Overview of Breast Examination Techniques
Knowing how to perform a detailed and correct breast exam is a crucial skill for many healthcare professionals in various fields. A clinical breast exam is vital in identifying and monitoring a range of non-cancerous and cancerous breast conditions. When used with other tests and evaluations, the breast exam gives us essential information to help diagnose and manage many breast diseases.
Currently, there are varied recommendations on how often a woman should have a breast cancer screening and what tests should be used. However, many of these guidelines agree that a clinical breast exam should be performed when a woman has abnormal results on her mammogram (a type of breast scan), and on a yearly basis for women who are at a higher risk of developing breast cancer.
Anatomy and Physiology of Breast Examination Techniques
Understanding the basic structure and function of the breast is key to comprehending the disorders that can arise within it. Many breast diseases occur when the normal function of the breast is disrupted, leading to a range of issues from mild and harmless irregularities to cancerous growth.
The development of breasts begins when we’re still in the womb, around five to six weeks into a pregnancy. These early breasts start as small offshoots of skin known as ‘ectoderm’ on the embryo. These offshoots extend from the area that will become the armpit all the way to the groin, forming what is called the “milk line”. Sometimes, in adults, we might find extra nipples or breast tissue along this line. These ectoderm buds push into a type of tissue called ‘mesenchyme’, a process that forms the first buds of breast tissue called primary buds. These buds then multiply into around 15 to 20 secondary buds which later become the lobes, or compartments, we see in adult breasts. The framework that supports the breast comes from skin cells.
Till puberty, male and female breasts develop similarly. At puberty, hormones like estrogen and progesterone trigger further growth in female breasts. However, the final stage of breast maturity only occurs during pregnancy and after the baby’s birth, when milk production begins. Breastfeeding keeps the milk flow continuous until it stops; then the pressure buildup of the unused milk leads to the shrinking of the milk production cells. As a woman reaches menopause, the levels of estrogen and progesterone in her body decrease, causing the lobular, or milk-producing tissue, to shrink. At this stage, the breast tissue gets denser, and fat gradually replaces the active breast tissue.
The adult breast is roughly cone-shaped, with its base lying over the chest muscles. Its boundaries are the collarbone at the top, the sternum or breastbone towards the center, the lower end of the chest muscles at the bottom, and a muscle called the ‘serratus anterior’ towards the side. The back of the breast tissue rests on a layer of tissue called the ‘pectoralis major fascia’. Inside, the breast contains 15 to 20 compartments, or lobes, which are further divided into smaller functional lobules. Support for the breast comes from structures called ‘Cooper’s ligaments’ which are attached to the skin. For convenience, doctors often describe the breast in quadrants or like a clock face when explaining findings from an examination. The top outer part of the breast has more tissue than the rest and is the most common site for breast cancer. This part extends towards the armpit and shoulder, and is known as the ‘axillary tail of Spence’.
Throughout a woman’s life, and even during her menstrual cycle, breast changes are normal. During pregnancy and breastfeeding, the milk-carrying ducts in the breast get bigger. In women who aren’t pregnant, swelling of the breast can occur due to fluid build-up before her period, causing discomfort. This fluid can cause changes to the breast tissue, which usually resolve by the end of her menstrual cycle. After menopause, breast tissue is often replaced with fat and connective tissue, a process called ‘involution’.
Why do People Need Breast Examination Techniques
If you notice any changes in your breasts that concern you, it’s a good idea to get a clinical breast exam. These changes could include things like breast pain, changes to your skin or nipples, nipple discharge, lumps, or a noticeable change in the size or shape of your breasts. Even though there’s some debate about whether or not women should do self-checks for breast cancer, if you do notice any changes during a self-exam, you should let your doctor know.
In fact, many women end up discovering breast cancer themselves during these kinds of self-exams. Also, if you get any other kind of imaging test (like a mammogram, ultrasound, MRI, chest CT, or PET) and the radiologist sees something suspicious, they’ll likely recommend a clinical breast exam to check it out further.
Different organizations have different recommendations for how often women should get breast exams:
- The National Comprehensive Cancer Network suggests that women between the ages of 25 and 40 who don’t have any symptoms or extra risk factors for breast cancer get a breast exam every 1 to 3 years. Women over 40 or those who have more risk factors or a history of breast cancer should get checked more often.
- The American Congress of Obstetricians and Gynecologists suggests that women between 25 and 39 get offered a breast exam every 1 to 3 years, and that women over 40 get one every year. They also recommend that doctors talk about the potential risks of screening with their patients.
- The American Cancer Society doesn’t recommend regular clinical breast exams for cancer screening. However, they do recommend that all women be aware of what their breasts usually look and feel like so that they can quickly notice and report any changes.
