UPDATE ARTICLE

Clinical Examination Of The Breast

K L Cheung,* MBBS(HK), FRCSEd, FACS,Department of Surgery

The University of Hong Kong

Summary

Clinical examination of the breast plays a crucial role in the management of symptomatic breast conditions.Triple assessment, with clinical assessment forming part of the process, is superior to using any one modality alonein the diagnostic work-up of a breast symptom. The techniques of clinical examination are described with referenceto the common breast symptoms.

There is little evidence to support the use of either breast self-examination or physical examination byprofessionals as a screening procedure for the well women. However, the concept of breast awareness should bepractised and encouraged. (HK Pract 1999;21:62-70)

Is &

Introduction

The scope of breast servicei n c l u d e s t h e m a n a g e m e n t o fsymptomatic breast conditions andbreast cancer screening. I n i t i a linvestigation of breast symptomsshould be by cl inical examinat ion(CE).1 Clinical assessment, withphysical examinat ion forming thepillar, should be the starting point ofthe triple assessment process for awoman with breast symptoms. Notall women need breast imaging fromthe r ad io log i s t . 1 This a r t i c l ediscusses the role of CE of the breastin the management of symptomatic

breast conditions. Description of thetechniques of examination forms thecore of this article, which shouldbetter be read in conjunction with theauthor 's article on common breastconditions.2 It is followed by a shortreview of the current evidence on theusefulness of breast examination inscreening for the well women.

Role of clinical examinationof the breast

The crucial role of CE of thebreast lies in the symptomat icmanagement of breast conditions. A

woman w i t h a breas t symptomshould first be assessed clinically.Clinical examination generally playsa much more important role than thehistory in the diagnostic assessmentof the s y m p t o m . Very o f t enr a d i o l o g i c a l a n d c y t o l o g i c a lassessments, the other components inthe triple assessment process, are notnecessary after a carefully performede x a m i n a t i o n has exc luded anyclinical abnormality. For a womancomplaining of feeling a lump, shecan be reassured and discharged ifCE detects no abnormality. On thecontrary, CE should aim to identifyfeatures that distinguish a malignant

Address for correspondence : Dr K L Cheung, Department of Surgery. The University of Hong K o n g , Queen Mary Hospital. Hong Kong.

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f rom a ben ign lump. 3 C l i n i c a lexamination can differentiate single-d u c t f r o m m u l t i - d u c t n i p p l edischarge which is often physio-logical or surgically insignificant. Aw o m a n w i t h m a s t a l g i a can bedischarged if CE is normal and thepain does not disturb her quali ty oflife.2

Although the sens i t iv i ty of CEof the breast (84% in one series)4 isnot as high as mammography or fineneedle aspiration cytology, CE playsa complementary role in the tr ipleassessment process. Around 10% ofc a n c e r s a r e no t d e t e c t e d bymammography. The combination useof all assessments is superior to usingany one modality alone and leads toa very high diagnostic accuracy.5,6

Many other breast conditionssuch as gynaecomastia, accessorybreasts and nipples, and Mondor'sdisease are diagnosed by CE only.2,7

In a series of Paget's disease of thenipple , half of the patients hadnormal m a m m o g r a m s and thediagnosis was suspected only onclinical ground.8

Techniques of c l i n i c a lexamination of the breast

Clinical examina t ion of thebreast is an embarrassing procedurefor the woman and can sometimeslead to medicolegal consequences ifinappropriate ly performed. Tominimize embarrassment and toavoid misunderstanding, adequateexplanation of the procedure andcompetence in the skills are essential.Privacy should be ensured and theroom t e m p e r a t u r e s h o u l d be

acceptable. A nurse can both act asa chaperon for a male clinician andgive explanation and instruction tothe woman prior to CE. Other tipsinclude: not to stay with the womanwhile she is taking off or putting onher top; to give appropriate cueswhen necessary e.g. before palpatingthe 'normal' breast; to complete theprocedure efficiently and to avoidcha t t i ng on other subjects wh i l ecarrying out the examination.

There are many ways to performCE of the breast. The traditionalmethod has been crit icized to bet i m e - c o n s u m i n g because of thecomplicated manoeuvres necessary toinspect for retraction or tethering.9

Here the au thor in t roduces onea c c e p t a b l e m e t h o d w h i c h , i fcompeten t ly carried out, can becompleted within a couple of minuteson average. The techniques areoutlined and emphases relating todifferent symptomatic presentationsare described.

