What are the steps to complete a breast exam?

How to Complete a Clinical Breast Examination (CBE)

A proper clinical breast examination requires a systematic approach including clinical history, visual inspection, and palpation using specific techniques to thoroughly examine all breast tissue and nearby lymph nodes. 1

Clinical History

• Identify screening practices including previous breast self-examinations, clinical breast examinations, and mammograms 1
• Ask about any breast changes including skin/nipple changes, lumps, pain (focal vs. general, constant vs. cyclic), itching, or spontaneous nipple discharge 1
• Assess risk factors including age, personal history of benign breast disease, previous biopsies, cancer, breast surgeries, hormonal therapy use, obstetric history, and family history 1

Visual Inspection

• Position the patient sitting with hands pushing tightly on hips to contract pectoralis major muscles and enhance identification of asymmetries 1
• Inform the patient in advance about the visual inspection and what is being assessed 1
• View breasts from all sides, assessing:
  • Symmetry in breast shape or contour 1
  • Skin changes including erythema, retraction, dimpling, and nipple changes 1
• Remember the acronym BREAST for signs of advanced breast cancer: Breast mass, Retraction, Edema, Axillary mass, Scaly nipple, and Tender breast 1

Palpation

Lymph Node Examination

• Begin with the patient sitting to palpate axillary, supraclavicular, and infraclavicular lymph nodes 1

Breast Tissue Examination

• Position the patient lying down with ipsilateral hand overhead to flatten breast tissue on chest wall 1
• If needed, place a small pillow under the shoulder/lower back on the side being examined to evenly distribute breast tissue 1
• Use the finger pads of the middle three fingers to palpate one breast at a time with overlapping dime-sized circular motions 1

Examination Pattern and Coverage

• Cover the entire pentagon-shaped area of breast tissue using these landmarks: 1
  • 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
• Use a vertical strip pattern to ensure thorough coverage of all breast tissue 1
• Pay special attention to the upper outer quadrant and the area under the areola/nipple as these are the most common sites for cancer to arise 1, 2

Palpation Technique

• Apply three levels of pressure in sequence at each area: 1
  • Light (subcutaneous)
  • Medium (mid-level)
  • Deep (down to chest wall)
• Palpate tissue at and beneath the nipple but do not squeeze (squeezing can cause discharge and discomfort) 1
• Only spontaneous discharge warrants further evaluation 1
• Adapt palpation pressure based on breast size, shape, consistency, and presence of implants 1

Special Considerations

• For women with breast implants, the examination technique remains the same as implants are placed behind breast tissue 1
• The examination duration should be adequate for thoroughness, which may take several minutes for an average-sized breast 1
• Explain to the patient that a thorough examination takes time to avoid misunderstandings 1

Common Pitfalls to Avoid

• Failing to inform patients about the examination process beforehand, which can cause discomfort and misunderstanding 1
• Using inadequate pressure levels during palpation, missing deeper lesions 1
• Incomplete coverage of breast tissue by not following the pentagon-shaped perimeter 1
• Squeezing the nipple instead of gentle palpation 1
• Rushing the examination, as thoroughness is essential for detection 1, 3
• Ordering incorrect imaging follow-up when abnormalities are detected 4, 5