2 Clinical assessment of the breast

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Contents

• Objectives
• Case studies
• History taking
• The examination of the breasts
• Case studies

Objectives

By the end of this chapter you should be able to:

• Take a good history when a woman presents with a breast complaint.
• List the important questions to ask about her breasts.
• Know how to examine a woman’s breasts.

Case study 1

A 55 year old woman presents with a painless lump in her breast. She feels the lump is new. On examination, she has a hard mass in the upper outer quadrant of the breast.

1. With regard to the risk of breast cancer, what are the 3 most important facts given in the history?
2. Does breast cancer only occur in females?
3. Why is her age important?
4. What are the next most important questions to ask?
5. What specific factors are important to look for in the examination?
6. What should you feel for on palpation?

Case study 2

A young woman of 23 years visits her general practitioner with an upper respiratory infection. While taking a history she mentions that her father’s mother had breast cancer.

1. Why is a family history of breast cancer important?
2. Is a history of breast cancer on the father’s side of the family important?
3. Is it likely that she has breast cancer?
4. Why is the age at which the family member presented with breast cancer important?
5. What other cancer in the family will increase the risk of breast cancer?

Case study 3

A 40 year old woman presents with a bloody nipple discharge from one breast. She is very embarrassed and asks if she can keep her T-shirt on during the examination. The general practitioner, who is in a hurry, agrees and examines her breasts with her lying down. Her armpits are not examined. He only then asks about the discharge but not about her past or family history.

1. What is the problem with the way the history was taken?
2. Can you examine a woman’s breast without her undressing?
3. In what position should the woman be in when her breasts are examined?
4. How should the armpits (axillae) be examined?
5. What other lymph nodes should be palpated for?
6. Where else should be examined?

History taking

2-1 How is a clinical assessment of the breasts performed?

1. Taking a careful history
2. Asking important questions
3. Thoroughly examining the breasts

The purpose of the assessment is to think of the most likely diagnosis of the problem.

Always introduce yourself before starting the assessment.

2-2 Why is history taking so important?

An accurate history must be taken so that the patient’s risk of having breast cancer can be assessed. The biggest risk factor for developing breast cancer is being female. Breast cancer is rare in males although 1 in a 100 cases of breast cancer occur in males.

Note

Online risk assessment tools can be used. The two most used sites are Can Risk and IBIS.

Breast cancer almost always occurs in women.

2-3 What history is needed?

• A family history
• A past history
• A present history
• A general medical history

2-4 What is the most important question to ask?

The most important question to ask when taking a history is the age of the woman. The older the woman, the more likely she is to get breast cancer.

The risk of breast cancer increases with age.

Table 2-1: Risk of breast cancer by age with no family history of breast cancer.

The lifetime risk of breast cancer is 1 in 9 in a woman who lives to the age of 80.

The lifetime risk of breast cancer is 1 in 9 if a woman lives to 80.

Figure 2-1: The age of women at breast cancer diagnosis (data from the UK)

2-5 What is the importance of a family history when assessing the risk of breast cancer?

A family history is very important. It is essential to ask if anyone in the woman’s family has had breast cancer. If they have, they should be asked at what age did the breast cancer first present (not what age when they died of any cause). All the people with breast cancer in the family should be noted. Ask how many women there are in the family to get an idea of the frequency of any breast cancer. A family history from the father’s side is just as important as from the mother’s side.

Working out the risk of breast cancer from a family history is very complicated. The more cases of breast cancer there are in the family and the younger the women were at the time of diagnosis, the higher the risk to other family members. If there are women in the family who develop breast cancer at a very young age (less than 40) the risk is further increased.

A family history of breast cancer on the side of either the mother or father is an important risk factor.

Note

A number of mutations in genes such as BRCA 1 and 2 have been identified as carrying a high risk for breast cancer.

2-6 Are other cancers associated with breast cancer?

There are several other cancers that may also be a risk factor for breast cancer. The important ones are ovarian cancer and prostate cancer.

2-7 What questions should be asked in the past medical history?

• The most important question to ask is whether the woman has had breast cancer before. If she has and has a new complaint, it may well be a cancer-related problem.
• It is important to ask whether she has had other cancers, particularly ovarian cancer.
• Ask about previous operations to the breasts. Women often do not tell you if they have had plastic surgery unless you ask!

2-8 What present history should be taken?

• Always take a general medical history.
• Ask general questions.
• Take a history of the presenting breast complaint.
• Ask specific questions about the breasts.

2-9 Why take a general medical history?