Cl inical examinat ion of thebreast involves adequate exposure.The woman's top should be removedto expose her body above the waist.Inspection and palpation are carriedout separately and respectively in as i t t i n g and a s e m i - r e c u m b e n tposition. With the woman sitting onthe side of the examination couch,the clinician faces her squarely,sitting on a chair if available. Theobjec t ives are to look for thep r e s e n c e of (a) a l u m p , (b)inflammation and (c) tethering. Thepresence of a lump is suspected inany k i n d of asymmetry and iscertainly obvious when an ulceratedor f u n g a t i n g mass is ev iden t .Inflammation manifested as redness,

oedema and/or peau d'Orange can bedue to an inflammatory conditionsuch as mastitis or abscess, or aninflammatory breast cancer. Thenext step is to ask the woman to raiseher arms slowly up in the air (Figure1). By doing so, tethering of the skinand/or subtle nipple retraction can beseen. Tethering or retraction can bedue to an underlying cancer but canalso be the result of inflammation orprevious surgery. The lower half ofthe breast is inspected again for thepresence of a lump and inflamma-tion.

The woman is asked to liecomfortably in a semi-recumbentposition. There are many acceptableways in doing palpation e.g. circularor z ig-zag fash ion . The mostimportant points are (a) to use thepalmar aspect of the fingers; and (b)to make sure that the whole breast,including the retroareolar region andthe axillary tail, is systematicallycovered. With the woman's handsplaced alongside her body, a generalpalpation is done for both breastswith an aim of identifying any grossabnormalities which need to beconcentrated on at a later stage. Thewoman is then asked to put her handsbehind the head (Figure 2). In doingso, the breast, especially the lowerpart which is ptotic, becomes 'liftedupwards and flatter. This makespalpation more accurate. Detailedpalpat ion is carried out in thisposture. For a woman with largependulous breasts, the outer part ofthe breast can be better examined bypalpation when she turns slightly ina lateral manner, again to make thepart of the breast flatter.

(Continued on page 65)

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Figure 1: Inspection of the breasts Figure 2: Palpation of the breasts

When a discrete lump is felt, itssurface/edge, consistency/fluctuation,s ize , m o b i l i t y a re d e f i n e d anddocumented together with its locationon a diagram. Before the clinicianconcludes that a l u m p is freelymobile, one should demonstrate that(a) the skin can be picked up freelyfrom the lump; (b) the lump is mobilein the posture described in Figure 2(the pectoralis major is relaxed inthis pos ture - f ixa t ion impl iesadherence to the chest wall); and (c)the l u m p is mobi le when thepectoralis major is contracting (byasking the woman to press hard onthe waist - the muscle can be felttensing up in the anterior axillaryfold).

Occasions sometimes happenwhen the clinician cannot find thelump complained of by the woman.Clinical examina t ion has lowersensitivity for small lesions and inyoung women.4 The author wouldnormally ask the woman to point tothe alleged lump with one finger. Ifshe can do this swift ly, there isusua l ly a lump which has been

missed in the initial CE. Sometimesthe woman might wish to change toa different posture which can bettershow up the lump. However if shej u s t f idd les a round wi th manyfingers, it usually means that a truediscrete lump is not present.

After palpation of both breasts,the axillae are palpated in turn for thepresence of lymph nodes. Theclinician uses the right hand to feelthe left axilla and vice versa (Figure3), with the exception of the lateralgroup of lymph nodes along theupper arm where a change of hand isacceptable. While f ee l ing foraxillary lymph nodes, the clinicianholds the woman's opposite hand toensu re r e l a x a t i o n (Figure 3) .Whenever a lymph node is felt, itssize, consistency and mobility shouldbe delineated. The group or level towhich the lymph node belongs isclinically irrelevant. When there isa lump found in the supero-lateralaspect of the breast, sometimes it isdifficult to tell whether it is a lumpin the axillary tail of the breast or alymph node in the low axilla. The

trick is to ask the woman to tense thepectoralis major which forms theanterior boundary of the axilla. Alump situated behind the muscle ismost likely an axillary lymph node.

