Although monthly self breast examination (SBE) is recommended, it has not been shown to lower the mortality from breast cancer. Advising women to be aware of their breasts and report any masses or skin changes immediately may be more realistic.

It is difficult for clinicians to become proficient at physical examination of the breast. Unlike auscultation of the chest or assessment of cranial nerves, where normal findings do not vary among normal patients, normal breasts look and feel different among normal women. Similarly, normal mammograms look different from one woman to the next. It takes a long time before a doctor is comfortable stating that a woman’s clinical breast examination (CBE) is normal, and even when they do, the fact remains that CBE is not a very sensitive tool for detecting early-stage cancer.

One can approach CBE by trying to detect a finding in one breast such as a mass, that is not present in the other. Breasts should first be inspected with patients sitting with their hands at their side, then on their hips, and above their head. Breast size and any asymmetry, visible masses, and skin changes, such as ulceration, erythema, dimpling, skin thickening, or edema, should be noted. Clinicians should look for nipple inversion, retraction, discoloration, or dryness. Patients then recline to supine and the entire breast is systematically palpated. A circular, vertical, or horizontal approach can be used as long as the entire breast is palpated, including the nipple areolar complex, the retroareolar area, axillary tail of Spence, and the axilla. Large breasts

can be difficult to examine and in these cases it may be helpful to position the patient on her side and palpate the breast when it has fallen away from the chest wall. There is no need to squeeze the nipple to look for discharge unless the patient is concerned about nipple discharge. Fluid can be expressed from most nipples if enough pressure is applied, and this is considered normal.

Clinicians often use the term fibrocystic to describe a breast that is tender, nodular, or dense on clinical examination. Fibrocystic disease or fibrocystic changes is a pathologic term and should not be used to describe clinical findings. Most breasts are not smooth, soft, or homogeneous in texture; they may be nodular, hard, or dense, and all of these findings are within the spectrum of normal. Because normal breasts vary greatly among patients, often what a clinician describes as fibrocystic is a variation of normal breast tissue. Furthermore, most women report tenderness during CBE; it may be focal or generalized, unilateral or bilateral. Pain and tenderness associated with a palpable mass or erythema warrants investigation, but breast tenderness alone is not a sign of disease.

Adult women at normal risk for developing breast cancer should undergo baseline mammography at age 35 years and yearly screening mammogram beginning at age 40 years. This evaluation should be combined with CBE examination by a trained clinician.

Sources Elsevier

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