Breast

1 Pain. Any pain or tenderness in the breasts? When did you first notice it?

_ Where is the pain? Localized or all over?

_ Is the painful spot sore to touch? Do you feel a burning or pulling sensation?

_ Is the pain cyclic? Any relation to your menstrual period?

_ Is the pain brought on by strenuous activity, especially involving one arm; a change in activity; manipulation during sex; part of underwire bra; exercise?

Mastalgia

Is the pain cyclic? Any relation to your menstrual period?

Cyclic pain is common with normal breasts, oral contraceptives, and benign breast (fibrocystic) disease.

Is pain related to specific cause?

2 Lump.

Ever noticed a lump or thickening in the breast?

Where?

_ When did you first notice it? Changed at all since then?

_ Does the lump have any relation to your menstrual period?

_ Noticed any change in the overlying skin: redness, warmth, dimpling, swelling?

Carefully explore the presence of any lump.

A lump present for many years and exhibiting no change may not be serious but still should be explored.

Approach any recent change or new lump with suspicion.

3 Discharge. Any discharge from the nipple?

_ When did you first notice this?

_ What color is the discharge?

_ Consistency—thick or runny?

_ Odor?

Galactorrhea.

4 Rash. Any rash on the breast?

_ When did you first notice this?

_ Where did it start?

On the nipple, areola, or surrounding skin?

Paget's disease starts with a small crust on the nipple apex and then spreads to areola (see Table 17-6, Abnormal Nipple Discharge, p. 407).

Eczema or other dermatitis rarely starts at the nipple unless it is due to breastfeeding.

It usually starts on the areola or surrounding skin and then spreads to the nipple.

5 Swelling.

Any swelling in the breasts? In one spot or all over?

_ Related to your menstrual period, pregnancy, or breastfeeding?

_ Any change in bra size?

6 Trauma. Any trauma or injury to the breasts?

_ Did it result in any swelling, lump, or break in skin?

A lump from an injury is due to local hematoma or edema and resolves shortly.

Or, trauma may cause a woman to feel the breast and find a lump that really was there before.

7 History of breast disease.

Any history of breast disease yourself?

_ What type? How was this diagnosed?

_ When did this occur?

_ How is it being treated?

_ Any breast cancer in your family? Who? Sister, mother, maternal grandmother, maternal aunts, daughter?

How about your father's side?

_ At what age did this relative have breast cancer?

Past breast cancer increases the risk for recurrent cancer (see Table 17-2 on p. 391).

The presence of benign breast disease makes the breasts harder to examine;

the general lumpiness conceals a new lump.

Breast cancer occurring before menopause in certain family members increases risk for this woman (see Table 17-2).

8 Surgery.

Ever had surgery on the breasts? Was this a biopsy?

What were the biopsy results?

_ Mastectomy? Mammoplasty—augmentation or reduction?

9 Self-care behaviors.

_ Have you ever been taught breast self-examination?

_ (If so) How often do you perform it? What helps you remember?

That is an excellent way to be in charge of your own health.

I would like you to show me your technique after we do your examination.

_ (If not) This will be an excellent way that you can take charge of your own health.

You can make breast self-examination a very routine health habit, just like brushing your teeth.

I will teach you the technique after we do your examination.

_ Ever had mammography, a screening x-ray examination of the breasts? When was the last x-ray?

_ The American Cancer Society recommends that women ages 20 to 39 years should perform BSE and have a CBE every 3 years;

women ages 40 years and older should perform BSE, with an annual mammogram and an annual CBE conducted close to the same time.

⁴

Awareness that breast self-examination (BSE), clinical breast examination (CBE), and mammograms are

complementary screening measures.

With good BSE practice, a woman knows how her breasts normally feel and can detect any change more easily.

Mammography can reveal cancers too small to be detected by the woman or by the most experienced examiner.

However, interval lumps may become palpable between mammograms.

1 Tenderness, lump, or swelling.

Any tenderness or lump in the underarm area?

_ Where? When did you first notice this?

2 Rash. Any axillary rash? Please describe it.

_ Seem to be a reaction to deodorant?

Breast tissue extends up into the axilla.