For a complete examina t ionwhen breast cancer is the clinicald i a g n o s i s , p a l p a t i o n of bothsupraclavicular fossae for lymphn o d e s , t h e a b d o m e n f o rhepatomegaly , and percussion/auscultation of the lung bases forpleural effusion are necessary.

Following an out l ine of thetechniques of CE of the breast,important features which should belooked for in different symptomaticpresentations are now described.2

After examining a woman with adiscrete lump, the clinician mustarrive at a conclusion as to whetherthe lump is clinically benign, indeter-minate, suspicious or malignant. Aclinically benign lump is smooth andmobile. However, most women withcancer first present to a family

(Continued on page 68)

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physician and even a breast surgeonwith a lump which is small (the meansize in the author's series is 2 cm10)and mobile. Ulceration, fungatingmass with fixation to structures andlarge ax i l l a ry l y m p h nodes arediagnostic signs of breast cancer butare rarely seen. The consistency ofa lump cannot reflect its nature sincea very tense simple cyst can feel firmand even hard. The size of a lumpis also not useful in distinguishing abenign from a m a l i g n a n t l u m p ,though one has to th ink of thepossibility of phyllodes tumour incase of a large but clinically benignlump.2 In the author's opinion, themost u s e f u l s u b t l e s igns for amalignant lump are (a) a lump withan irregular surface/edge; and (b)skin tethering/retraction of nipple.

I n a w o m a n w i t h n i p p l edischarge, CE aims, after excludingmi lky or p u r u l e n t d ischarge, atd i f f e r e n t i a t i n g m u l t i - d u c t f romsingle-duct discharge which can bedue to a duct carcinoma. The authorusually would not attempt to elicitdischarge when the woman does nothave such symptom. In case of acomplaint of nipple discharge, thewoman is asked to squeeze her nippleto confirm the presence of dischargeand its appearance. The nipple isthen wiped dry with a piece of gauze.The woman is asked to squeeze thenipple again. Multi-duct discharge isdiagnosed if multiple droplets areseen almost at the same time. Single-duct discharge, on the contrary, isseen consistently and persistently asa single droplet from a constantposition. The discharge is driedagain. The segment of breast tissueclose to the areola corresponding tothe location of the discharging duct

Figure 3: Palpation of the axillae

Figure 4: Single-duct nipple discharge

i s t h e n p re s sed g e n t l y . Ther e p r o d u c t i o n of the d i s c h a r g esupports the diagnosis of a lesionsuch as papilloma or carcinoma inthe duct (Figure 4). Although thereare 15-20 ducts in one nipple, it isconvenient to document the locationof s ingle-duct discharge in such away as "discharge from the 3 o'clockduct". Finally, for a woman withmastalgia, after excluding palpableabnormalities, gentle palpation toe l i c i t t e n d e r n e s s i s d o n e .

Occasionally a tender spot in thebreast can be identified while veryof ten tenderness in the media l(costochondral junctions) and lateralchest wall can be elicited in cases ofnon-cyclical pain.

Examination of the breast ofthe well women

A l t h o u g h m a m m o g r a p h i cscreening of women above the age of

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Key messages

1. Clinical assessment, with physical examination forming the pillar, should be the starting point of the triple assessment

process for a woman with breast symptoms.

2. Despite having a relatively low sensitivity, clinical examination (CE) of the breast, when combined with radiological

and cytological assessments, is superior to using any one modality alone in the diagnostic process of breast symptoms.

3. A number of breast conditions are diagnosed only by CE.

4. Clinical examination involves inspection in a sitting position and palpation in a semi-recumbent position.

5. In the case of a lump in the breast, CE aims at distinguishing a benign from a malignant lump, the subtle signs ofwhich in an early stage being an irregular surface/edge and associated skin tethering/nipple retraction.

