Clinical Breast Examination Certification by NCBC

Cathy J. F. Cole, NP, MPH, CBPN-IC
The Breast Center of Los Robles Hospital
Thousand Oaks, CA

CBE™ certification is the process by which the NCBC validates, based on evidence based standards, a licensed breast health care provider’s knowledge in the performance of a clinical breast examination. The purpose is to assure the public that the certified licensed breast health care provider has completed the NCBC CBE™ course and has met minimum knowledge and performance standards by recognizing the individual who has met these standards. Candidates who pass the CBEC™ may use the mark CBEC™ to verify that they have met all eligibility and training requirements. All individuals with valid certifications will also be posted on the NCBC website

This course covers one and a half days and is designed to utilize Clinical Breast Examination Skills to accomplish a Certified Breast Examiner’s paramount objective, the detection of any abnormal breast finding as another early detection tool. This is accomplished through an intensive didactic review of Core Breast Knowledge, Breast Specific History, Breast Imaging, Diagnostic Procedures with Breast Pathology, Follow-up Recommendations and Risk Management. The didactic component of the course is followed by a half-day of demonstration and practicum on performing a Clinical Breast Exam. Patient models, students, and instructors will interface in life scenarios to experience issues and challenges in performing clinical breast exams. Additionally, this course will provide instruction and practice of the tactile skills associated in the performance of a clinical breast exam.

Prior to the course, each student is provided with study material outlining the major concepts that will be presented during the course and information that will be on the testing units. Also included in the study folder are supplemental reading materials, as well as a glossary of terms, meant to assist the student in the understanding of course material. Answers to the test questions are in the material included in the student participants’ material. Following course instruction, students will be evaluated on their core knowledge, ability to perform a Clinical Breast Exam in a real life approximated setting, and their tactile skills regarding lump detection. Students must receive an 85% on all test measures to be certified a Level III CBEC.

This course is available to licensed healthcare professionals such as physicians, physician assistants, nurse practitioners, registered nurses and radiologic technologists. Faculty involved in this course include Cathy Cole, RNC, NP, MPH, CHES; Eleanor Broaddus, RN, CBPN-IC; Penny Lynch, RT(R)(M), CBEC, CBPN-IC; Belinda Zaparinuk, RT(M),BS, CBEC; Susan Heath, NP, CBEC.

This year at the 24th Annual Interdisciplinary Breast Center Conference 17 practitioners were certified Level III CBEC. Our congratulations go out to all of them.  Go the NCBC web site for the persons certified.

Advance Health Care Directives and POLST – Useful Tools for Taking Control of Your Health Care

By Leilani Maxera, MPH
POLST Program Director for the Coalition for Compassionate Care of California

Many, if not most, of those who face breast cancer go on to live long and productive lives. However, for all breast cancer patients, planning ahead is an important component to their care. The advance care planning process helps to relieve the stress of last-minute decision-making that could be placed on them, their caregivers and healthcare providers in the event that their illness becomes serious.

For people with serious or progressive, chronic illness, the POLST form is a tool that helps to ensure that their medical wishes are honored. POLST is an acronym for "Physician Orders for Life-Sustaining Treatment," and is a legally binding medical directive. Unlike the Advance Health Care Directive, which contains treatment preferences for future care if the person becomes ill, the POLST form documents patient and family care preferences that are specific to the patient's current condition. POLST is appropriate for patients of any age whose illnesses make it likely that they will need to confront life-or-death medical decisions in the near future. Decisions for treatment include choosing what medical interventions a person would want or not want, such as CPR and artificial nutrition, if the patient is unable to eat. Making their wishes known will ensure that they will not receive care that they would not want. This process also lifts the burden of decision-making from loved ones and eliminates any conflict among the parties.

Initiating the advance care planning process is critical to learning more about what types of life-sustaining treatments are available. It is important to decide what types of treatments  the patients would want, and choose who they think would be the best person to be  their health care agent in the event that  they need someone else to make medical decisions for them. Remember, the best person for this role is not always the person to whom the patients are the closest – whether this be because the closest loved one is unable to cope with stressful situations or because they do not agree with the choices the patient has made. The patients must chose the person who is known will keep the patients’ wishes in mind and who is up to the task of being the patient’s health care agent. And, it is helpful to talk to loved ones about these personal choices.  The feelings should be shared so that everyone is clear about the types of treatment wanted at end-of-life. Lastly, they should be reminded to put it in writing – create an advance directive, and if appropriate and available in the patient’s state, a POLST form.

Although many states have POLST programs in place, the form does not exist in every state. Check to see if there is a program in the state where the patient lives. Since the POLST is a state form, it is legally binding only within the individual state it was created. The form goes by several different names, depending on the state, but the goal is the same – to make sure that the patient’s wishes are known so that they get the care that they want at the end–of-life.