Also, the axilla contains many lymph nodes.

Additional History for the Menopausal Woman

1.

Decreased estrogen level causes decreased firmness.

Rapid decrease in estrogen level causes actual shrinkage.

General Appearance

Note symmetry of size and shape (Fig. 17-7).

It is common to have a slight asymmetry in size;

often the left breast is slightly larger than the right.

Skin

The skin normally is smooth and of even color.

Note any localized areas of redness, bulging, or dimpling.

Also, note any skin lesions or focal vascular pattern.

A fine blue vascular network is visible normally during pregnancy.

Pale linear striae, or stretch marks, often follow pregnancy.

Normally, no edema is present.

 Edema exaggerates the hair follicles, giving a “pigskin” or “orange-peel” look (also called peau d'orange).

Hyperpigmentation.

Redness and heat with inflammation.

Unilateral dilated superficial veins in a nonpregnant woman.

Nipple

The nipples should be symmetrically placed on the same plane on the two breasts.

Nipples usually protrude, although some are flat and some are inverted.

They tend to stay in their original condition. Distinguish a recently retracted nipple from one that has been inverted for many years or since puberty.

Normal nipple inversion may be unilateral or bilateral and usually can be pulled out (i.e., it is not fixed).

Note any dry scaling, any fissure or ulceration, and bleeding or other discharge

A supernumerary nipple is a normal and common variation (Fig. 17-8).

An extra nipple along the embryonic “milk line” on the thorax or abdomen is a congenital finding.

Usually, it is 5 to 6 cm below the breast near the midline and has no associated glandular tissue.

It looks like a mole, although a close look reveals a tiny nipple and areola.

It is not significant; merely distinguish it from a mole.

Deviation in pointing (see Table 17-3).

Recent nipple retraction signifies acquired disease (see Table 17-3).

Explore any discharge, especially in the presence of a breast mass.

Rarely, additional glandular tissue, called a supernumerary breast, is present.

Maneuvers to Screen for Retraction

Direct the woman to change position while you check the breasts for skin retraction signs.

First ask her to lift her arms slowly over her head. Both breasts should move up symmetrically (Fig. 17-9).

Retraction signs are due to fibrosis in the breast tissue, usually caused by growing neoplasms.

The fibrosis shortens with time, causing contrasting signs with the normally loose breast tissue.

Note a lag in the movement of one breast.

INSPECT AND PALPATE THE AXILLAE

Examine the axillae while the woman is sitting. Inspect the skin, noting any rash or infection.

Lift the woman's arm and support it yourself, so that her muscles are loose and relaxed.

Use your right hand to palpate the left axilla (Fig. 17-13). Reach your fingers high into the axilla.

Move them firmly down in four directions:

(1) down the chest wall in a line from the middle of the axilla,

(2) along the anterior border of the axilla,

(3) along the posterior border, and

(4) along the inner aspect of the upper arm.

Move the woman's arm through range-of-motion to increase the surface area you can reach.

Usually nodes are not palpable, although you may feel a small, soft, nontender node in the central group.

 Expect some tenderness when palpating high in the axilla.

Note any enlarged and tender lymph nodes.

PALPATE THE BREASTS

Help the woman to a supine position.

Tuck a small pad under the side to be palpated and raise her arm over her head.

These maneuvers will flatten the breast tissue and displace it medially.

Any significant lumps will then feel more distinct (Fig. 17-14).

For pendulous breasts, to distribute the tissue medially across the chest wall, ask the woman to rotate her hips opposite to the side you are palpating.

Use the pads of your first three fingers and make a gentle rotary motion on the breast.

Vary your pressure so you are palpating light, medium, and deep tissue in each location.

The vertical strip pattern (Fig. 17-15, A) currently is recommended as the best way to detect a breast mass, but two other patterns are in common use:

from the nipple palpating out to the periphery as if following spokes on a wheel (Fig. 17-15, B;

and palpating in concentric circles out to the periphery

breast assessment cont.

For the vertical strip pattern, start high in the axilla and palpate down just lateral to the breast.

Proceed in overlapping vertical lines ending at the sternal edge.

