How do you instruct the patient if you assess the breast using palpation technique?

Examination of the Breast

The medical history related to the breasts should include their development, previous experience with breastfeeding, systemic illnesses, infections, breast surgery or trauma, medications, allergies, self–breast examinations and findings, and any anatomic or physical concerns the mother has about her breasts.

The breast examination at prenatal and postpartum visits should include careful inspection and palpation. Inspection of the breasts is most effective in the sitting position, first with the arms overhead and then with the hands on the hips. Skin changes, distortions in shape or contour, and the form and size of the areola and nipple should be noted. Palpation can begin in the sitting position, looking for axillary and supraclavicular adenopathy. Palpation in the supine position is easier for the complete examination of the breast and surrounding anterolateral chest wall. Size, shape, consistency, masses, scars, tenderness, and any abnormalities can be noted in both descriptive and picture form for future comparison. Serial examinations should document maturational changes of pregnancy (size, shape, fullness, enlargement of areola) and nipple position (inversion or eversion).

The changes in the breast during pregnancy provide important prognostic data regarding successful breastfeeding. With the increased frequency of cosmetic breast surgery, it is important to be aware of the nature of any surgery and to examine carefully for the location of the surgical scars. Many women successfully breastfeed after surgery for benign breast disease, breast augmentation, or breast reduction. However, a periareolar incision or “nipple translocation technique” for breast reduction can damage nerves and ducts, making this more difficult. Nipple piercing is another increasingly common procedure, after which breastfeeding can be successful with the jewelry removed. Such surgeries do not preclude successful breastfeeding but rather remind us that additional early support should be provided to these mothers from physicians, nurses, lactation consultants, and peer support groups.

Clinical breast examination

The contribution of CBE in screening women with or without BRCA mutation, was reviewed in a recent publication.50 The sensitivity of CBE ranged from 3% to 50% and the cancer yield of CBE was from 0% to 3% or 4% of the total breast cancers.50 The two studies reporting the contribution of CBE to be about 3–4% of the breast cancers 34,45 had less screened detected breast cancers compared to other studies in which no additional breast cancers were detected by only CBE. Further, these two studies performed CBE semiannually compared to annually in the other studies. Another study which was not included in the review reported that biannual CBE detected four intervals cancers.42 Therefore, the contribution of annual CBE in screening women at high risk for breast cancer did not improve breast cancer detection. However, semi-annual CBE was shown to have a small contribution to breast cancer detection, though the evidence is very limited. It is important to balance the benefit with the harm of screening, as the price for detecting more breast cancer should be acceptable.

Breast Examination

If a woman has difficulty latching the baby in the neonatal period or if she complains of pain at any time, her breasts should be examined. For latching problems, it is important to determine whether a woman has flat or inverted nipples. Nipple inspection alone does not answer this question and the pinch test must be performed. The nipple is normally everted if the nipple protrudes when the areola is compressed, inverted when it retracts toward the breast when the areola is compressed, and flat when it neither protrudes nor retracts. Although flat or inverted nipples may make it more difficult for the infant to latch in the first few days, women with flat or inverted nipples should not be discouraged about breastfeeding, because in many cases of flat and inverted nipples, babies latch without difficulty. However, if an infant has difficulty latching, the mother/infant dyad should be seen within the first day of birth by someone experienced in lactation support. The adhesions that cause the nipple to flatten or invert can usually be broken. Having the mother use a manual or electric breast pump for a few minutes before the baby latches to draw out the nipple can do this. Another option is to use a nipple shield (Fig. 2.55) for a short time to allow the baby to latch more easily. If a nipple shield is offered, it should be done under the supervision of someone experienced in lactation support, because it is not intended for long-term use. Flat and inverted nipples usually improve with nursing. The use of breast shells during pregnancy has not been shown to improve flat and inverted nipples.

D. Breast Examination

The breast examination is done at the first visit to look for flat or inverted nipples or, less commonly, signs of breast disease such as fibrocystic changes or cancer. Traditionally, women with flat or inverted nipples were prescribed either breast shields or nipple exercises. Two randomized controlled trials find no clear evidence that either treatment improves success in breastfeeding and recommend that routine examination of the nipples be discontinued.15,16 Although not recommended for the promotion of breastfeeding, routine breast examination during the initial visit may be useful in diagnosing occult breast disease.

Examination of the Breasts

There are several accepted methods for examining the breasts; one is shown inFig. 45.3. All areas of the breast must be examined, with particular attention to the axillary tail and retroareolar regions. Breast examination involves six distinct manoeuvres:

observation with the patient sitting up;

observation with the patient raising and lowering her arms;

examination of the nipples;

systematic palpation of each breast;

palpation of axilla and supraclavicular fossa;

general examination for signs of distant metastases.

During inspection, the signs to be looked for are listed inFig. 45.1.

