Clinical Corner - Normal CBE & No Screening Mammogram? What do you do!

Question: We have a client who had a normal clinical breast exam (CBE) and did not present with any symptoms or history of breast cancer. She is 54 years old and her last screening mammogram was in 2011. We provided education about a referral to another screening mammogram. She did not complete the screening mammogram. We attempted to contact her without success. Should this person be closed out as “Lost to Follow-up” in eCaST or “Follow Routine Screening?"

How to document suspicious vs. non-suspicious CBE findings in WWC

Non-suspicious (normal) includes:

• Benign exam- clinical breast exam (CBE) findings are not a concern for cancer (tenderness, cyclic pain, or fibrocystic may fall into this category)
• Normal or negative exam
• Discrete lump, previously diagnosed as benign. Non-suspicious lumps should still be included in documentation since this is helpful in evaluating change or lack of change at future visits.

Suspicious or abnormal includes:

• Discrete palpable lump (suspicious)
• Bloody, clear or serous nipple discharge
• Nipple or areolar scaliness, rash or color change
• Skin dimpling or nipple retraction
• Inflammation 
• Suspicious breast pain (non-cyclic or pain/tenderness determined by provider to need further diagnostics)

All clients with an abnormal CBE finding should be referred for further diagnostic testing. The provider should indicate whether or not, based on the CBE and patient report, they would like to see additional diagnostics in cases of breast pain or tenderness. If the provider recommends further diagnostic testing in these cases, the CBE results should be documented as “suspicious."