In every pattern, take care to palpate every square inch of the breast and to examine the tail of Spence high into the axilla.

Be consistent and thorough in your approach to each woman.

In nulliparous women, normal breast tissue feels firm, smooth, and elastic.

After pregnancy, the tissue feels softer and looser.

Premenstrual engorgement is normal from increasing progesterone.

This consists of a slight enlargement, a tenderness to palpation, and a generalized nodularity;

the lobes feel prominent and their margins more distinct.

breast assessment cont.

Also, normally you may feel a firm transverse ridge of compressed tissue in the lower quadrants.

This is the inframammary ridge, and it is especially noticeable in large breasts. Do not confuse it with an abnormal lump.

After palpating over the four breast quadrants, palpate the nipple (Fig. 17-16).

Note any induration or subareolar mass. With your thumb and forefinger, gently depress the nipple tissue into the well behind the areola.

The tissue should move inward easily.

If the woman reports spontaneous nipple discharge, press the areola inward with your index finger—repeat from a few different directions.

If any discharge appears, note its color and consistency.

Note the number of discharge droplets and the quadrant(s) producing them.

Blot the discharge on a white gauze pad to ascertain its color.

Test any abnormal discharge for the presence of blood.

Except in pregnancy and lactation, discharge is abnormal (see Table 17-6).

Note the number of discharge droplets and the quadrant(s) producing them.

Blot the discharge on a white gauze pad to ascertain its color.

Test any abnormal discharge for the presence of blood.

For the woman with large pendulous breasts, you may palpate by using a bimanual technique (Fig. 17-17).

 The woman is in a sitting position, leaning forward. Support the inferior part of the breast with one hand.

 Use your other hand to palpate the breast tissue against your supporting hand.

If the woman mentions a breast lump that she has discovered herself,

examine the unaffected breast first to learn a baseline of normal consistency for this woman.

If you do feel a lump or mass, note these characteristics (Fig. 17-18):

1 Location—Using the breast as a clock face, describe the distance in centimeters from the nipple (e.g., “7:00, 2 cm from the nipple”).

Or diagram the breast in the woman's record and mark in the location of the lump.

2 Size—Judge in centimeters in three dimensions: width × length × thickness.

3 Shape—State whether the lump is oval, round, lobulated, or indistinct.

4 Consistency—State whether the lump is soft, firm, or hard.

5 Movable—Is the lump freely movable, or is it fixed when you try to slide it over the chest wall?

6 Distinctness—Is the lump solitary or multiple?

7 Nipple—Is it displaced or retracted?

8 Note the skin over the lump—Is it erythematous, dimpled, or retracted?

9 Tenderness—Is the lump tender to palpation?

10 Lymphadenopathy—Are any regional lymph nodes palpable?

Premenopausal women at midcycle often have tissue edema and mastalgia (pain) that make it hard to detect a lesion.

If your findings are in question, consider asking this woman to return for a follow-up examination the first week after her menses

when hormone levels are lower and edema is not present.

TEACH BREAST SELF-EXAMINATION

Finish your own assessment first, and then teach self-examination.

You need to focus your skill and concentration on the examination,

and you may be diverted by teaching at the same time.

The same is true for the woman. She waits to hear that your examination of her affirms that she is healthy.

Once reassured, she can relax about the findings and concentrate on your teaching.

Help each woman establish a regular schedule of self-care.

The best time to conduct BSE is right after the menstrual period, or the 4th through 7th day of the menstrual cycle,

when the breasts are the smallest and least congested.

Advise the pregnant or menopausal woman who is not having menstrual periods to select a familiar date to examine her breasts each month—

for example, her birth date or the day the rent is due.

Stress that self-examination will familiarize the woman with her own breasts and their normal variation.

Emphasize the absence of lumps (not the presence of them).

However, do encourage her to report any unusual finding promptly.

While teaching, focus on the positive aspects of BSE.

Avoid citing frightening mortality statistics about breast cancer.

This may generate excessive fear and denial that actually obstruct a woman's self-care action.

Rather, be selective in your choice of factual material:

(1) the majority of women will never get breast cancer;

(2) the great majority of breast lumps are benign; and

(3) early detection of breast cancer is important—if the cancer is not invasive, the survival rate is 98%.

