What are the general warning signs for breast cancer on a breast exam?

Warning Signs for Breast Cancer on Breast Exam

The most important warning signs for breast cancer on breast exam include new lumps, skin changes, nipple abnormalities, and breast contour changes, which should prompt immediate medical evaluation to reduce mortality and morbidity.

Key Physical Findings to Identify During Breast Examination

Palpable Abnormalities

• New breast lumps or masses: The most common presenting sign of breast cancer 1

  • Cancerous masses typically feel:
    • Firm or hard
    • Have indistinct or irregular borders
    • Fixed/immobile (not freely movable)
    • Asymmetric compared to the other breast

• Breast thickening or nodularity: Asymmetric firmness of an area compared to the contralateral breast or other quadrants of the same breast (associated with breast cancer in about 5% of women) 1

Visible Changes

• Skin changes:

  • Peau d'orange (skin dimpling with orange peel-like appearance)
  • Erythema (redness)
  • Edema (swelling)
  • Ulceration

• Nipple abnormalities:

  • Nipple retraction or inversion (especially new)
  • Nipple discharge (particularly spontaneous, unilateral, clear or bloody)
  • Nipple excoriation or scaling/eczema 1

• Breast contour changes:

  • Asymmetry not previously noted
  • Changes in size or shape of the breast 1

Lymph Node Involvement

• Enlarged axillary lymph nodes
• Supraclavicular or infraclavicular lymphadenopathy 1, 2

Anatomical Considerations

• The upper outer quadrant and the area under the areola/nipple are the two most common sites for breast cancer to appear 2

Important Clinical Correlations

Characteristics That Increase Suspicion

• Unilateral findings: Asymmetric findings are more concerning than bilateral changes
• New or changing: Recent onset or progressive changes are more concerning
• Fixed to skin or chest wall: Attachments to skin or deep fascia with dimpling or nipple retraction 1
• Hard consistency: Cancerous masses are typically firmer than surrounding tissue

Benign vs. Malignant Features

Benign masses typically:

• Have discrete, well-defined margins
• Are mobile
• Have a soft or rubbery texture 1

Malignant masses typically:

• Have indistinct borders
• Are firm or hard
• May be fixed to surrounding tissues
• May be associated with skin changes or nipple abnormalities 1

Common Pitfalls in Breast Examination

1. Failure to recognize non-lump presentations: About 1 in 6 women with breast cancer present with symptoms other than a breast lump 3

2. Relying solely on physical examination: Physical examination alone has limitations - in one study, four surgeons agreed on the need for biopsy in only 73% of masses subsequently proven malignant 1

3. Misinterpreting cysts as benign: Cysts cannot reliably be distinguished from solid breast masses by palpation alone - only 58% of palpable cysts were correctly identified by physical examination in one study 1

4. Overlooking subtle changes: Subtle signs of breast cancer can be missed, leading to delayed diagnosis 4

5. Neglecting to examine all breast tissue: Failure to systematically examine the entire breast from the clavicle to the inframammary fold and from the sternal midline to the midaxillary line 2

Clinical Approach to Suspicious Findings

When suspicious findings are identified on breast examination:

1. Document thoroughly: Location, size, consistency, mobility, and associated findings
2. Refer for imaging: Diagnostic mammography and ultrasound are the first-line imaging studies 1
3. Consider biopsy: Any highly suspicious breast mass detected by imaging or palpation should undergo biopsy unless exceptional clinical circumstances exist 1

Remember that negative imaging should never overrule a strongly suspicious finding on physical examination. The negative predictive value of mammography with ultrasound for a palpable mass ranges from 97.4% to 100%, but clinical suspicion should guide management 1.