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Vertical Strip Breast Exam Improves Detection


 

QUEBEC CITY — Residents trained using the vertical strip clinical breast exam are significantly more likely to detect and be able to describe small breast masses, Elizabeth Steiner, M.D., reported at the annual meeting of the North American Primary Care Research Group.

The vertical strip three-pressure method examines the breast in overlapping vertical strips using the pads of the first three fingers with light, then medium, then deep pressure. It covers a wide area of the chest from the clavicle down to the inframammary ridge and out to the lymph nodes.

Unlike the standard concentric circle or wedge methods, it includes the entire nipple-areolar complex where 15%–20% of breast cancers originate, said Dr. Steiner of Oregon Health and Science University, Portland.

The method has been endorsed as the best breast exam method by the Centers for Disease Control and Prevention and the American Cancer Society (CA Cancer J. Clin. 2004;54:327–44). But it has a drawback: It takes 3–5 minutes per breast to perform.

“One of the things we get from diagnosticians is that this takes too long,” Dr. Steiner said in an interview. “But the one factor that has been shown to make a difference in every study about breast exam sensitivity is the time you take. In our study, for every 15 seconds you took, it made you 29% more likely to find a 3-mm mass.”

In the study, 72 first-year residents were trained using a 1− to 2-hour online self-study with a video and a 2.5-hour practicum with trained faculty using silicone breast models and a patient surrogate. A total of 93 second-year residents received no training in the vertical strip method beyond what they'd received in medical school.

Standardized, structured clinical exams were performed 3–6 months after training using a silicone model, and were evaluated by trained (but not blinded) observers. Residents who were unavailable because of their clinical responsibilities were excluded from analysis.

A 3-mm mass was detected by 42 of 50 (84%) trained residents and 30 of 65 (46%) untrained residents. The difference was statistically significant.

Of those finding a mass, 62% of trained and 10% of untrained residents were able to document their findings using at least five of eight standardized descriptors.

About 85% of trained residents were able to find a mass within 6 minutes, compared with about 45% of untrained residents.

When the concentric circle or wedge methods with only one or two levels of pressure were used, 70% of trained vs. 40% of untrained residents were able to find the mass.

“We believe that this confirms the consensus report recommending the vertical strip, three-pressure method as the most sensitive technique, but also that thorough training improves sensitivity regardless of technique used,” Dr. Steiner said.

Based on the study's findings, Oregon recently became the first state to approve reimbursement for the vertical strip breast exam separate from a comprehensive women's health exam.

This could lead the way toward greater national acceptance of the method, and also encourage more physicians to teach their patients to use this method at home, said Dr. Steiner.

“A lot of women don't feel very skilled [at the breast self-exam],” she said. “We can do a better job of teaching women to do this exam.”

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