Breast Examination
How to examine the breasts for doctors, medical student exams, finals, OSCEs, PACES and USMLE
Introduction (WIIPPPE)
For a breast examination the introduction is vital. The patient must feel at ease with you and know why you are carrying out each step.
- Wash your hands (and try to ensure your hands are warm)
- Introduce yourself (name and position)
- Identity of patient (confirm name and date of birth)
- Permission (consent and explain examination: “I’m going to examine your breasts now. This will involve inspecting and pressing them quite firmly. Is that OK?”)
- Note that any intimate examination (including the breast exam) should be done with a chaperone present, particularly if the doctor is male
- Pain?
- Inform the patient they should let you know if you cause them any discomfort
- Position
- Initially sitting on the edge of the couch for inspection. Lying flat (with one arm above head) to palpate
- Privacy
- Provide a cover such as a blanket or a hospital gown (with the opening at the front) and ensure the curtain or door is firmly closed
- Exposure
- You need to be able to compare both breasts visually and then palpate both breasts in turn. Most women will not have any issue with such exposure provided you are relaxed and explain fully
Inspection
Breasts
- Begin by asking the patient to point to the area of concern, and always explain what you are doing to avoid any embarrassment
- Asymmetry
- Look for any asymmetry in the size of the breasts and in the breast contour
- The size and shape of the breasts in healthy women varies and having one breast larger than the other is common
- Skin change
- Look for lumps and associated skin changes including signs of inflammation, ulceration and skin retraction which may be caused by an underlying cancer
- Dimpling known as peau d’orange (“orange peel”) may be visible. This arises due to obstruction of lymphatics (which can be caused by tumour cells, infection, or treatment with radiotherapy) resulting in skin oedema with multiple small indentations caused by the hair follicles of the breast
- Colour changes which may be a sign of imminent ulceration
- Scars
- Indicating previous surgery
Nipples and areolae
- Nipple skin change
- Scaling and flaking around the nipples is commonly due to primary dermatitis and will often be present elsewhere on the body
- Unilateral eczematous skin changes on the nipple may indicate Paget’s disease which is caused by carcinoma cells migrating along ducts to the nipple
- Nipple inversion, deviation and colour
- Benign nipple inversion is bilateral and slit-like and is typical of duct ectasia
- Nipple retraction due to malignant disease is asymmetrical and distorting and can pull the nipple away from its central position leading to nipple deviation
- If an inverted nipple is seen, it is important to ask the patient if it is normal for them or they can evert it
- Unless it is longstanding, formal investigation is essential to rule out the possibility of carcinoma
- The ability to evert a newly inverted nipple is suggestive of benign breast disease
- Nipple discharge
- Is it originating from a single duct or multiple ducts? Note its colour
- If you are unsure of where it originates, you can ask the patient to try to express some discharge if they are comfortable to
- On no condition try to express it yourself!
Manoeuvres
- Various maroeuvres can be used to accentuate any subtle masses. The examiner should demonstrate these and ask the patient to copy. Watch the breast closely as the patient moves.
- 1. Ask the patient to raise their arms above their head so that skin tethering becomes more apparent
- 2. Ask them to press their hands against their hips in order to tense their pectoral muscles to accentuate chest wall tethering
Video demonstarting the breast examination
Palpation
- Ask the patient to lie on the couch to palpate the breasts. This maybe supine or at 45 degrees
Boundaries of the Breast
- Consider the main area of breast tissue as a rectangle bordered by the clavicle superiorly, the bra-strap line inferiorly, the midsternum medially and the midaxillary line laterally
- The tail of the breast extends beyond the midaxillary line into the axilla and must also be examined carefully
Patterns of Palpation
- Vertical strip pattern
- To use this technique, start in the mid-axillary line at the bra-strap line, and palpate by moving your fingers in a vertical strip upwards until you reach the apex of the axilla
- Then move your fingers medially and palpate downwards in a vertical strip to the bra-strap line, moving your fingers medially again and palpate up to the clavicle
- Continue palpating in a linear pattern until the sternum is reached and all breast tissue has been palpated (don’t forget the axillary tail of the breast)
- Concentric circles pattern
- Spiral outwards from the nipple
- Radial spokes pattern
- Working outwards from the nipple in strips as if palpating along the hands of a clock face
- There is conflicting evidence for the effectiveness of each method. The most important point as a clinician is that you are confident in your palpation that you have examined all the important areas. As such, use the method you are most confident with.
