Clinical Encounter With the Patient

Breast Self-Awareness and Breast Self-Examination

Whereas the clinical encounter between patient and physician provides an ideal opportunity for screening and diagnosis of breast disease, breast cancer can be identified after self-detection, although the relative contributions of systematic self-examination and incidental discovery are not definitively established. Breast self-examination (BSE) formerly played a larger role in breast cancer screening recommendations, but it is no longer recommended by the American Cancer Society (ACS), US Preventive Service Task Force (USPSTF), or National Comprehensive Cancer Network (NCCN) guidelines as data on BSE have not shown an improvement in breast cancer–specific mortality. Tumor size and stage have also not been associated with the performance of BSE. Whereas the USPSTF has gone as far as to discourage teaching of BSE based on an unfavorable risk/benefit ratio (with the risks of potential psychological harm, inconvenience, and possibility for overdiagnosis and unnecessary procedures outweighing potential benefits), the most recent ACS guidelines from 2015 offer no change to their 2003 guidelines, which maintained that although BSE is not warranted for average-risk individuals, all persons should become familiar with their own breast examination so that they may report any changes to their health care provider. The most recent USPSTF guidelines similarly support patient awareness of “changes in their bodies” and discussing these changes with clinicians.

With this in mind, any discussion between clinician and patient about BSE should emphasize the importance of becoming familiar with how one’s breasts normally look and feel. The NCCN guidelines promote “breast self-awareness” (i.e., patient familiarity with one’s breasts) for all individuals age 25 and older, encouraging individuals to become familiar with their breasts so that they can promptly report changes to their health care provider. When patients inquire about BSE, we recommend clinicians address both the limitations and potential benefits of BSE as part of one’s routine self-awareness and health care. Women who wish to use BSE as a method for becoming more familiar with their breasts' normal appearance and physical examination should have a systematic approach to looking at and examining their breasts.

Instruction on BSE should be prefaced with a discussion of risk factors for development of breast cancer, including patient age, race, ancestry, family history, age of menarche, menopausal status, obesity, alcohol consumption, and hormone replacement utilization. During this discussion with patients, clinicians should mention that most early-stage breast cancers do not produce symptoms, with the most common presentation being a painless mass. The importance of reporting breast changes, including alterations in the contour of the breast, swelling, dimpling, nipple retraction, skin thickening, nipple discharge, or a palpable finding, to their health care provider should be emphasized, again highlighting the importance of breast self-awareness. In the premenopausal setting, a lump may be normal if it appears and regresses with the menstrual cycle. A lump that persists past one or two cycles should be brought to the health care provider's attention. A lump that persists for more than a few weeks in the postmenopausal setting should also be brought to a care provider's attention.

The technique for BSE varies but should involve the woman looking at herself in a full-length mirror, with arms to her side, then over her head, and then to her side with flexion against the side to look for symmetry, dimpling, and retraction ( Fig. 11.1 ). A slight asymmetry in breast size can be considered normal, but a progressive change in size in one or both breasts should be brought to the attention of the health care provider. A BSE should also be performed lying down with the arm over the head to allow the breast tissue to splay out evenly over the chest. The examination should be performed with two or three fingers using a circular approach with three degrees of pressure (light, moderate, and deep) and should cover the entire breast from the clavicle to the inframammary fold, laterally to the latissimus, medially to the sternum, and also the low axilla. The entire breast should be examined either in a spoke-wheel fashion or using a vertical-horizontal blind or circular method, covering the entire surface area encompassing sternum to the top of the rib cage, and from the latissimus to the sternum ( Fig. 11.2 ). This technique should be performed in the same manner on both sides.