People do not need to be seriously ill to start thinking about the types of care they might want when approaching the end-of-life. In fact, everyone over the age of 18 should have an Advance Health Care Directive, as it enables the person to appoint another person as their health care agent to make decisions for them in the event that they are unable to speak for themselves. Whether or not the person is ill, now is the time to think about preferences for care and to share these personal values, beliefs, and wishes for medical treatment with loved ones. The future is uncertain, so encourage patients to not put off planning for medical care – one never knows when it will be too late. In fact, that is a critical responsibility of professionals – helping patients and survivors find their way to this critical information.

Some resources for getting started include –

The Coalition for Compassionate Care of California is a statewide partnership of regional and statewide organizations and individuals dedicated to the advancement of palliative medicine and care in California.

Advance Health Care Directive Physician Orders for Life Sustaining Treatment (POLST)
Criteria- For anyone 18 or olderPurpose/Function

- Provides instructions for future treatment

- Appoints a Health Care Representative

- Does not guide Emergency Medical Personnel

- Guides inpatient treatment decisions when made available

Criteria- For persons with advanced illness — at any agePurpose/Function

- Provides medical orders for current treatment

- Guides actions by Emergency Medical Personnel when made available

- Guides inpatient treatment decisions when made available

For additional information or questions, please contact

Editor’s Note

Another supporting article appeared in the Wall Street journal about the same time this feature article was submitted for peer review.  It summarized a study by researchers at the Oregon Health & Science University. It is the first study to look at preferences stated in the form where patients actually die.  And, it is the largest study to date on POLST.  "We think almost everyone in our study who wanted to be with family and avoid an unwanted terminal hospitalization, as long as their comfort could be managed, got their wish," said Susan Tolle, senior author of the study and director of the Center for Ethics in Health Care at the university. "There is a remarkable association between where you die and the orders selected on your POLST form.

"Landro L. Patients’ End-of-Life Wishes Granted, Study Finds.  Wall Street Journal. June 9, 2014.

SSO-ASTRO Margin Guidelines
BCS with Whole-Breast Irradiation
Stages I and II Breast Cancer

Moran MS, Schnitt SJ, Giuliano AE, et al. Society of Surgical Oncology – American Society for Radiation Oncology Consensus Guideline on Margins for Breast-Conserving Surgery with Whole-Breast Irradiation in Stages I and II Invasive Breast Cancer. Int J Radiation Oncol Bio Phys, Vol. 88, No. 3, pp 553-564, 2014.

Changes in breast cancer management has changed over time.  Currently, there is a decreased rate of ipsilateral breast cancer recurrence [IBTR].  In 2013, the SSO and ASTRO developed guidelines on margins in breast-conserving surgery for invasive cancer.  These guidelines are summarized below.

  1. Positive Margins. A positive margin, defined as ink on an invasive cancer or DCIS is associated with at least a two-fold increase in IBTR.  This increased risk is not nullified by:
    1. delivery of a boost dose of radiation
    2. delivery of systemic therapy [endocrine therapy, chemotherapy or biologic therapy] or
    3. favorable biology
  2. Negative Margin Widths. Negative margins [no ink on tumor] minimize the risk of IBTR.  Wider margin widths do not significantly lower this risk.  The routine practice to obtain negative margin widths wider than no ink on tumor is not indicated.
  3. Systemic Therapy.  The rates of IBTR are reduced with the use of systemic therapy.  In the uncommon circumstance of a patient not receiving adjuvant systemic therapy, there is no evidence that margins wider than no ink on tumor are needed.
  4. Biologic Subtypes.  Margins wider than no ink on tumor are not indicated based on biologic subtype.
  5. Radiation Therapy Delivery. The choice of WBRT delivery technique, fractionation and boost dose should not be dependent on margin width.
  6. Invasive Lobular Carcinoma and Lobular Carcinoma In Situ.  Wider negative margins than no ink on tumor are not indicated for invasive lobular carcinoma [ILC].  Classic lobular carcinoma in situ [LCIS] at the margin is not an indication for re-excision.  The significance of pleomorphic LCIS at the margin is uncertain.
  7. Young Age.  Young age [<40 years] is associated with increased IBTR and BCT as well as increased local relapse on the chest wall after mastectomy, and is also more frequently associated with adverse biologic and pathologic features.  There is no evidence that increased margin width nullifies the increased of IBTR in young patients.
  8.  Lobular Carcinoma In Situ.  A lobular carcinoma in situ [EIC] identifies patients who may have a large residual DCIS burden after lumpectomy.  There is no evidence of an association between increased risk of IBTR and EIC when margins are negative.