Three-finger Technique
- Palpate the breast using the palmar surface of the middle three fingers, not the finger tips
- Two hands can be used in women with larger breasts in order to fix the area you wish to palpate
- If a lump is found, use two hands to assess its characteristics:
- Site
- Size
- Shape
- Surface
- Consistency
- Margins
- Skin fixation or tethering
- A tethered lesion is suggestive of locally advanced cancer and occurs when the fibrous ligaments that separate the lobules of breast tissue are shortened
- These ligaments are anchored to the skin so that shortening them puckers the skin and pulls it inwards although the lesion is mobile and can be moved independently of the skin.
- A fixed lesion has spread into the skin itself so that the mass cannot be moved independently of the skin and implies more advanced local disease
Characteristics of a breast lump
- Side
- Site
- Size (measured in mm)
- Consistency (Soft; firm; hard)
- Margins (discrete vs diffuse)
- Surface (smooth vs irregular)
- Mobility
- Fixation
Manouevres
- In patients with large or pendulous breasts it may be necessary to use manouevres to flatten the breast tissue against the chest wall to optimise the examination
- To flatten the lateral part of the breast, ask the patient roll onto her contralateral hip, with her shoulders in a supine position, and place her ipsilateral forearm on her forehead
- To flatten the medial part, ask the patient to lie flat on her back and move her elbow up until it is level with her shoulder
Nipple Discharge
- Nipple discharge is a common symptom and may be clear, cloudy, or blood-stained
- It is most often due to duct ectasia, but can also be the result of lactation, a duct papilloma, or carcinoma
- If the patient is complaining of discharge, ask them to try to express some discharge if they are comfortable to
- On no condition try to express it yourself unless the patient is totally happy for you to do so!
Palpation for axillary and supraclavicular lymphadenopathy
- The axillary lymph glands form a three-sided pyramid whose apex is in the narrow gap between the first rib and the axillary vessels
- In order to feel for axillary lymphadenopathy, the patient’s pectoral muscles need to be relaxed
- To examine the right axilla the examiner should hold the patient’s right elbow with their right hand and take the weight of their arm whilst palpating with the left hand and vice versa. Alternatively, the patient can rest their hands on the shoulders of the examiner.
- Place your hand into the axilla, and using your three middle fingers move them in small circles as you would to palpate the breast
- Move upwards from the base of the axilla palpating along the lateral chest wall to feel for nodes lying centrally or medially
- Work your way upwards ensuring you cover the entire area of the axilla and push the tips of your fingers upwards and inwards to palpate at the apex of the axilla
- Small “shotty” glands may be felt in thin patients and are not significant. Lymph nodes containing metastases are usually hard and discrete but they can mat together as they enlarge and become tethered or fixed to the skin
- Finally, examine the supraclavicular fossa
- Examine from in front of the patient, place your fingers in the supraclavicular fossae and move them in small circles to try and identify any enlarged lymph nodes as illustrated in figure
Gynaecomastia
- Gynaecomastia (literally “a woman’s breasts”) is an important sign in men
- It can present as a clearly palpable disc of firm breast tissue behind and attached to the areola more often seen in younger men. It is caused by an imbalance of oestrogens and androgens and can be idiopathic, occurring at puberty
- Some of the important secondary causes include cirrhosis, renal failure, hypogonadism, suprarenal tumours and oestradiolproducing testicular tumours
- Drug-induced breast enlargement such as from spironolactone and cimetidine, tends to be more diffuse with a fatty element
- Tenderness is unusual and the axillary lymph nodes will not be enlarged
- Examine for signs of liver disease, and examine the testes, since a carcinoma may produce paraneoplastic oestradiol causing gynaecomastia
- In patients with any suspicious changes, such as skin changes or a firm lump, carcinoma must be excluded
Examination for metastases
- If any lump has been found, look for signs of metastases. This is not relevant if no suspicious lump has been found
- Inspect the arms for lymphoedema
- Palpate the abdomen for hepatomegaly
- Examine the chest for effusion secondary to lung metastases
- Examine the spine for pain (a sign of spinal metastasis)
Completing the Examination
- Thank the patient, help them back into comfortable posture and wash your hands
- Give the patient some privacy to re-dress
- In an exam situation you should finish by addressing the examiner, stethoscope behind your back, not looking back at the patient and presenting your findings slowly and concisely. See here for a summary.
- In clinical practice the patient should be given privacy to redress before discussing the findings of the examination with them
Discussion
- All patients with signs of breast cancer, and those presenting with breast symptoms in whom cancer cannot be excluded by examination, must be formally assessed with ‘triple assessment’
- The three elements are:
- Clinical examination
- Imaging (ultrasound or mammography)
- Pathological analysis (core biopsy or fine needle aspirate)
- Ultrasound is usually the imaging modality of choice in women under 35 years of age, whereas mammography is preferred for women over 35 years