the Breast Cancer Awareness Month.

Breast cancer is the most common cancer among women in Malaysia, where it is predicted that one in 19 Malaysian women will be diagnosed with breast cancer in their lifetimes.

Sadly, a majority of women in Malaysia tend to be diagnosed with breast cancer at later stages, where treating the disease tend to be more complicated and also costly.

Therefore, when it comes to breast cancer, early detection is paramount in saving lives. 

Due to the wide global attention given to mammography as a screening modality for breast cancer, it is not surprising that many Malaysians are more aware of it as an early detection method for breast cancer.

Although shown to be effective, mammography may not be an optimal screening method to detect breast cancers early in many Malaysian settings, due to logistical issues and lack of infrastructure particularly in the rural areas.

Like mammography, self-breast examination has also been widely promoted among women, young and old, to increase breast cancer awareness. Its role in aiding early detection of breast cancer, however, remains unproven.

On the other hand, clinical breast examination, or CBE, remains less well known among the public as a method of detecting breast cancers early in women who appear well (i.e. screening).

Clinical breast examination involves physical examination of the breasts for lumps and abnormalities by health care professionals. It is not only cheap, but also accessible, since it can be easily performed by any trained health care worker at any location.

A CBE is generally considered “abnormal” if the following are present: lump, nipple discharge or retraction, or changes in the overlying skin. Such findings in a women will then warrant further investigation in a hospital setting to confirm whether breast cancer is really present. 

While the effectiveness of CBE has been a matter of debate in the past, evidence has emerged that it may potentially save lives. Notably, findings from a community-based study in Mumbai, India that was conducted among more than 150,000 women has shown very promising results.

After a follow-up period of 20 years, the study investigators in February 2021 published their findings in the British Medical Journal. Here, CBE conducted by trained female health care workers led to not only earlier stages of breast cancer at diagnosis, but also reduced death from the disease by nearly 30 per cent in women aged 50 and older.

Nonetheless, no mortality reduction was seen in women younger than 50 years old. Given these findings, it was concluded that CBE should be considered as a breast cancer screening modality specifically in the low and middle income countries. 

While CBE is not something new and has been included as one of the breast cancer screening modalities in Malaysian health care over the past few decades, it is only offered on an opportunistic basis to women visiting clinical settings such as klinik kesihatan for common ailments, as well as for women who are accompanying other family members.

However, opportunistic screening may be problematic, given that the success of its implementation depends on individual women to request for CBE, or on their health care providers to recommend it.

Apart from cultural barriers, there may also be time barriers, since health care professionals, especially in the public sector, are also struggling to provide other more “urgent” clinical services for high volumes of patients, and on a busy day, it is conceivable that they may forego offering cancer screening services. 

To this end, it is felt that cancer screening services that are organised in community settings where women are systematically invited to undergo CBE in a nearby location, close to their homes, are more likely to succeed, particularly if done by female health care workers.

Since there is no denying that this inexpensive screening tool will help to increase the rate of early detection of breast cancer in the community, it is perhaps the right time to roll out organised breast cancer screenings via CBE, at least for women aged 50 years and above, in the district health settings in Malaysia.

Equally important will be the evaluation of the programme from time to time to improve the understanding on attitudes towards CBE and the barriers to uptake among Malaysians, especially older women.

All of the above ultimately requires the political will to ensure that adequate and sustainable funding mechanisms are put in place to support training, implementation, and evaluation of such a programme within the national health care system. 

Written by medical students P’ng Chun Wei, Nor Ain Aqilah Hisham, Subashini Ambalahen, Nurin Azizah Ismail, Ng Siew Yoong, Justin Ling Kwan Yeu, Muhammad Aisar Aznal, and Chung Yi Ren, guided by Kong Yek Ching, and Prof Dr Nirmala Bhoo-Pathy from the Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya.

  • This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.

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