Breast Examination

August 1, 2011

A breast examination is a simple means of detecting changes in breast tissue. There are two kinds of examinations, self-exam and clinical exam. The goal of these procedures is early detection of breast cancer because early treatment can increase survival rates.

Breast cancer is not only the most common non-skin cancer in women, but is also the second deadliest as well. If a woman lives to age 90, she has a 1 in 8 chance of developing breast cancer. Breast cancer is mostly a disease of older women. Statistically, the 1-year incidence for breast cancer in a 40-year-old woman is 1 in 800, for a 50-year-old woman it is 1 in 400, and for women age 60 the incidence is 1 in 200. In younger age groups, breast cancer is uncommon and screening tests may be less effective. Therefore, we have different recommendations for different age groups. Screening recommendations are also different for patients with a strong family history of breast cancer or a personal history of breast cancer. This discussion is for women who are at average risk for development of breast cancer.

Much research in the last 40 years has been done on screening for breast cancer, but guidelines do not always agree on what type of screening method to use and frequency with which to screen. The screening methods currently in use include mammography, clinical breast exam (CBE), and breast self-exam. Mammography will be discussed elsewhere. This section will discuss the evidence and recommendations for CBE as well as breast self-examination.

The CBE is a breast exam performed by a health care professional on a patient without symptoms. Some women are more willing to accept CBE instead of mammography for breast cancer screening, which makes it an especially important clinical skill. To perform a CBE, one must know the distribution of breast tissue. Breast tissue extends from the breastbone medially to the underarm laterally and from the collarbone superiorly to the “bra line” inferiorly. Normal breast tissue can be lumpy due to the mammary ducts and lobules.

No randomized controlled trial has looked at CBE alone versus not screening at all for breast cancer. However, mammography has been evaluated with and without CBE for breast cancer detection. Mammography has been shown to be effective in decreasing breast cancer mortality. Since mammography is known to be an effective screening tool, a clinical trial that excludes it would be unethical. Therefore, we must look at indirect evidence to decide if CBE is effective in detecting breast cancer and decreasing mortality. Some of the indirect evidence comes from studies including the meta-analyses by Barton, Harris, and Fletcher (1999). Many of these patients had CBE and screening mammography for breast cancer detection. From these trials we see that breast cancer mortality decreased by about 25% in women aged 50-69 years and by 18% in women in their 40s. One of the studies reviewed by Barton 1999 was the Canadian National Breast Screening Study. This study looked at women from 50 to 59 years old and offered them CBE alone or CBE plus mammography each year for 5 years. The 7-year mortality rates were similar, suggesting that mammography may not decrease mortality in women in their 50s, and that careful CBE alone may be as good as CBE plus mammography. Another study reviewed by Barton et al. (1999) was the Edinburgh randomized trial of breast cancer screening, which found mammography detected 26% of breast cancers while CBE detected only 3%. However, another randomized trial done with the Health Insurance Plan of New York (HIP) found breast cancer detection rates of 33% with mammography and 45% with CBE. The HIP study was conducted with early mammography techniques, but still suggests that CBE does have a role in detection of breast cancer. Other studies report that CBE can find from 3% to 45% of breast cancers. The exact percentage of cancers found on CBE is not known.

One reason that cancer detection may vary is the difference in technique used. Rates of CBE sensitivity (finding disease in those who really have it) range from 53% to 68% in women between 40 and 49 years and 48% and 63% in women between 50 and 59 years. Different studies use different methods for performance of the CBE. Some studies did not report their method of CBE. The Mammacare method has been advocated for universal use since its components have been validated in independent investigations of CBE technique. The components include palpation, examination pattern, and duration and inspection. Palpation (physical examination) of the breast is most accurately done while the patient is lying down with her arm extended above her head (Figure 1). This flattens out the breast tissue. The entire breast is palpated using the boundaries previously outlined in a vertical strip pattern or lawnmower pattern. The pads of the index, middle, and fourth fingers palpate each row (Figure 2). In each row, the clinician should stop and make small circular motions as if tracing the outer edge of a dime at a superficial, intermediate, and deep pressure. Each CBE can take up to 3 minutes for each side in an average-sized breast (B cup). Checking the armpit and area above the collarbone for enlarged lymph nodes is usually performed, but has not been clinically tested. Palpation of the nipple area is usually performed as well. Expression of fluid from a nipple is not a useful prognostic sign for cancer. However, spontaneous nipple discharge may need further evaluation.

Several guidelines recommend that CBE be performed every 1-2 years for all women over age 40.

However, women at higher than average risk need to discuss individual screening recommendations with their health care provider. Evidence shows that clinicians taught the Mammacare method of CBE were better at finding breast cancers. Barton et al. (1999) found in their review that a well-conducted CBE can detect breast cancers about 50% of the time in patients without symptoms. There is some overlap with mammography and CBE; 10% of breast cancers detected are invisible on mammography. Similarly, 40% of breast cancers detected are not found on CBE. Patients have a better long-term survival if their breast cancer is detected by mammography, probably because mammography can detect smaller cancers.

The second type of examination method is breast self-examination. This is a simple means for women to detect changes in their own breast tissue. It is performed each month, usually within a week after menstruation, when the breast is least bumpy. Technique is important in breast self-examination. Patients should ask their health care providers for help in learning the proper technique. The proper technique includes looking at the breast and systematically examining the breast using the middle three fingers. Breast self-examination is not a substitute for screening mammography or CBE.

Few studies have shown that the chance of dying of breast cancer is reduced by breast self-examination. However, there may be some small evidence to support this method of screening. Patients need to be aware that the evidence for self-breast examination is unproven and that it may increase their chances of having a benign breast biopsy. The American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the American Cancer Society all recommend routine teaching of breast self-examination.

SEE ALSO: Breast cancer, Breast lumps, Fibrocystic breast disease, Mammography

 

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