Although a woman may present with a breast complaint she may have other important medical problems. These may or may not be related to the breast complaint but still need to be managed.

2-10 What general questions are important?

Ask about:

• Her menstrual cycle. It is important to know whether she is pre-, peri- or post-menopausal or pregnant. To be considered as post menopausal, it must have been at least two years since she last had a menstrual period.
• Is she actively breastfeeding. If not, when did she stop.
• Has she lost or gained weight recently.
• Is she taking any medications: some drugs can cause women to produce milk.

2-11 What history should be taken about the breast complaint?

It is important to ask what the main complaint is and whether one or both breasts are affected. If one, which breast is affected?

Unfortunately there are no presenting complaints that reliably indicate that the patient has breast cancer. In addition there are many non-cancerous breast problems that can give the same symptoms as breast cancer.

While the history can strongly suggest that the patient has breast cancer, the diagnosis cannot be made on the history alone.

There are no presenting complaints that always indicate breast cancer.

2-12 What are the commonest breast complaints?

The commonest breast complaints are:

• Lump in the breast
• Pain in the breast
• Discharge from the nipple
• Change in breast appearance
• Breast increasing in size
• Lump in the armpit
• Redness of the breast
• Thickening of the breast
• Nipple change

The important questions to be asked depend on the main complaint. This additional information is very helpful in identifying the cause of the complaint.

2-13 What questions should be asked about a lump in the breast?

• How long has the lump been present?
• Have you had a lump like this before?
• Is the lump painful? If it is painful she should be asked whether the lump or the pain presented first. If she noticed the lump first then it should be considered a painless lump. Lumps nearly always become tender once they have been noticed.
• Has the lump changed in size since it was noticed? If the patient is still menstruating and the lump has been there for over a month, ask whether it altered during menstruation.

2-14 What questions should be asked about pain in the breast?

• When did the pain start?
• Is the pain related to menstruation?
• Is the pain worse in any particular part of your breast?
• Can you put a finger on the point of tenderness?

2-15 What questions should be asked about discharge from the nipple?

• Are you pregnant?
• What colour is the discharge?
• Is it from a single place on the nipple or from more than one place?
• Does it stain your clothes? This gives a good idea of the amount of discharge.
• Is there a discharge from both nipples?
• Does it come out without the breast being squeezed?

2-16 What questions should be asked about the change in appearance of the breast?

• When did you first notice the change in appearance?
• In what way has the breast changed? Colour, skin appearance, shape, symmetry or size.

2-17 What questions should be asked about a breast increasing in size?

• Have both breasts become bigger or only one breast?
• Have you put on weight in general?
• Are you pregnant?
• Are you on any drugs such as ARVs? (Antiretroviral drugs for HIV may cause the breasts to increase in size.)

2-18 What questions should be asked about a lump in the armpit?

• Have you got lumps anywhere else? Particularly in the groins, armpits or neck.
• Have you had a fever?
• Do you have a cough?
• Have you had an injury to your arm in the last month? Specifically ask about burns to the hand from cooking.
• Always ask about HIV status.

2-19 What questions should be asked about redness of the breast?

• Is it associated with any pain or tenderness?
• Is it associated with a fever?
• Are you pregnant?
• Are you a smoker?
• Has it changed since it was first noticed?
• How long has it been present?

2-20 What questions should be asked about thickening of the breast?

With thickening an area of the breast tissue feels more dense (firmer) than the surrounding tissue:

• Is there thickening in both breasts?
• How long has it been present?
• Has it changed since it was first noticed?

2-21 What questions should be asked about nipple changes?

• Has the nipple inverted (gone in): if so, when?
• Has the skin over the nipple changed?
• Have the changes happened to both breasts?

Having taken a careful history and asked the important questions, the patient’s breasts should now be thoroughly examined.

The examination of the breasts

2-22 How should the patient be prepared for a breast examination?

If the patient is comfortable, she should undress down to her waist and put on a gown. The examination must be done somewhere private and well lit. Always explain what you are going to do.

Most women will be comfortable sitting undressed down to the waist. However, some teenagers may be uncomfortable and women who have large tumours may be very reluctant to show you their breasts particularly if the tumour is fungating (ulcerated and often smells offensive).

It is very important to be able to have a good look at both breasts.

2-23 How should a step-by-step examination of the breast be done?

The examination consists of both looking (inspection) and feeling (palpating). Wherever possible, the examination should be done in a standardised step-by-step manner. Once you have done a breast examination a few times, it will become quite quick.

