Clinical Breast Exams: Practical Recommendations for
Maximizing Performance and Reporting

Comments from the American College of Preventive Medicine:

Thank you for the opportunity to comment on the above document, which we find to be clearly written, well organized, explicit, and useful with regard to its intended goals. We do, however, have some concerns that we believe could be addressed by the following recommended general revisions:

1. While the document does acknowledge a lack of research regarding the effectiveness of CBE, there is a consistent impression that CBE is indeed effective and that the research to corroborate is just insufficient to date. To conform to an evidence-based approach, the paper should state explicitly that the research needed to evaluate CBE could serve to demonstrate its utility or its lack of utility. Either way, standardization of methods is required so that the research may proceed; heterogeneity in performance decreases our ability to identify the true utility of CBE.
2. Throughout the document, biased statements (e.g., "…encouraging belief in the utility of CBE as an independent, complementary component of good breast health care;…" under training of trainers) should be neutralized, or placed in an unbiased context (e.g., trainers should encourage consistent performance of standardized CBE as the necessary means both to delivering a clinical service of acceptable quality, and assuring a base of data amenable to meaningful interpretation as the research effort to elucidate the value of CBE advances…").
3. We are concerned about statements throughout the document that "CBE and mammography are complementary examinations. Neither should be substituted for the other," when systematic reviews of the literature (such as those done for the U.S. Preventive Services Task Force) have failed to show an independent benefit of CBE. Thus, the USPSTF recommends routine mammography with or without CBE at this time. While is it logical and clinically prudent to perform a CBE at the time of mammography, compelling evidence that this increases screening effectiveness is so far lacking.
4. In our view, the standardization and training recommended should be seen in the service of facilitating research to establish the effectiveness of CBE. Therefore, we recommend that research be placed above training, standardization, and public education as a priority in the recommendations, e.g., in the Executive Summary on pages 1-2.
5. Athough we understand that Advisory Committee discussions and a literature review gave fuller attention to barriers, the elaboration in this independent document fails to acknowledge that the standardization of CBE methods advocated involves a considerable time commitment on the part of the practitioner and there is no discussion of prevailing reimbursement policies. A reimbursement scheme for CBE should be devised (or at least advocated) so that until or unless it is no longer recommended, CBE can be billed for commensurate with the time, effort, and expertise on which it is based. Funds also should be dedicated to an RCT to generate the data needed to guide recommendations. Until or unless evidence supports the effectiveness of CBE, use of the examination will remain a matter of the individual clinician’s discretion.
6. Finally, we recommend shortening the final document when it is circulated to clinicians.

In addition to the above general comments, minor correction of typos are incorporated in the attached version of the original document.