Palpation may be donecircumferentially using the flat of one hand, starting at the nipple then moving in progressively larger circles;radially from the nipple outwards, like the spokes of a wheel; or bysectors, examining each quadrant in turn. Axillary lymph nodes are palpated, whilst the examiner’s other hand supports the patient’s arm (seeFig. 45.3G and H). This helps relax the muscles and aids assessment of the nodal groups (medial, lateral, anterior, posterior and apical). Note that clinical assessment of axillary nodes is unreliable, with a 30% false positive and a 30% false negative rate.

A history ofnipple discharge can often be confirmed by pressure over the appropriate sector near the areola. Discharges not obviously blood-stained should be tested for blood using urinalysis dipsticks. In all cases, a smear preparation should be examined for cytological abnormalities.

III. BREAST ASSESSMENT

FOLLOW-UP CARE AND INSTRUCTIONS

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A breast examination not recorded is a breast examination not performed. The clinician should clearly document the performance and findings of the CBE and the plan of action.

If referral for further diagnostic or screening studies is warranted or recommended, “tickler” files or computer reminders to ensure and document patient compliance and the results obtained are essential. Written documentation of all patient contacts regarding referral or recommended further diagnostic or screening studies is vital. Patients who do not keep referral appointments should be contacted by telephone and certified mail.

Patient education concerning the CBE should include information on the sensitivity and specificity of the examination and information about why the duration of the examination is important.

Education must also include accurate information concerning breast cancer prevalence.

Information concerning current recommendations for other breast cancer screening modalities, such as mammography and breast self-examination, should be provided as well.

The patient education provided must be accurately documented in the medical record.

Most clinicians include information and education concerning the breast self-examination during the annual CBE. The effect of breast self-examination on breast cancer mortality is uncertain. Self-reported frequency of breast self-examination has never been correlated with improved outcome. Appropriate teaching of technique, however, has been shown to improve the efficacy of breast self-examination in the discovery of smaller, and hence more treatable, masses. Many studies of this practice have provided contradictory results; the evidence is not considered strong enough to make a clear recommendation for or against breast self-examination by many governmental health authorities. Private organizations, however, including the American Cancer Society, recommend this procedure. As a result, women should be instructed in appropriate technique, frequency, and duration of breast self-examination. These examinations, however, should not substitute for CBE.

Many clinicians traditionally included information and education concerning the breast self-examination during the annual CBE. However, breast self-examination has not been demonstrated to decrease breast cancer deaths; it does increase the number of negative invasive diagnostic procedures without providing a corresponding survival benefit. Although some prominent organizations continue to recommend the procedure and it is widely publicized, its risks and lack of demonstrated positive outcomes should be discussed with each patient thoroughly.

Screening and Diagnosis

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Breast examinations. Monthly breast self-examinations and expert clinician breast examinations are critical in the early identification of a breast lump.

Mammography (x-ray of the breast) can be useful in identifying and locating the lump. The procedure involves exposing the breasts to small amounts of radiation.

Fine-needle biopsy to assess the fluids in the mass.

Excisional biopsy to remove the lump and assess the tissues.

Laboratory analysis, including complete blood count (CBC) and liver function tests.

Chest x-ray.

Ultrasound can identify masses missed by mammography and differentially diagnose a solid mass from a fluid-filled mass.

Pathologic review of biopsy, and estrogen and progesterone receptor determination and S-phase determination.

Bone scan should be performed if symptoms suggest bony metastasis, if alkaline phosphatase is elevated, or if widespread disease is suspected.

Ductal lavage is used to identify cancerous and precancerous cells in the milk ducts of the breast. The procedure involves injecting saline solution into fluid-producing ducts. The saline solution then is suctioned out along with cells from the epithelial lining of the ductal system. The fluid is analyzed for normal, atypical, or malignant cells.

Thermography. Breast thermography can be used to evaluate the degree of vascular dilation of the breasts. This measure is compared with the degree of dilation during lactation when estrogen levels are elevated. Prolonged exposure to estrogen is a risk factor for breast cancer. The degree of vascular dilation in the breast may provide an assessment of the levels of estrogen in the breast.

There is evidence to suggest that the breasts can hold 10 to 50 times more estrogen than identified on a typical blood test. Excess estrogen stimulates breast tissue and dilates blood vessels. Dilated blood vessels are more visible on thermo-grams than nondilated vessels because they have more blood and heat flowing through them.

Breast Cancer Screening

Assessment of the Breast

The breast examination is included as a routine part of the gynecologic examination. If the patient has complaints about discomfort or pain in a breast, the health care professional should begin by examining the nonaffected breast and axilla. Inspect the breasts with the patient in the supine and sitting positions, with her hands above her head and then on her hips. Care should be taken to observe the contour, symmetry, and vascular pattern of the breasts for signs of skin retraction, edema, or erythema. Then, the examiner should systematically palpate each breast, the axillae, and the supraclavicular areas using the pads of the fingers to feel for masses. This can be accomplished by going in a circle, dividing the breast into segments, or by going up and down. Regardless, care must be taken to examine the breast in its entirety. Finally, the nipple should be evaluated for discharge, crusting, or ulceration.