Abstract
BackgroundThere is uncertainty about the effectiveness of clinical breast examination (CBE) and conflicting recommendations regarding its usefulness as a screening tool for breast cancer. This paper provides an overview of systematic reviews that assessed the effectiveness of CBE as a ‘stand-alone’ screening modality for breast cancer compared to no screening and focused on its value in low- and middle-income countries (LMICs).MethodsWe searched MEDLINE, EMBASE, Scopus, Web of Science, and the Cochrane Database of Systematic Reviews for systematic reviews reporting the effectiveness of CBE published prior to October 29, 2019. The main outcomes assessed were mortality and down staging. The AMSTAR 2 checklist was used to assess the methodological quality of the reviews including risk of bias.ResultsEleven systematic reviews published between 1993 and 2019 were identified. There was no direct evidence that CBE reduced breast cancer mortality. Indirect evidence suggested that a well-performed CBE achieved the same effect as mammography regarding mortality despite its apparently lower sensitivity (40–69% for CBE vs 77–95% for mammography). Greater sensitivity was recorded among younger and Asian women. Moreover, CBE contributed between 17 and 47% of the shift from advanced to early stage cancer.ConclusionsCBE merits attention from health system and service planners in LMICs where a national screening programme based on mammography would be prohibitively expensive. In particular, it is likely that considerable value would be gained from conducting implementation scientific research in countries with large numbers of Asian women and/or where younger women are at higher risk.RegistrationPROSPERO, registration number CRD42019126798.
Highlights
There is uncertainty about the effectiveness of clinical breast examination (CBE) and conflicting recommendations regarding its usefulness as a screening tool for breast cancer
Search strategy and selection criteria Selection criteria for studies were based on the PICOS framework (PICOS – Population, intervention, comparator, outcome, study type) as follows: (1) Population: women aged 18+ years without a high-risk of breast cancer; (2) Intervention: CBE; (3) Comparator: no screening or other screening modalities; (4) Outcomes included were in relation to benefits, harms and accuracy; (5) Study type: systematic review with or without metaanalysis (Details of inclusion and exclusion criteria are presented in Appendix 1, Supplement materials)
There is no ‘direct’ evidence that CBE is effective in terms of reducing breast cancer mortality
Summary
There is uncertainty about the effectiveness of clinical breast examination (CBE) and conflicting recommendations regarding its usefulness as a screening tool for breast cancer. This paper provides an overview of systematic reviews that assessed the effectiveness of CBE as a ‘stand-alone’ screening modality for breast cancer compared to no screening and focused on its value in low- and middle-income countries (LMICs). The effectiveness of the three most common screening modalities Mammography (MMR), Clinical breast examination (CBE), and Breast self-examination (BSE) has been assessed over a long time. The Canadian Task Force on Preventive Health Care (CTFPHC) in 2011 and 2018, the American Cancer Society (ACS) in 2015, and the Japan National Cancer Center (JNCC) in 2016 recommended not using CBE for population-based screening [5,6,7,8]. The discord between guidelines/recommendations may arise from differences regarding the methods and quality of systematic reviews that were used to inform them, contextual variation in relation to the assessment of evidence and the adequacy of the evidence
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