The Clinical Encounter: Clinical Breast Exam

The role of the CBE has a stronger foundation in the early detection of breast carcinoma than BSE; however, limitations in the evidence supporting its routine use are recognized by both the USPSTF and the ACS. The ACS notably shifted their stance away from recommending CBE for women at average risk of breast cancer, regardless of age, in their 2015 guidelines, citing a lack of evidence showing benefit for CBE performed either alone or in conjunction with mammography, concurrent with an increase in false-positive rates. The most recent USPSTF guideline did not update its recommendation on the additional potential benefit of CBE, referring back instead to the 2009 guidelines which had concluded that the evidence remains insufficient to assess the additional benefits and harms of CBE beyond screening mammography in women 40 years or older. The most recent NCCN guidelines recognize that a breast cancer screening evaluation should take into account multiple factors including age and medical and family histories, and can include breast awareness, regular clinical encounters, and breast imaging. Per the guidelines, breast cancer risk assessment and preferably a CBE—to be performed even in asymptomatic individuals when feasible—are recommended constituents of the clinical encounter. Individuals should undergo their first clinical encounter with a formalized breast cancer risk assessment at age 25 in the average-risk asymptomatic patient, and then subsequently should have a repeat evaluation every 1 to 3 years until age 40 when annual clinical encounters are recommended. We continue to perform CBE as part of our clinical encounters in our practices, following these NCCN guidelines.

The CBE technique should include thorough inspection and palpation of the entire breast and the draining lymph node areas. The physician (and a chaperone where appropriate) should stand in front of the gowned patient. In a manner that allows for minimal patient disrobement, both breasts should be inspected with the patient's arms by her side, with her hands over her head, and finally with her arms to her side with contraction of the pectoralis major muscle. The size, shape, and symmetry of the breasts should be noted. Attention should be made to any changes to the skin, including indentation, dimpling, protrusions, or skin thickening, as well as to any skin color changes. One must maintain a high clinical suspicion for inflammatory breast cancer (IBC) if there are appropriate clinical signs, including the presence of edema, peau d’orange, and erythema (often involving over one-third of the breast) developing over a relatively short time frame (often within <6 months). Whereas a skin punch biopsy may be diagnostic (and we recommend using at least a 3-mm punch when undertaken), the characteristic dermal lymphovascular involvement is noted in less than 75% of IBC cases and as such it remains a primarily clinical diagnosis.

The clinical examination should also include inspection of the nipples, noting any ptosis, retraction, thickening, flaking, or erosions potentially signifying Paget disease of the breast. Clinicians should take care to search for any scars and inquire from the patient about any prior breast surgeries that correlate with these, including prior biopsies as well as oncologic or cosmetic operations.

After inspection is complete, palpation should be performed with the patient in sitting and supine position. The breast should be examined from the clavicle superiorly to the rectus sheath insertion inferiorly, extending from the latissimus laterally to the sternum medially, and palpation should be performed using the pads of the fingers and may again be in the spoke-wheel, vertical-horizontal blind, or circular fashion with light, moderate, and deep pressure. Special attention should be made to the lymph nodes in the sitting position. With one arm supporting the patient’s hand, the other hand examines the axilla. The supraclavicular and infraclavicular lymph nodes are best examined from behind with the woman in a seated position. Lymph nodes that measure over 1 cm in diameter or that are hard, fixed, or matted warrant further diagnostic workup. If a mass is found, measurements with a ruler/caliper should be taken in two dimensions and its location should be noted with reference to a clock time and measured in centimeters from the nipple. Details about how long the mass has been present, whether it has changed in size and if size fluctuates with menses, and whether there is any associated tenderness should be ascertained.

During the examination of the breast, focused attention should be given to the nipple-areolar complex. Manipulation of the nipple should occur only if the patient reports nipple discharge. Nipple discharge accounts for 5% of all breast symptoms and is a common breast-related complaint, affecting up to 80% of women during their reproductive years. For most individuals, nipple discharge is most likely to be of benign origin. The clinician’s role is to differentiate physiologic benign nipple discharge from pathologic nipple discharge, which often arises in patients with an underlying papilloma, high-risk lesion, or cancer. If present, the clinician should note whether the discharge occurs spontaneously or only with mild manual compression and indicate whether the discharge is unilateral or bilateral, and involves one or many ducts. The color of the discharge can help with diagnosis and should be noted and accompanied with a description of the offending duct(s). Common discharge colors include clear, white, green, brown, black, and red (bloody). Brown or black fluid should undergo guaiac testing to look for breakdown products of hemoglobin. Discharge that is unilateral and bloody or guaiac-positive has a malignancy risk of approximately 20% to 25%, which is often DCIS; however, the vast majority are caused by benign entities, with the most frequent being intraductal papilloma followed by duct ectasia. Discharge that is bilateral, multiductal, and milky, clear, green, or bluish in color is almost always benign.