6. In the case of non-galactorrhoeic and non-purulent nipple discharge, CE aims at identifying surgically significantdischarge which is often unilateral and from a single duct. :

7. There is little evidence to give support to the practice of breast examination, either as self-examination or as physicalexamination by professionals, as a screening procedure for the well women. ::

8. The concept of breast awareness should be practised and encouraged, : ; .,:••.•'•.. "•• \:'.'/.•'•.'

50 has been demonstrated to producea significant survival benefit,11-12

there is little evidence to support theusefulness in routinely examining thebreast, either as self-examination ora s p h y s i c a l e x a m i n a t i o n byprofessionals , as a screeningprocedure for the well women.13-14

Neither a change in the size of breastcancer, nor in the extent of nodalinvolvement, could be seen in apopulation study.15 The efficacy ofbreast examina t ion of the wellw o m e n b y p r o f e s s i o n a l s i squestionable, and is liable to givefalse reassurance. The Government'sAdvi so ry Commit tee on BreastCancer Screening, United Kingdomhas advised that palpation of thebreast by either medical or nursingstaff should not be included as part

of rou t ine hea l th screening forwomen.16

Breast self-examination is themonthly palpation performed by awoman at the same time each monthaccording to a set method. Thee f f e c t i v e n e s s o f b r e a s t s e l f -examination in reducing mortalityfrom breast cancer has never beenconsistently demonstrated. Inaddition it produces a high number offalse pos i t i ve s and can induceunnecessary anxiety. Therefore theAdvisory Committee also recom-mended that it should not bepromoted as a screening procedure.16

Instead the idea of breast awarenesshas been introduced. The Committeenoted that over 90% of breast cancerswere found by women themselves.

Women should be conscious of whatwas normal for them, about the feeland look of their breasts throughoutthe menstrual cycle. They recom-mended that women, especially thoseaged over 40 years, should be awareof their breasts in such every dayactivities as bathing, showering anddressing.17 They should seek medicaladvice whenever they notice anychange in the breast. The concept ofbreast awareness should be widelypractised and encouraged. •

References

Breast Surgeons Group of the B r i t i s h

Association of Surgical Oncology. Guidelinesfor surgeons in the management of symptomatic

breast disease in the United Kingdom. Eur J

Surg Oncol 1995;21A:1-13.

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Cheung KL. Common breast conditions - when

to refer and what will the specialist do? HK

Pract 1998;20:260-268.

Steering Commit tee on C l i n i c a l PracticeGuidelines for the Care and Treatment of Breast

Cancer. The palpable breast lump: informationand recommendations to assist decision-making

when a breast lump is delected. CMAJ 1998;158(Suppl 3):S3-S8.

Cardona G, Catal iot t i L, Ciatto S, et al.

Reasons for failure of physical examination in

breast cancer detection (analysis of 232 false-

negative cases). Tumori 1983:69:531-537.Winchester DP. Physical examination of the

breast. Cancer 1992;69(Suppl 7):1947-I949.

Mok CO, Yang WT, Ying SY, et al. Triple

evaluation of palpable breast lump in Chinese

women [Abstract]. Presented in 8th OverseasMeeting of the Royal College of Surgeons of

Edinburgh jointly with the College of Surgeons 13.of Hong Kong 1996.

7. Duff P. Mondor disease in pregnancy. Obstet 14.

Gynecol 1981;58:117-119.

8. Ikeda DM, Helvie MA, Frank TS, et al. Paget

disease of the nipple: radiologic-pathologic

correlation. Radiology 1993;189:89-94. 15.

9. Mahoney L, Csima A. Efficiency of palpation

in clinical detection of breast cancer. Can MedAssoc J 1982; 127:729-730.

10. Cheung KL. Improving the quality standards in

the management of pr imary breast cancer. 16.

Asian J Surg 1998;21:117-123.11. Shapiro S. Evidence on screening for breast

cancer from a randomized trial. Cancer 1977;39:2772-2782. 17.

12. Department of Health & Social Security. Breast

cancer sc reen ing (Cha i rman ; Sir Patr ick

Forrest). London: HMSO, 1986.

Miller AB. Screening for cancer. West J Med

1988; 149:718-722.

Baines CJ, Miller AB, Bassett AA. Physicalexamination. Its role as a single screeningmodali ty in the Canadian National Breast

Screening Study. Cancer 1989;63:1816-1822.Saltzstein SL. Potential l imits of physical

examination and breast self-examination in

detecting small cancers of the breast. Anunselected population-based study of 1302

cases. Cancer 1984;54:1443-1446.Department of Health. Clinical examination of

the breast. London: Department of Health, 1998(Professional Letter: PL/CMO/98/1, PL/CNO/

98/1).

Department of Heal th . Breast awareness.

L o n d o n : D e p a r t m e n t o f H e a l t h , 1991

(Professional Letter: PL/CMO/91/15, PL/CNO/

91/12).

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