- The United States Preventive Services Task Force doesn’t have current recommendations for clinical breast exams in cancer screening because of a lack of evidence. But they do recommend getting a detailed medical history to see if there’s a higher genetic risk for breast cancer. This historical evidence could include a personal history of breast cancer before age 50, a personal history of cancer in both breasts, family history of breast and ovarian cancer, a family history of a male with breast cancer, multiple family members with breast cancer, and Ashkenazi Jewish heritage. If any of these factors apply to you, they recommend genetic counseling.
Remember, the most important thing is to be aware of your body and to talk to your doctor if you notice any changes.
When a Person Should Avoid Breast Examination Techniques
There are a few reasons why a medical procedure may not take place. One of them is if the patient doesn’t agree to it or can’t cooperate. Sometimes, a patient might be too nervous to go through with the procedure. This can often be managed by reassuring the patient and making sure they are as comfortable as possible.
Preparing for Breast Examination Techniques
Depending on the hospital or clinic’s policies, it’s often recommended to have a chaperone of the same gender present during the patient’s examination. This is to make the patient feel more at ease and secure. Doctors are encouraged to be kind and understanding since patients might feel nervous during the exam.
Before the exam, it’s important for the patient to change into a hospital gown. This allows the doctor to easily examine the full area of the patient’s breast. A sheet should be available to cover the lower part of the patient’s body. This helps the patient feel more comfortable. During the exam, a sheet or the hospital gown should also be used to cover the other breast. This helps make sure the patient’s privacy and comfort level are respected during their examination.
How is Breast Examination Techniques performed
Doctors have various methods for performing a breast exam, and they will likely have a way they prefer. Regardless of the method used, it is crucial that the doctor follows the same steps each time to ensure nothing is overlooked.
Observation
First, the doctor will visually inspect the breasts while the patient is sitting and facing them. The patient will be asked to put their hands on their hips and then raise them above their head. The doctor will carefully observe to notice the following aspects of the breasts: overall size, shape, symmetry, nipple size, shape, texture, and color. Any changes in these aspects compared to previous exams or between one breast and the other will be noted. The doctor will also look out for areas of thicker skin, or areas where the skin seems to pull in or stick to the underlying breast tissue. These alterations can be more noticeable when the patient moves or flexes the muscles in the chest.
Feeling the Breast Tissue
After inspecting the breasts visually, the doctor will ask the patient to lie flat on their back. If the patient has a concern about one specific breast, the doctor will start examining the opposite or “normal” breast. The patient will be asked to place the hand on the same side as the breast being examined above or behind their head to flatten the breast tissue as much as possible.
The doctor will then feel (palpate) the breast tissue, progressing from the surface to deeper tissues. There are several techniques for this, but common ones involve moving the fingers in a radial pattern (like the spokes of a wheel), in vertical strips, or in concentric circles. Regardless of the technique used, it’s important that the doctor uses the same one each time.
If the doctor finds a lump or an abnormal area, they will note its location (using a “clock face” or quadrant method), its size, shape, texture, how movable it is, how distinct its borders are, if it’s tender, and how deep it feels. The doctor will also examine the nipple and areola (the darker skin around the nipple) for abnormalities, and they might try to see if any fluid can be squeezed out of the nipple.
After examining the breast, the doctor will palpate the armpit (axilla) and the area above the collarbone for enlarged lymph nodes. If any are found, they will be described like a lump in the breast.
Examining Male Breasts
In men, a breast exam is usually simpler because there is usually less tissue to examine. However, if a man is overweight or has gynecomastia (increased breast tissue), the exam will be more complex. The same principles as in women apply to examining the male breast.
Writing the Results Down
Common terms in a report of a breast exam include:
* Symmetrical (both breasts look the same) or asymmetrical (they look different)
* Shape (sagging or pendulous, any scars or unusual shapes)
* Texture (soft, lumpy, dense, cyst-filled, simple)
* Lumps (described as above, or none found)
* Nipple-areola complex (pink or brown, pointing out or in, if any discharge is present and what it looks like, if the skin is dry and scaly which could indicate Paget’s disease)
* Skin (warm and dry, any redness or swelling, a skin-like orange look, open sores, fluid draining)
What Else Should I Know About Breast Examination Techniques?
Results from a breast exam play a key role in determining the next steps for care related to the specific issue. For instance, if there’s a spot seen in an imaging scan but cannot be felt by touch during the exam, doctors may need to get a sample from it (biopsy) while looking at the image. Imaging guidance provides precise location for the biopsy procedure.
When it comes to skin infections of the breast (cellulitis) or a pocket of pus in the breast (breast abscess), closely watching the breast’s condition is essential for knowing if the infection is getting better with treatment.
When being treated for cancer, it’s important to check if there are swollen lymph nodes that can be felt. The presence or absence of these nodes will guide the doctors on what to do next, both in terms of surgery and cancer treatment.
