To the Editor:
Few would deny that the physical examination of patients is devalued today. There are several reasons for this. Crowded waiting rooms exert an abortive pressure on this time-honored art. Also, validated, simplified but “equally effective” instruments used in drug trials concentrate the rheumatologist’s attention on the joint homunculus at the neglect of almost everything else. Lastly, widespread access to ultrasonography and magnetic resonance imaging has shifted the emphasis from physical findings as a diagnostic method.
Rheumatic diseases and cancer (the second most common cause of women’s death) overlap in age of onset. Also, some rheumatic diseases occur by tumor invasion or have a paraneoplastic origin. Finally, in women, breast cancer is the leading cause of cancer death. With these as a background, cases in which to offer breast palpation on initial evaluation include (1) women over the age of 40 years who did not have the breast examined within the past year; (2) men and women, regardless of age, with a possible invasive or paraneoplastic syndrome; and (3) patients who requested the examination.
Between June 1, 1995, and June 25, 2010, the author, who is a rheumatologist in private practice, saw 6860 new patients. Of these, 4615 were female and within this group, 1223 fulfilled the criteria and were offered a breast examination. Only 1 patient refused because she felt it was inappropriate. In 7 of these patients (0.6%) a nodule was found that led to the diagnosis of breast cancer (Table 1). One patient (Patient 4) had a (false) negative mammogram subsequent to the finding of the tumor and this led her gynecologist to dismiss an obvious physical finding. After appropriate referral and treatment, 5 of these patients are well, with a median followup of 6 years.
We rheumatologists take pride in being internists who specialize in an array of conditions that, as a common denominator, involve or could involve the musculoskeletal system. The cases presented here suggest that a thorough physical examination, beyond the inner pride of a job well done, may make a life or death difference in a patient with previously undetected malignant disease.