Can a breast exam be completed during a Medicare (Medicare) Annual Wellness Exam?

Can a Clinical Breast Exam Be Completed During a Medicare Annual Wellness Exam?

Yes, a clinical breast exam (CBE) can and should be performed during a Medicare Annual Wellness Visit (AWV) when clinically appropriate, as the AWV is designed to include preventive health services and cancer screening discussions, and CBE is a recommended component of periodic health examinations for breast cancer screening.

Clinical Breast Examination Recommendations

The American Cancer Society guidelines clearly establish that CBE should be integrated into periodic health examinations:

• For women ages 20-39: CBE should be performed at least every 3 years as part of a periodic health examination 1
• For women ages 40 and older: CBE should be performed annually, preferably as part of a periodic health examination 1

Integration with Medicare Annual Wellness Visits

The Medicare AWV is specifically structured as a prevention-focused annual check-up that has been available since 2011 2. Research demonstrates that AWVs effectively increase breast cancer screening rates, with a 22.4 percentage point increase in the probability of receiving a screening mammogram within 6 months of an AWV 2.

The AWV framework explicitly supports cancer screening activities, making it an appropriate setting for CBE performance. The cancer-related checkup during periodic health examinations should include examination for multiple cancer sites, including breast examination 1.

Clinical Context and Practical Considerations

When CBE Should Be Performed

The CBE serves multiple important functions during the AWV:

• Risk assessment: Provides opportunity to update family history of breast and ovarian cancers across three generations 1
• Patient education: Allows discussion of breast cancer detection, mammography importance, and breast self-awareness 1
• Symptom evaluation: Enables identification of breast changes that patients may not spontaneously report 1
• Screening coordination: CBE should ideally be performed prior to ordering mammography 1

Critical Pitfall to Avoid

Approximately one-third of women report not having a CBE performed prior to mammogram ordering 3. This represents a significant gap in care, as lack of CBE can lead to:

• Ordering the wrong type of mammogram (screening vs. diagnostic) 3
• Increased healthcare costs 3
• Delays in diagnosis 3

In one study, 8.7% of patients with self-reported breast symptoms had screening mammograms ordered rather than diagnostic mammograms, likely due to lack of CBE 3.

Evidence on CBE Effectiveness

While breast self-examination (BSE) alone has not shown mortality benefit in large randomized trials 4, the role of CBE in clinical practice remains important:

• Patient-detected masses are highly significant: 96% of breast cancers and 81% of positive ultrasound findings resulted from patient-identified lumps 5
• Provider expertise matters: Among provider-identified lumps, 100% of cancers and 92.3% of positive ultrasound findings were diagnosed by physicians rather than midlevel providers 5
• CBE quality varies by specialty: OB/GYN physicians performed CBE significantly more often (81.6%) compared to internal medicine (45.4%) and family medicine (50.5%) physicians 3

Practical Implementation During AWV

The CBE during an AWV should include:

1. Clinical history addressing screening practices, breast changes, and risk factors 1
2. Visual inspection with patient sitting, hands on hips, assessing symmetry and skin changes 1
3. Systematic palpation of all breast tissue and nearby lymph nodes 1
4. Documentation of findings and follow-up plans

The examination provides an essential opportunity to counsel women about breast awareness, discuss mammography scheduling, and ensure appropriate screening is ordered based on clinical findings 1.