Health: Hands off my chest, doctor

Junior doctors used to boast about how many "Tubes" they had done. The initials stood for Totally Unnecessary Breast Examinations. The irony is that when these doctors first coined the acronym, 20 years ago or so, they did not realise that most breast examinations by non-specialists were unnecessary, if not downright misleading.

The former Chief Medical Officer (CMO), Dr Kenneth Calman, told doctors in February that they should not carry out clinical examination of the breast as part of routine health screening, because it was liable to give "false reassurance".

Women should be aware of their breasts in such everyday activities as bathing and showering, and women over 50 should be offered a mammogram (X-ray) every three years. But women without symptoms should not be examined. "There is no evidence to support the efficacy of breast examination by health professionals of the well woman," he said.

You could be forgiven for thinking that this advice was never issued, as many doctors continue to examine women's breasts in the same way as they have done for the last 30 years. They often check patients' breasts when taking a smear or prescribing the contraceptive pill, or putting women on hormone replacement therapy. Many NHS Well Woman clinics also include a breast examination in their check-ups.

Dr David Rubra, a GP from Hornsey, north London, said: "I was taught that breast examination was an integral part of a gynaecological assessment, and always to perform it when taking a cervical smear. Although I do not often find abnormalities, many women are reassured to hear normal findings. I qualified more than 30 years ago, so my ideas may be a bit out of date, but I still think these tenets hold."

He is not alone. Doctors at many private clinics, which offer health screening to well women for several hundred pounds an assessment, also continue to check the breasts of women patients, despite the lack of evidence that it does any good and the message from the Department of Health that it could do harm.

The Medical Defence Union, the body that insures doctors against malpractice litigation, has weighed in on the side of the former CMO, saying: "Palpation of the breast by either medical or nursing staff should not be included as part of routine health screening."

But some experienced GPs disagree. Dr Rubra said: "I am appalled at the advice given by the MDU. Are we not to examine chests for fear of missing lung cancer, or not do rectal examinations for fear of missing a carcinoma of the prostate? To reduce it to absurdity, no doctor should ever examine any patient."

So what is behind the Department of Health's advice, and does it matter that it is not being followed? Dr Muir Gray, director of the Department of Health's National Screening Committee's programme, says: "Yes, it does matter. Examination of the breast by a GP gives false reassurance, or raises unnecessary anxiety. There is no evidence that it reduces mortality.

"We do not think that the hand of another person (as opposed to the hand of the woman herself) is sensitive enough to detect the emergence of a new, discreet lump. If doctors have not yet adopted this advice, it is because it takes time for the message to get through."

His words are echoed by Michael Baum, professor of surgery at University College London Hospital. "I totally support the CMO's point of view," he says. "For a GP to examine a woman's breasts is a completely futile activity. I do not know who is kidding whom.

"There is not a shred of evidence that checking breasts prevents breast cancer deaths. It generates lots of anxiety. Most GPs and practice nurses cannot distinguish a lump from physiological lumpiness in young women, because it is very difficult. Doctors therefore refer many young women with lumpy breasts to our clinic. As it is unlikely that women in their twenties will have breast cancer, they are given low priority, and usually have to wait several weeks to be seen. During that time, they suffer a huge amount of anxiety.

"If a woman goes to her GP with a lump, the GP is perfectly entitled to send her to us, particularly in these days of litigation. But that is quite different from choosing to examine the breasts of a young woman who has not found a lump herself, but who is going on to the pill, or having a cervical smear.

"There should not be a bland assumption that such examinations can do no harm. They can do a great deal of harm.

"I sometimes wonder whether the doctors who carry out these examinations explain fully to the patient what it may lead to, in terms of investigations and so on. If they do not do so, they are not getting the patient's fully informed consent for the examination, and could therefore be accused of assault."

Dr Angela Raffle, a consultant in public health medicine at Avon Health Authority, also backs Dr Calman. She says: "If you are a doctor who wants to examine opportunistically women who come into the surgery, because it makes you and the patient feel better, do not imagine that it has any validity.

"If a doctor examines a young woman's breasts with the main purpose of giving reassurance (on the assumption that most women under 40 do not get breast cancer), why not include male patients as well? You would be able to reassure even more people, as breast cancer in men is so rare. It would, of course, be a nonsensical thing to do.

"If a doctor carried out a breast examination on me, just because I was having a cervical smear, I would definitely question it. I might even change my doctor.

"The practice of doing a breast examination at the time of a cervical smear is one of those time-honoured medical rituals that is not supported by evidence."