Keep your teaching simple! The simpler the plan, the more likely the person is to comply.

Describe the correct technique and rationale and the expected findings to note as the woman inspects her own breasts (Fig. 17-19).

Teach the woman to do this in front of a mirror while she is disrobed to the waist.

At home, she can start palpation in the shower, where soap and water assist palpation.

Then palpation should be performed while lying supine.

Encourage the woman to palpate her own breasts while you are there to monitor her technique.

Use the return demonstration to assess her technique and understanding of the procedure.

teaching breast exam cont.

Many examiners use a simulated breast model so that the woman can palpate a “lump.”

Pamphlets are helpful reinforcers; give the woman two pamphlets to take home, and encourage her to give one to a relative or friend.

This may promote discussion, which is reinforcing.

Current evidence is inconclusive on the effectiveness of detection procedures of BSE and CBE.¹⁸

Concern exists that these procedures may result in more benign biopsies and create anxiety.⁸,³²

However, the value of early detection of breast cancer is clear.

While screening mammography is available for many groups of women in developed countries,

BSE is available to virtually all women.

 BSE is valuable to women who are younger or older

than the ages recommended for screening mammography or who have barriers to access mammography.

BSE is cheap, noninvasive, can be accomplished without visits to expert professionals, and enhances self-care action.

THE MALE BREAST

Your examination of the male breast can be abbreviated, but do not omit it.

Combine the breast examination with that of the anterior thorax. Inspect the chest wall, noting the skin surface and any lumps or swelling.

Palpate the nipple area for any lump or tissue enlargement (Fig. 17-20). It should feel even, with no nodules. Palpate the axillary lymph nodes.

The normal male breast has a flat disk of undeveloped breast tissue beneath the nipple.

Gynecomastia is a benign growth of this breast tissue, making it distinguishable from the other tissues in the chest wall (Fig. 17-21).

It feels like a smooth, firm, movable disk. This occurs normally during puberty.

It can be unilateral or bilateral and is temporary.

The adolescent is acutely aware of his body image.

Reassure him that this change is normal, common, and temporary.

Gynecomastia also occurs with use of

anabolic steroids,

some medications,

and some disease states.

 See Table 17-8, Abnormalities in the Male Breast.

The Aging Woman

Increasing age is the primary risk factor for developing breast cancer, so a yearly CBE is important.

On inspection, the breasts look pendulous, flattened, and sagging.

Nipples may be retracted but can be pulled outward.

On palpation, the breasts feel more granular and the terminal ducts around the nipple feel more prominent and stringy.

Thickening of the inframammary ridge at the lower breast is normal, and it feels more prominent with age.

Reinforce the value of the breast self-examination.

Women older than 50 years have an increased risk for breast cancer.

 Older women may have problems with

arthritis,

 limited range of motion,

or decreased vision that may inhibit self-care.

Suggest aids to the self-examination;

 for example, talcum powder helps fingers glide over skin.

Because atrophy causes shrinkage of normal glandular tissue, cancer detection is somewhat easier.

Any palpable lump that cannot be positively identified as a normal structure should be referred.

breast cancer risk factors

cannot be changed

Female gender, age >50 years

Personal history of breast cancer

Mutation of BRCA1 and BRCA2 genes

First-degree relative with breast cancer (mother, sister, daughter)

High breast tissue density

Biopsy-confirmed atypical hyperplasia

High-dose radiation to chest

Early menarche (<12 years)

or late menopause (>55 years)

breast cancer

lifestyle related risk factors

Nulliparity or first child after age 30 years

Recent oral contraceptive use

Never breastfed a child

Recent and long-term use of estrogen and progestin

Alcohol intake of ≥1 drink daily

Obesity (especially after menopause)

and high-fat diet

Physical inactivity

Edema (Peau d'Orange)

Lymphatic obstruction produces edema.

This thickens the skin and exaggerates the hair follicles, giving a pigskin or orange-peel look.

This condition suggests cancer.

 Edema usually begins in the skin around and beneath the areola, the most dependent area of the breast.

Also note nipple infiltration here.