Breast Cancer Clinical Presentation

Updated: Oct 24, 2017
  • Author: Pavani Chalasani, MD, MPH; Chief Editor: John V Kiluk, MD, FACS  more...
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Presentation

History

Many early breast carcinomas are asymptomatic, particularly if they were discovered during a breast-screening program. Larger tumors may present as a painless mass. Pain or discomfort is not usually a symptom of breast cancer; only 5% of patients with a malignant mass present with breast pain.

Often, the purpose of the history is not diagnosis but risk assessment. A family history of breast cancer in a first-degree relative is the most widely recognized breast cancer risk factor.

The US Preventive Services Task Force (USPSTF) has updated its 2005 guidelines on risk assessment, genetic counseling, and genetic testing for BRCA-related cancer in women. The current USPSTF recommendations are as follows [76, 77] :

  • Women who have family members with breast, ovarian, tubal, or peritoneal cancer should be screened to identify a family history that may be associated with an increased risk for mutations in the breast cancer susceptibility genes BRCA1 or BRCA2
  • Women who have positive screening results should receive genetic counseling and then BRCA testing if warranted
  • Women without a family history associated with an increased risk for mutations should not receive routine genetic counseling or BRCA testing
Next:

Physical Examination

If the patient has not noticed a lump, then signs and symptoms indicating the possible presence of breast cancer may include the following:

  • Change in breast size or shape
  • Skin dimpling or skin changes (eg, thickening, swelling, or redness)
  • Recent nipple inversion or skin change or other nipple abnormalities (eg, ulceration, retraction, or spontaneous bloody discharge)
  • Nipple discharge, particularly if bloodstained
  • Axillary lump

To detect subtle changes in breast contour and skin tethering, the examination must include an assessment of the breasts with the patient upright with arms raised. The following findings should raise concern:

  • Lump or contour change
  • Skin tethering
  • Nipple inversion
  • Dilated veins
  • Ulceration
  • Edema or peau d’orange

The nature of palpable lumps is often difficult to determine clinically, but the following features should raise concern:

  • Hardness
  • Irregularity
  • Focal nodularity
  • Asymmetry with the other breast
  • Fixation to skin or muscle (assess fixation to muscle by moving the lump in the line of the pectoral muscle fibers with the patient bracing her arms against her hips)

A complete examination includes assessment of the axillae and supraclavicular fossae, examination of the chest and sites of skeletal pain, and abdominal and neurologic examinations. The clinician should be alert to symptoms of metastatic spread, such as the following:

  • Breathing difficulties
  • Bone pain
  • Symptoms of hypercalcemia
  • Abdominal distention
  • Jaundice
  • Localizing neurologic signs
  • Altered cognitive function
  • Headache

The clinical evaluation should include a thorough assessment of specific risk factors for breast cancer (see Breast Cancer Risk Factors).

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