Targeted Clinical Breast Examinations In Older Women On Acute Medicine Of The Elderly Wards.

摘要

Breast cancer is a significant health problem with considerable morbidity and mortality. It has a high incidence in older women. Most mammography screening programmes apply upper age limits for routine screening protocols. The value and role of clinical breast examination as an additional cancer detection strategy to screening mammography and breast self-examination has been the subject of considerable debate. We prospectively audited the practice of clinical breast examination (CBEs) in acute medicine on the elderly wards of a teaching hospital, to ascertain if five pragmatically pre-defined criteria would increase the yield of obtaining positive results for the detection of clinically significant breast lesions in targeted older women-. The findings of this audit indicate a positive trend towards CBEs done in selected patients who meet certain inclusion criteria, translating into an increased yield of abnormal breast related findings. However, our initial findings note that this possible higher detection rate for abnormal lesions identifies both benign and malignant abnormal breast findings. Further studies are required to determine if, and which particular older patients would benefit most from such targeted examinations. Introduction Breast cancer represents a significant health problem and accounts for a major proportion of cancers in women.1,2 The incidence of breast cancer is particularly high in postmenopausal women.1,2 Some studies have noted that the practices of breast self-examination (BSE) and clinical breast examination (CBE) have not resulted in a clear reduction in morbidity or mortality from breast cancer.3,4 BSE and CBE can however translate into the identification of increased numbers of benign breast lesions, an increased number of biopsies being performed, and more psychological distress, physical discomfort or pain.3,4 The significance of BSE and CBE in the detection of the earlier stages of breast cancer also remains unproven and even disputed.4 Mammography has developed over time as a screening option that can potentially facilitate the early detection of breast cancer and thereby save lives.5 However, mammography also requires informed decision making, as the screening outcomes can generate some false negative and also false positive results. The latter in particular can contribute to overdiagnosis, psychological distress, and possibly lead to further unnecessary investigations and/or treatments.5 Despite the aforementioned limitations, both BSE and CBE remain components in many breast cancer detection strategies that are still widely practised. In addition to BSE, and any CBE performed in primary care settings, it might be appropriate for selected / targeted patients presenting to secondary or tertiary care facilities to undergo opportunistic CBE. Aims Two prospective audits were conducted to assess the role of five pragmatically pre-defined criteria, used as supportive indications for CBEs, in older (≥ 65 years) female inpatients in an acute medicine of the elderly service based in a tertiary hospital. Methods Setting: A teaching hospital in Scotland, United Kingdom with 104 dedicated acute beds caring for older patients, most of whom are nominally aged ≥ 65 years, although the ‘needs based’ admission system is also accessible to some adults under 65 years. The acute medicine of the elderly service is subdivided into 82 acute medical beds and 22 acute stroke beds. Methodology: Two prospective audits were performed in the periods June 2009 (Audit 1), and a re-audit between June/July 2011 (Audit 2). Five pre-defined audit criteria were used to identify cases for inclusion in the audits. The criteria were set pragmatically, and in an attempt to try and improve the positive pick-up rates of CBEs for detecting more clinically significant breast related pathologies. The criteria adopted were: The audits employed anonymised data collection tools. Medical records of all older female patients aged ≥ 65 years