1. Sit the patient down on the examining couch and look at her breasts with her arms relaxed. Look for breast asymmetry, nipple inversion, skin changes and redness.

   

   Figure 2-2: Position during inspection of breasts

2. Ask the patient to raise her arms above the head. Look for any skin puckering. Ask the patient to point out where the problem is. Look specifically in that area to see if there is any change in the skin while she is moving her arm. This will help identify if a lump is attached to the skin.

   

   Figure 2-3: Position with arms raised while looking for a lump or skin puckering.

3. Ask the patient to put her hands on her hips and squeeze. Look and see if the area over the lump changes. This will show whether a lump is attached (tethered) to underlying muscle.

   

   Figure 2-4: Position with hands on hips while looking for tethering to underlying muscle.

   The breasts should be examined from the front with the patient sitting and relaxed, then with the arms raised and finally with the hands pressing on the hips.

4. Feel in the area above the clavicle (collar bone) for any lumps in the neck.

   

   Figure 2-5: Position for supraclavicular node examination

5. To examine the armpits properly the patient must be relaxed. If the patient is very ticklish it helps to press more firmly. The best way to get the patient to relax her muscles is by asking her to extend her arms and rest them on your shoulders while you examine the armpits. Feel in the two armpits (axillae) at the same time for any lumps. This allows you to compare the two armpits. The armpits are shaped like pyramids. You should feel along the inside wall and towards the front (anterior) for lymph nodes. Remember to feel at the top of the armpit also. If you think you feel a lump, examine that armpit very carefully. If you think you can feel a lump in one armpit it is best to examine that side alone. Palpating the armpits is an essential part of breast examination.

   

   Figure 2-6: Position while feeling in the armpits for nodes

To examine the armpits properly the patient must be relaxed.

6. Finally lie the patient down flat on her back and palpate (feel) her breasts with her arms above her head. This will flatten the breasts and make examination easier. It is easier to think of the breasts being divided into strips and then palpate each breast from the centre of the chest outwards. The breast extends from the clavicle (collarbone) above to the 6th rib below. The whole area of the breast must be examined. Always use the pulps of your fingers (the most sensitive part of your hand) with the rest of your hand gently resting against the breast. Do not use cold hands.

   

   Figure 2-7: The breast is palpated in strips to make sure the whole breast is examined.

   

   Figure 2-8: The breast being examined using finger tips with a flat hand.

7. Never forget to examine behind the nipple-areola complex (NAC) for any abnormalities such as skin changes, lumps or an inverted nipple. It is best to leave the nipple examination to the end once you have won the woman’s trust.

   

   Figure 2-9: Examining the nipple and areola for skin changes and lumps.

2-24 What do you look for when examining the breast?

1. Asymmetry: a woman has 2 breasts which can be compared!
2. Skin changes: the skin changes that are important include:
   • Peau d’orange means skin of an orange and usually indicates that there is a cancer.
   • Redness. Mark the area of redness.
   • Note if there are any areas where the skin seems to be stuck to the underlying breast tissue.
3. Change in the nipple. The 3 important things to look for are:
   • Inversion: a nipple pulled in instead of sticking out. This may be normal for the patient but is important if it has changed and the nipple used to stick out.
   • Change in the skin over the nipple: eczema-like changes need to be tested to ensure they are not Paget’s disease which involves the nipple and areola. Eczema is usually confined to the areola. They MUST be biopsied.
   • Discharge: if there is discharge from one or both nipples, note the colour and how many places in the nipple it comes from. Discharge from only one duct is more likely to be associated with malignancy.
4. There can be any number of skin-related problems that can be seen over the breast: melanomas, other skin cancers or sebaceous cysts.

2-25 What should you feel for when examining a breast?

1. Lumps in the breast. It is important to note:
   • The texture of the lump. The texture may be soft, firm or hard. Soft feels like your lips, firm feels like the tip of your nose, hard is like bone (your forehead).
   • Whether the lump is fixed to the skin or underlying muscle.
   • The size of the lump.
   • If the lump is easy to move or not (mobility).
   • If the lump has well-defined edges.
2. Thickening of the breast. Women with dense breasts may have normal dense tissue overlying and hiding a small cancer. If there is obvious asymmetry in the thickening, there may be a pathological cause. These patients should be referred for imaging. However, some asymmetry is normal.
3. Lumps in the armpit. It can be normal to feel lymph nodes in a thin patient. Normal lymph nodes are rubbery and mobile. Pathological lymph nodes are firm or hard and are not mobile. If a lymph node is felt, check the arm for burns, cuts or sores. Check the other armpit: if abnormal nodes are felt in both armpits, the patient may have another cause for enlarged nodes, e.g. HIV.

