Breast Examination

The role of radiographic screening for breast cancer (mammography) in women younger than 50 years is controversial. Physical examination of the breasts had been considered both an important adjunct to mammography and a significant screening tool in its own right, but its utility in screening for breast cancer is being questioned.

Barriers to accurate and thorough examination include provider or patient discomfort, fear of misinterpretation of attention to the patient’s breasts, and lack of knowledge or skill with the technique.

Although evidence of benefit is insufficient to recommend clinical breast examination (CBE), it is often incorporated into annual physical examinations.

The American Cancer Society no longer recommends clinical breast examination in women at average risk for developing breast cancer. Breast self-exam is also no longer recommended as an option for women of any age. ^[1]

By contrast, the American College of Obstetricians and Gynecologists (ACOG) recommends that women aged 19 years or older undergo annual clinical breast examination. ^[2]

The United States Preventive Services Task Force (USPSTF) concluded that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination beyond screening mammography in women aged 40 years or older at average risk. ^[3]

Approach considerations

Several different palpation techniques can be used for clinical breast examination. Limited comparative data on the efficacy of these techniques are available. Key elements of a successful examination include careful observation and systematic palpation.

Observation

First, with the patient sitting up with arms at her sides, the clinician observes the shape, color, and skin characteristics of the breasts. It is important to note skin retraction, ulceration, erythema, or crusting of the nipples and to note and either establish or compare with the baseline whether the nipples are inverted, everted, or flat.

Next, the patient is asked to raise her arms over her head. The clinician should note the movement of the breast tissue as she does this and observe for any tethering of breast tissue to the chest wall. The clinician may also ask the patient to arch her back with hands on her hips, again observing for the movement of the breast tissue.

Palpation

With the patient sitting up, palpation is started.

The clinician should use the flats of the finger pads, not the tips, for enhanced sensitivity and should remain cognizant of the patient’s nipple and avoid incidental contact with his or her hand.

The examiner is responsible for evaluating all tissue between the skin and the chest wall.

Although it is possible to repeat the palpation pattern using different degrees of pressure (and therefore depth of tissue being assessed), a more efficient approach is to spiral in each position from superficial to deep, paying attention to the tissue at each level.

Palpation is begun at the medial portion of the chest wall below the clavicle and progresses down and up in a “vertical strips” pattern.

The examiner should slide from palpation position to position rather than lifting his or her hand.

Palpation is repeated on the opposite breast.

In this position, it is difficult to have confidence in the examination of the underside of the breast in full-breasted patients.

Next, the patient is asked to lie flat with the arm of the breast being examined behind the patient's head. This stretches out the breast tissue against the chest wall and is particularly helpful in examining the lower quadrants.

The breast is palpated following a “spokes of the wheel” pattern. The areola and subareolar breast tissue in is included in the palpation pattern.

Attempting to “milk” the breast is unnecessary unless the patient has described a discharge.

Examination of associated structures

When performing a breast examination for the purpose of cancer screening, it is appropriate to include an evaluation of the supraclavicular and axillary nodal groups.

Examination of the axilla is best performed with the patient sitting upright. The patient is asked to raise her arm. The anterior wall of the axilla is formed by the pectoralis major muscle. With palm facing forward, the examiner inserts his or her hand into the axilla, just posterior to the pectoralis major and parallel to the plane of the muscle. The patient lowers her arm with the examiner’s hand in place. The examiner then rotates his or her palm perpendicular to the plane and sweeps downward. Pathologic lymph nodes may be palpated and may "pop" during the downward sweep.

Examination of the supraclavicular nodes is best performed with the patient sitting upright. Beginning medially within the supraclavicular fossa, the examiner palpates the supraclavicular fossa thoroughly to its lateral boundaries. Nodes that are hard, fixed to the underlying structures, or greater than 1 cm may be pathologic and warrant further investigation.

Documentation

If an abnormality is identified, it is important to record it accurately.

Using the nipple as the center of a clock face, any lesion is described by its clock position, distance from the nipple, and relative depth from the skin. It is useful to draw a simple diagram of the abnormalities identified.

Abnormalities should be described by their contour (linear, round, or lobulated), texture (fluctuant, soft, firm, rock hard), mobility (eg, fixed to the underlying tissue), and standard findings for inflammation, if present (warm, red, tender). It is also important to note any associated skin changes such as peau d'orange,ulceration, or new nipple inversion.

Documentation of a normal breast examination includes a description of symmetry, contour, and the presence of any lesions. Normal tissue is usually soft and may be finely granular. Asymmetry of breast size may be a normal variant.

Because of the sensitive nature of the breast examination, many providers choose to have a chaperone present during the examination. There are pros and cons to this approach, and a generally accepted policy is to have clinical staff who can act as chaperones available, to ensure that patients are aware that they are available, and to provide patients with an opportunity for private conversation without the chaperone present.

The harms of undergoing clinical breast examination include the risks of false reassurance or referral for unnecessary procedures like biopsies.

In the Canadian National Breast Cancer Screening Study, a high percentage of women who were diagnosed with breast cancer had undergone a screening clinical breast examination with negative findings. ^[4]

Patient education concerning the role of different screening modalities for the diagnosis of breast cancer is important and varies by age.

Annual mammography for women older than 40 years has been advised by some groups, although the utility in women aged 40-49 years is controversial.

MRI screening is more sensitive in younger women with denser breasts and has been recommended as an adjunct to mammography in extremely high-risk women such as those with genetic predisposition to breast cancer.

Beginning after age 19, women should be told about the limitations and potential benefits of breast self exam (BSE) in the context of building awareness about their bodies. Regardless of the practice of regular, haphazard, or occasional practice of BSE, women should be told to report any new breast symptoms to their health provider. For those women choosing to perform BSE, proper technique should be demonstrated by a health professional.