Breast Examination

Techniques

DR. MAHMOUD AL-BALAS

CONSULTANT BREAST ONCOPLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY
ASSISTANT PROFESSOR OF SURGERY – THE HASHEMITE UNIVERSITY
Objectives

• Describe the importance of performing a breast exam.

• Outline the current guidelines for breast examination by clinicians.

• Review how to perform a breast exam.

• Explain interprofessional team strategies for improving care coordination and

communication to advance detection of breast masses during physical exam and
improve patient outcomes.
Introduction

 The ability to perform a thorough and accurate breast exam is an important skill for
medical practitioners of many levels and specialties.

 A clinical breast exam is a key step in the diagnosis and surveillance of a number of
benign and malignant breast diseases.

 When used as part of a multimodal evaluation, the breast exam provides important
information used in both the workup and management of many diseases of the breast.

 Current recommendations for breast cancer screening intervals and tests vary;
however, many guidelines agree that a clinical breast exam is warranted for women
with abnormal findings on mammography and as part of annual screening for certain
groups of women at increased risk for breast cancer.
Clinical Anatomy

 The adult breast is roughly conical, the base of which overlies the pectoralis muscles in
the upper portion of the chest

 The physical boundaries of the breast are the clavicle superiorly, the sternum medially,
the insertion of the rectus abdominis muscles inferiorly, and the serratus anterior
muscles laterally. The posterior breast tissue lies on the pectoralis major fascia.

 The breast contains 15 to 20 lobes which are further divided into smaller functional
lobules.

 Cooper's ligaments are connective tissue that attach perpendicularly to the dermis that
help to support the breast.
Clinical Anatomy (cont.)

 The breast is divided into quadrants or described in comparison to a clock face for
ease of communication of any findings. The upper outer quadrant of the breast
contains a greater volume of tissue than elsewhere, and this is also the most
common location for a breast malignancy to arise.

 The upper outer quadrant extends superior-laterally toward the axilla and shoulder.
This portion of the breast is called the axillary tail of Spence.
Common Physiologic Changes
 The breast undergoes many changes throughout a woman's life and a typical menstrual
cycle, and these are important to keep in mind when performing a breast exam.

 During pregnancy and lactation, hypertrophy of the lactiferous ducts occurs with
engorgement of ducts and alveoli with breast milk.

 In a non-pregnant female, in the late luteal phase before menses, fluid accumulation in
the breast occurs in the form of intralobular edema which may cause discomfort.

 Fibrocystic changes may become exacerbated and resolve over the course of a
menstrual cycle.

 After menopause, the breast undergoes involution, with the replacement of the pre-
existing breast parenchyma with adipose and connective tissue.
Indications
 Complaints of breast pain, skin changes, nipple discharge, lumps, gross changes in size
or shape, or any other feature that cause concern to the patient warrant a clinical breast
exam.

 While there is currently controversy regarding the recommendation for women to

perform self-breast exams for breast cancer screening, the medical practitioner
nonetheless must evaluate a patient who presents with changes noticed during a self-
breast exam.

 Many breast cancers are in fact discovered by patients themselves during intentional or
incidental self-breast exam.

 Additionally, abnormal findings on screening, surveillance, or incidental breast

imaging (mammogram, ultrasound, MRI, chest CT, and PET) that are identified as
suspicious by the interpreting radiologist should be further evaluated through clinical
breast exam
Guidelines

 The National Comprehensive Cancer Network screening guidelines suggest that

women between 25 and 40 years old who are asymptomatic and have no special
risk factors for breast cancer undergo a clinical breast exam every 1 to 3 years.

 Women older than age 40, women with increased risk factors for breast cancer,
history of breast cancer, and/or symptomatic patients are recommended to receive
more frequent clinical breast exams.

 The American Congress of Obstetricians and Gynecologists recommends that any

screening regimen should involve a discussion of potential risks of screening with
the patient. With this in mind, the group recommends offering a clinical breast
exam for average-risk women aged 25 to 39 every 1-3 years, and an annual breast
exam to women aged over 40 years.
Guidelines (cont.)

 The American Cancer Society does not recommend regular clinical breast exams
for cancer screening for women in any risk group. It does state, however, that all
women should pay attention to the typical appearance and texture of their breasts
and report any changes to their doctor right away.

 The United States Preventive Services Task Force does not currently provide
recommendations for the use of clinical breast exams in breast cancer screening,
citing a lack of complete evidence based on available studies. However they do
recommend obtaining an extended medical history for increased genetic
susceptibility to breast cancer.
Contraindication

 Lack of patient cooperation or consent.

