What is involved in a physical breast exam?

Clinical Breast Examination Procedure

A thorough clinical breast examination should include a systematic approach with visual inspection, lymph node evaluation, and methodical 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 History

• Inform the patient about the examination process before starting, explaining each step and what will be assessed 2, 1
• Collect relevant clinical history including:
  • Screening practices (previous breast self-exams, clinical exams, mammograms)
  • Any breast changes or symptoms (lumps, pain, nipple discharge, skin changes)
  • Risk assessment (personal/family history, hormonal therapy, obstetric history) 2

Visual Inspection

• Position the patient sitting upright with hands pushing tightly on hips to contract pectoralis muscles 2, 1
• Assess from all angles for:
  • Symmetry in breast shape and contour
  • Skin changes (erythema, retraction, dimpling)
  • Nipple changes (inversion, discharge, scaling)
  • Signs of advanced cancer using the BREAST acronym: Breast mass, Retraction, Edema, Axillary mass, Scaly nipple, Tender breast 2

Lymph Node Examination

• With the patient still sitting, examine:
  • Axillary lymph nodes
  • Supraclavicular lymph nodes
  • Infraclavicular lymph nodes 2, 1

Breast Palpation

• Position the patient lying down with the ipsilateral arm placed overhead to flatten breast tissue on the chest wall 2, 1
• Place a small pillow under the shoulder/lower back on the side being examined if needed to evenly distribute breast tissue 2
• Use the finger pads of the middle three fingers
• Apply three levels of pressure in sequence: light, medium, and deep 1
• Use overlapping dime-sized circular motions in a systematic search pattern
• Follow a vertical strip pattern, covering the entire breast from the clavicle to the inframammary fold and from the sternum to the mid-axillary line 2, 1
• Give special attention to the upper outer quadrant and area under the areola/nipple 1
• Palpate the tissue at and beneath the nipple without squeezing 1

Common Pitfalls to Avoid

• Inadequate coverage of breast tissue
• Insufficient pressure variation (not using all three pressure levels)
• Rushing the examination (a thorough exam may take several minutes)
• Overreliance on physical examination alone
• Squeezing the nipple instead of properly palpating tissue beneath it
• Attempting to distinguish cysts from solid masses by palpation alone 1

Warning Signs to Note

• Firm or hard masses with indistinct or irregular borders
• Fixed/immobile masses
• Asymmetric findings compared to the other breast
• Skin changes (peau d'orange, erythema, edema, ulceration)
• Nipple abnormalities (retraction, discharge, excoriation, scaling) 1

Limitations and Follow-up

• Clinical breast examination alone has limited sensitivity (approximately 54%) 1
• Suspicious findings should prompt immediate diagnostic imaging (mammography and ultrasound) 1
• Negative imaging should never overrule a strongly suspicious finding on physical examination 1

Remember that while clinical breast examination is important, approximately 96% of breast cancers are initially detected by patients themselves, highlighting the continued importance of breast self-awareness 3.