What key history questions should be asked during a breast exam?

Key History Questions for Breast Examination

During a breast examination, clinicians should ask comprehensive questions about personal and family history, breast changes, screening practices, and risk factors to properly assess breast cancer risk and guide appropriate management.

Personal and Breast Health History

• Current breast symptoms or changes:

  • Presence of lumps or masses
  • Skin changes (redness, dimpling, retraction)
  • Nipple changes (inversion, discharge, scaling)
  • Pain (focal vs. general, constant vs. cyclic)
  • Itching
  • Staining of garments indicating spontaneous discharge 1

• Previous breast screening history:

  • Prior clinical breast examinations and results
  • Prior mammograms (screening and diagnostic) and results
  • Breast self-examination practices 1, 2

• Personal breast health history:

  • History of benign breast disease
  • Previous breast biopsies and results
  • Previous breast cancer
  • Cosmetic or other breast surgery 1, 2

Family History Assessment

• Detailed family cancer history:
  • First and second-degree relatives with breast cancer
  • Age at diagnosis of relatives with breast cancer (especially before age 50)
  • Relatives with ovarian cancer at any age
  • History of bilateral breast cancer in family
  • Male relatives with breast cancer
  • Multiple primary cancers in single individuals
  • Pattern of cancer across generations (both maternal and paternal sides) 1, 2

Risk Factor Assessment

• Reproductive and hormonal history:

  • Age at menarche
  • Parity
  • Age at first live birth
  • Breastfeeding history
  • Menopausal status
  • Use of hormonal therapy or oral contraceptives 1, 2

• Demographic and lifestyle factors:

  • Age
  • Ethnicity (particularly Ashkenazi Jewish heritage)
  • Exercise habits
  • Nutrition
  • Alcohol consumption
  • Smoking status 2

Genetic Risk Assessment

• Indicators for genetic counseling referral:
  • Strong family history of breast, ovarian, colon, or endometrial cancer
  • Personal history of breast cancer diagnosed at age ≤65 years
  • Triple-negative breast cancer diagnosed at age ≤60 years
  • Bilateral breast cancer
  • Male breast cancer
  • Ashkenazi Jewish ancestry
  • Known genetic mutations in family 1

For Breast Cancer Survivors

• Additional history for survivors:
  • Age at diagnosis
  • Type of cancer
  • Treatment received
  • Time since diagnosis
  • Follow-up care and surveillance
  • Signs and symptoms of local or regional recurrence 1, 2

Clinical Pearls and Pitfalls

• Many providers focus primarily on family history but fail to ask about other important risk factors like parity, previous biopsies, or age at menarche, potentially missing women at increased risk 3.

• Providers should periodically review family history, as new cancer events may have occurred in the family after initial assessment 1.

• Patients may not volunteer symptom information unless specifically asked, making a thorough clinical history essential for detecting early signs of breast cancer 1.

• The American Cancer Society recommends collecting family history information beginning in a patient's 20s and updating it regularly 2.

• Consider using validated risk assessment tools (e.g., Gail model) for patients with concerning risk factors, though many providers report not routinely calculating these scores 3.