 Patient anxiety may occasionally prevent an exam (i.e this may be

minimized with calm assurance and working with the patient to
optimize comfort)
Preparation
 Policies vary by institution, but it is often advisable to ask a same-sex chaperone to
accompany the examiner into the patient's room for the patient's comfort and
protection.

 Adopting a courteous and gentle approach toward the patient is encouraged, as

patients may feel some degree of anxiety during the exam.

 It is important to have the patient change into a hospital gown before the exam to
facilitate exposure of the entire breast anatomy.

 A sheet should be available to cover the patient's lower half for comfort.

 During the exam, a sheet or the hospital gown should be used to cover the
contralateral breast
Examination Technique
Inspection

 The breasts are first visually inspected with the patient in a seated
position facing the examiner.

 The patient is instructed to place their hands on their hips as well as

raise them above their head (i.e. This allows the examiner to assess
the breasts in many positions)
Inspection

 Overall breast size  Variations in any of these should be

noted concerning previous exams as
 Breast Shape
well as in comparison to the
 Symmetry contralateral breast.
 Nipple size, shape, position, color
 Skin texture, and color.  Findings can be exaggerated during
 Areas of skin thickening, dimpling, movement as well as by asking the
or fixation relative to the underlying patient to flex the pectoral muscles
breast tissue. with hands on hips

 Axillary swelling
 Spontaneous nipple discharge
Palpation

 After completing the visual inspection, the patient should be instructed to lay supine.

 If a side-specific breast complaint is being evaluated, the examiner should begin

his/her exam on the opposite, or "normal" side.

 As one breast is examined, the other is covered for the patient's comfort.

 The patient should place the ipsilateral hand above and/or behind their head to flatten
the breast tissue as much as possible.

 The breast tissue itself is evaluated using a sequence of palpation that allows serial
progression from superficial to deeper tissues. This is best accomplished utilizing the
examiner's finger pads, usually with the hand in a slightly cupped position.
Palpation

 A variety of techniques exist, but the

most often used are the radial "wagon
wheel" or "spoke" method, the
vertical strip method, and the
concentric circle's method.

 As stated previously, it is important

that the examiner chooses a method
and is consistent from exam to exam..
Palpation
 The overall consistency of the breast is documented (soft, firm, nodular).

 Any masses or tender lesions are noted concerning their location in a conventional
quadrant or clock face configuration.

 If mass / lesion → size, shape, texture, mobility, delimitation, tenderness, and

approximate depth.

 Nipple areolar complex (NAC) → palpate for abnormalities

 Assess NAC for expressible nipple discharge by placing both hands on the breast on
either side of the areola and gently but firmly pressing down into the breast tissue
Axillary nodes examination
Axillary nodes examination

 The axilla and supraclavicular area should be palpated for lymphadenopathy.

 Lymph node abnormalities may present in a variety of forms, but most often any
palpable nodes of concern will be slightly enlarged and have a somewhat firmer
texture than the typical soft, rubbery one.

 As with any masses, approximate document number, size, texture, mobility, and
delimitation of any palpable lymph nodes.

 Occasionally, the entire axilla will feel "full," without defined lymphadenopathy.
This may relate to the patient's normal anatomy or indicate the presence of
diffusely matted lymph nodes.
Documentation
Common terminology found in the documentation of a breast exam includes the
following:

➢ Symmetrical or asymmetrical
➢ Shape (ptotic, pendulous, any scars or deformities with descriptions)
➢ Texture (soft, nodular, fibrocystic, dense, presence of inframammary ridge in large
breasts)
➢ Masses (described as indicated above versus no masses evident)
➢ Nipple-areolar complex (pink, brown, everted, inverted, discharge present/absent
with description, presence of dry, scaly texture concerning for Paget's disease)
➢ Skin (warm, dry, presence/absence of erythema, edema, peau d'orange appearance,
open sores, draining fluid collections)
Clinical Significance

 The findings of the breast exam are important in guiding future clinical care
related to the specific complaint (e.g. A lesion identified on imaging that cannot be
palpated may need to be biopsied under image guidance)

 For cellulitis or breast abscess, clinical observation of the breast will be crucial to
determining if the infection is responding to therapy.

 Presence or absence of palpably enlarged lymph nodes at the initiation of

treatment for malignancy will dictate next steps in both surgical and oncological
management.
Enhancing Healthcare Team Outcomes

 Breast exams may be performed by many clinicians including nurses. However, it

is important to understand that current guidelines do not recommend regular
clinical breast exams for cancer screening for women in any risk group.

 The women should be educated on the importance of changes to the

typical appearance and texture of their breasts and report any changes to
their doctor right away
References

 Henderson JA, Duffee D, Ferguson T. Breast Examination Techniques. [Updated

2021 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2021 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK459179/