Physical examination. Its role as a single screening modality in the Canadian National Breast Screening Study.

Although often recommended as an important component in screening for breast cancer, physical examination of the breasts (PE) by medical professionals has not been well evaluated. The Canadian National Breast Screening Study (NBSS) permits estimation of sensitivity, specificity, and positive predictive value (PPV) of PE alone as performed by screen-examiners because 50% of the 89,835 NBSS participants did not receive mammography. There were 19,965 women aged from 50 to 59 years who were eligible to receive four or five annual PEs from 77 nurse-examiners, in 12 screen centers outside Quebec province and 58 physician-examiners in three screen centers in Quebec. The gold standard was histologically proven breast cancer. When a test was positive the participant was referred to the study surgeon for review. For screens one to five, sensitivity was 83, 71, 57, 83, and 77; specificity was 88, 94, 96, 96, and 96; and PPV was 3, 3, 4, 3, and 4, respectively. For 25,620 women aged 40 to 49 years who were eligible to receive only one PE, sensitivity was 71, specificity 84, and PPV 1.5. Using a binomial regression model, X2 for heterogeneity suggested there was no difference between nurse and physician examiners (P = 0.6879). Similar estimates made for the surgeons who performed 8914 reviews showed that sensitivity and PPV were higher than for the screen examiners and specificity was lower. These results support the conclusion that physical examination of the breasts by trained nurses is a useful component in screening for breast cancer.

Needle-guided breast biopsy for mammographic abnormalities in 561 patients.

Between 1977 and 1983, 561 consecutive patients underwent 595 surgical biopsies for suspicious mammographic lesions with negative clinical correlation. The procedure consisted of preoperative needle localization, with or without immediate radiologic examination of the biopsy specimen, depending on the presence or absence of microcalcifications in the mammographic lesion. Eighty-four carcinomas were found. Of these, 60 (71%) were infiltrating carcinoma and 24 (29%) were noninvasive carcinoma. The carcinoma yield was 24.2% in the patients with lesions involving foci of microcalcifications and 9% in those lesions without calcifications. Surgical treatment of infiltrating carcinoma consisted of 39 modified radical mastectomies, 10 (25.6%) of which were associated with positive nodes, 16 partial mastectomies with axillary dissection, 3 (18.7%) of which were associated with positive nodes, and 5 wedge resections. Treatment of noninvasive carcinoma consisted of 19 partial mastectomies with axillary dissection and 5 modified radical mastectomies. None of these were associated with positive nodes. Modified radical mastectomy was used with decreasing frequency. Of the 10 patients with infiltrating carcinoma and positive axillary nodes treated by modified radical mastectomy, 7 had one to three involved nodes and 3 had four or more; of those with positive nodes treated by partial mastectomy, 1 had one to three involved nodes and 2 had four or more. These results confirm the correlation between suspicious mammographic non-clinical lesions and breast carcinoma.

Role of needle aspiration in reducing the number of unnecessary breast biopsies.

The accuracy of the results obtained from 2334 open breast biopsies performed during a 9-year period at Mount Sinai Hospital in Toronto are reviewed. With meticulous follow-up and the liberal use of needle aspiration, the senior author (A.A.B.) noted a progressive increase in his malignant to benign ratio, from 18% in 1970 to as high as 56% near the end of the study. In contrast, the overall hospital ratio of malignant to benign breast biopsies obtained over the same decade remained stationary at 25%. A low ratio implies unnecessary hospital admissions and biopsies, all adding to the patient's anxiety. The authors conclude that a currently acceptable malignant to benign ratio is 1 to 3 and that with the use of fine-needle aspiration the number of surgical biopsies can be reduced, minimizing patient anxiety and morbidity, and increasing the efficiency of hospital bed use.

Role of cytology in management of lesions of the breast.

Study of 3,724 cytologic specimens mainly obtained by fine needle aspiration biopsy of breast lesions has demonstrated several advantages in clinical management: confirmation of clinical or other impression without open biopsy; avoidance of open biopsy in inoperable instances; avoidance of operation for certain benign lesions; excision under local anaesthesia on an ambulatory basis of other benign lesions; more efficient operating room scheduling; reduction in the number of operations for benign lesions, and the institution of more effective and humane preoperative counseling. It is concluded that these benefits alone justify the use of the method, and there is no compelling need to abandon the routine use of premastectomy frozen sections. Indeed, the problems created by abandoning frozen section routinely appear to be a prime reason for the lack of wider application of the method.