2-26 When is the best time to examine a woman’s breasts?

Examining the breasts can be very difficult particularly in young women. They can vary enormously depending on individual changes, the age of the patient and the stage of the menstrual cycle. The ideal time to examine a young woman is between day 6 and14 of her menstrual cycle. (Day 1 being the first day of the period.)

2-27 How should a breast examination be performed in a man?

The majority of patients with breast complaints are female. However, there are a number of male patients and they must be treated with empathy and compassion, as they are often very embarrassed to admit to having a problem with their breast. The approach to taking a history and examining the breasts of a man must be the same at that of a woman. It is very important not to ask questions that obviously only relate to women such as the date of the last menstrual period.

A sample form for recording your notes and examination is included as an appendix.

2-28 Should women be taught to examine their own breasts?

Yes. All women should be shown how to examine their breasts every month. Women soon get to know what their own breasts look and feel like and can detect any changes.

All women should be taught to examine their own breasts. They should look for change.

Case study 1

A 55 year old woman presents with a painless lump in her breast. She feels the lump is new. On examination, she has a hard mass in the upper outer quadrant of the breast.

1. With regard to the risk of breast cancer, what are the 3 most important facts given in the history?

The patient is female, 55 years of age and has no family history of breast cancer.

2. Does breast cancer only occur in females?

Breast cancer almost always occurs in females. However, breast cancer can occur in males and this should not be missed.

3. Why is her age important?

Because the risk of a breast lump being malignant increases with age.

4. What are the next most important questions to ask?

• When did she have her last period?
• Is the lump painful?
• How long has the lump been there?
• Has it changed since it was first noticed?

5. What specific factors are important to look for in the examination?

• Any area of overlying skin that appears to be attached to underlying tissue
• Inversion of the nipple
• Skin changes such as peau d’orange

6. What should you feel for on palpation?

• Size of the lump
• The firmness of the lump: sort, firm or hard
• The mobility of the lump: is the lump fixed to skin or muscle or does it seem to move freely?
• Are the lymph nodes palpable in the armpit on that side?

Case study 2

A young woman of 23 years visits her general practitioner with an upper respiratory infection. While taking a history she mentions that her father’s mother had breast cancer.

1. Why is a family history of breast cancer important?

Because breast cancer is more common in some families.

2. Is a history of breast cancer on the father’s side of the family important?

Yes. A family history of breast cancer is important on both the mother’s and father’s side of the family.

3. Is it likely that she has breast cancer?

No, as breast cancer is very uncommon in a woman of 22 years old.

4. Why is the age at which the family member presented with breast cancer important?

Because the younger the woman was when breast cancer was diagnosed the higher is the risk to other family members. If there are women in the family who develop breast cancer at less than 40 years, the risk is further increased.

5. What other cancer in the family will increase the risk of breast cancer?

Ovarian and prostate cancer are the two commonest associated cancers.

Case study 3

A young woman presents with a nipple discharge from one breast. She is very embarrassed and asks if she can keep her T-shirt on during the examination. The general practitioner, who is in a hurry, agrees and examines her breasts with her lying down. Her armpits are not examined. He only then asks about the discharge but not about her past or family history.

1. What is the problem with the way the history was taken?

Always start with a full history before beginning the examination. He should have asked whether she was pregnant as this could be the cause of the nipple discharge. Never rush a breast examination.

2. Can you examine a woman’s breast without her undressing?

No, as breast inspection is important. He needed to assess whether the discharge was from one or multiple sites on her nipple. She need only undress to the waist.

3. In what position should the woman be in when her breasts are examined?

First sitting up with her arms at her sides and then held above her head. Following this she should be examined with her hands pressing against her hips and finally examined lying down with her arms extended above her head.

4. How should the armpits (axillae) be examined?

Get the woman to relax her muscles by asking her to extend her arms and rest them on your shoulders while you examine her armpits.

Feel in the two armpits (axillae) at the same time as this allows you to compare the two sides. You should feel along the inside wall and towards the front (anterior) for lymph nodes. Remember to feel at the top of the armpit also. If you think you can feel a lump in one armpit it is best to examine that side alone.

5. What other lymph nodes should be palpated for?

The supraclavicular nodes.

6. Why should her armpits be examined?

Because it is part of the full breast examinations. It is important to feel for enlarged lymph nodes.