Abstract P2-02-01: Comparison of 4 techniques of clinical breast examination: A cross-sectional diagnostic test evaluation
Authors: Lohani Kush Raj , Srivastava Anurag , Jeyapradha D Anjaline , Ranjan Piyush , Dhar Anita , Kataria Kamal , Upadhyay Ashish Datt , Dwivedi Sada Nand 
Published: March 2020

Abstract
Background The incidence of breast cancer is rapidly increasing. While mammographic screening is employed in the western world, clinical breast examination (CBE) is recommended as the modality of choice for breast cancer screening in the developing countries. Although CBE is found to be effective in detecting breast cancer in early stage by a randomized control trial by Sankaranarayanan et al (1), the most sensitive technique of CBE has not been established. Hence, we evaluated 4 common techniques of CBE, viz. Dial of clock (Dc) (2), Vertical stripes (Vs), Quadrant (Qn) and Concentric (Cc). Objectives To measure the various diagnostic test indices for 4 techniques of breast palpation carried out by a senior Professor (P), a Resident trainee (R) and a trained female Nurse (N). Methodology After Institutional ethical clearance and informed written consent, a cross-sectional study was conducted on ladies presenting with breast complaints to the Breast clinic of All India Institute of Medical Sciences, New Delhi; a tertiary care University teaching hospital. Ladies with prior history of breast surgery were excluded. Examiners R and N underwent initial training on 10 patients from P and were included in the study as examiners. Ladies were recruited in a set of 3 at a time and were randomly examined by 3 examiners with 4 techniques of breast palpation, with only one technique at a time. Patient and examiners were not allowed to communicate during the examination. Palpation findings and time taken for each technique was recorded separately for each examiner. Abnormality was noted as any nodularity or lump detected. The findings were compared with the breast sonogram, which was considered as the gold standard. Statistical analysis was carried out using STATA 14 and openEpi software for diagnostic test indices. Results Fifty five ladies (mean age 39.6, SD = 11.8 years) with palpation findings on both breasts, formed the study population (n=110). Majority presented with lump (69%) and pain (27.3%). On CBE, values for diagnostic indices were highest with dial of clock technique for all examiners. Table 1 presents data on diagnostic indices for Dc conducted by 3 examiners. Minimum sonographic tumor size picked up by dial of clock technique by all examiners was 7mm. Sensitivity of the techniques in the descending order was Dc (74.5%) &gt; Cc (64.7%) &gt; Qn (58.8%) &gt; Vs (49%) for Professor, Dc (64.7%) &gt; Vs (60.7%) &gt; Qn (58.8%)&gt; Cc (56.8%) for Resident and Dc (82.3%) &gt; Vs (76.4%) &gt; Cc (74.5%) &gt; Qn (72.5%) for Nurse. Mean time taken for CBE was less for Qn and more for Dc for all the examiners (32.3 to 54.4 seconds for P, 34.2 to 49.9 for R, and 52.4 to 56.9 for N). Conclusion Dial of clock technique is most sensitive with the highest likelihood ratio (positive) and diagnostic odds ratio in picking up an abnormality in the breast. Hence, we recommend the dial of clock technique of breast palpation to be utilized for clinical breast examination for symptomatic ladies. This may also be used for screening asymptomatic ladies in the population-based screening. Trained female nurse can be a valuable asset in the screening program. References: (1) Sankaranarayanan R et al. Clinical breast examination: preliminary results from a cluster randomized controlled trial in India. J Natl Cancer Inst. 2011 Oct 5;103(19):1476-80. (2) Sultania M et al. Validation of Different Techniques in Physical Examination of Breast. Indian J Surg. 2017 Jun;79(3):219-25.
Table 1ExaminerSensitivityLikelihood ratio (+)Likelihood ratio (-)Diagnostic odds ratioProfessor74.51% (61.13, 84.45)3.663 (3.057 - 4.39)0.32 (0.2723 - 0.376)11.45 (4.685 - 27.98)Resident64.71% (50.99, 76.37)3.471 (2.812 - 4.284)0.4338 (0.3854 - 0.4883)8 (3.347 - 19.12)Nurse82.35% (69.75, 90.43 )2.858 (2.522 - 3.24)0.2479 (0.1957 - 0.3141)11.53 (4.621 - 28.76)
Citation Format: Kush Raj Lohani, Anurag Srivastava, D Anjaline Jeyapradha, Piyush Ranjan, Anita Dhar, Kamal Kataria, Ashish Datt Upadhyay, Sada Nand Dwivedi. Comparison of 4 techniques of clinical breast examination: A cross-sectional diagnostic test evaluation [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P2-02-01.