What are the steps for conducting a breast examination?

Step-by-Step Guide to Performing a Breast Examination

A thorough clinical breast examination should include visual inspection of the breasts, lymph node evaluation, and systematic palpation of breast tissue in a vertical strip pattern, with the breast tissue spread evenly over the chest wall to maximize detection of concerning lesions. 1

Patient Preparation and Positioning

1. Inform the patient in advance about the examination process and explain what will be assessed during each part 1
2. Position the patient appropriately:
   • Begin with the patient sitting upright for visual inspection and lymph node examination
   • For breast palpation, have the patient lie down with their ipsilateral hand placed overhead to flatten breast tissue on the chest wall 1
   • If needed, place a small pillow under the shoulder/lower back on the side being examined to centralize and evenly distribute breast tissue 1

Visual Inspection

1. Observe both breasts for:
   • Asymmetry or changes in size or shape 2
   • Skin changes (peau d'orange, erythema, edema, ulceration) 2
   • Nipple abnormalities (retraction, inversion, discharge, excoriation, scaling) 2
   • Breast contour changes 2

Lymph Node Examination

1. With patient sitting, examine:
   • Axillary lymph nodes
   • Supraclavicular lymph nodes
   • Infraclavicular lymph nodes 1

Breast Palpation

1. Define the perimeter of breast tissue to be examined:

   • Down the midaxillary line
   • Across the inframammary ridge at the fifth/sixth rib
   • Up the lateral edge of the sternum
   • Across the clavicle
   • Back to the midaxilla 1

2. Use a systematic search pattern:

   • The "vertical strip" pattern is recommended for thoroughness 1
   • The "dial of a clock" pattern has shown highest sensitivity in some studies 3

3. Palpation technique:

   • Use the finger pads of the middle three fingers 1
   • Make overlapping dime-sized circular motions 1
   • Apply three levels of pressure in sequence:
     • Light (subcutaneous tissue)
     • Medium (mid-level tissue)
     • Deep (down to chest wall) 1

4. Pay special attention to:

   • Upper outer quadrant and area under the areola/nipple (most common cancer sites) 1
   • Palpate tissue at and beneath the nipple (do not squeeze) 1

5. Take adequate time:

   • A careful examination of an average-sized breast may take several minutes 1
   • Explain this to patients to prevent surprise or discomfort 1

What to Look For

1. Concerning findings that warrant further evaluation:

   • Firm or hard masses with indistinct or irregular borders 2
   • Fixed/immobile masses 2
   • Asymmetric thickening or nodularity 2
   • Skin changes or nipple abnormalities 2

2. Benign characteristics typically include:

   • Discrete, well-defined margins
   • Mobile masses
   • Soft or rubbery texture 2

Common Pitfalls to Avoid

1. Inadequate coverage of breast tissue (not examining the entire breast) 2
2. Insufficient pressure variation (not using all three levels of pressure) 1
3. Rushing the examination (not taking adequate time for thorough assessment) 1
4. Overreliance on physical examination alone (sensitivity is only about 54%) 4
5. Squeezing the nipple instead of properly palpating tissue beneath it 1
6. Attempting to distinguish cysts from solid masses by palpation alone (only 58% accuracy) 2

Important Considerations

• The clinical breast examination alone has limitations, with sensitivity estimated at 54% and specificity at 94% 4
• Approximately 5% of breast cancers are identified solely by clinical breast examination 1
• Any suspicious findings should prompt appropriate diagnostic imaging (mammography and ultrasound) 2
• Negative imaging should never overrule a strongly suspicious finding on physical examination 2

Remember that a thorough, systematic approach to breast examination can help identify concerning lesions that warrant further evaluation, potentially reducing breast cancer morbidity and mortality.