Four Positions of Breast Examination Inspection
The traditional teaching of "four positions" for breast inspection is not supported by current evidence-based guidelines; instead, a single optimized position—sitting with hands pushing tightly on hips—is recommended for visual inspection during clinical breast examination. 1
The Evidence-Based Approach to Visual Inspection
Single Position Recommendation
The American Cancer Society guidelines explicitly state that the patient should sit with hands pushing tightly on hips as the primary inspection position. 1
This single position contracts the pectoralis major muscles and enhances identification of asymmetries, which is the key goal of visual inspection. 1
Although adding multiple positions (such as hands over head and hands at sides) may further assist in identifying asymmetries, these additional positions do not add substantively to the single recommended position and may reduce time devoted to palpation. 1
What to Assess During Visual Inspection
The provider must view the breasts from all sides during this single position and should assess:
Symmetry in breast shape or contour, looking for subtle changes or differences between the two breasts. 1
Skin changes, particularly any erythema, retraction, dimpling, or edema. 1
Nipple changes, including retraction, scaling, or other abnormalities. 1
Clinical Significance Using the BREAST Acronym
Physical signs associated with advanced breast cancer can be remembered using the acronym BREAST: 1, 2
- Breast mass
- Retraction (skin or nipple)
- Edema (including peau d'orange)
- Axillary mass
- Scaly nipple
- Tender breast
Why This Matters for Patient Outcomes
Visual inspection allows monitoring of changes in appearance over time when observations are compared with previously documented examinations, which is critical for early cancer detection. 1
Clinical breast examination (including visual inspection) detected between 3% and 45% of breast cancers that screening mammography missed in clinical trials. 3
In one large study, 8.7% of breast cancers were detected by clinical breast examination alone, and these cancers were more often triple-negative, HER2-positive, node-positive, and larger than those detected by mammography alone. 4
Common Pitfalls to Avoid
Failing to inform patients in advance that visual inspection will be performed can cause awkwardness and potential misunderstandings. 1, 2
Spending excessive time on multiple inspection positions reduces time available for palpation, which is the more sensitive component of the examination. 1
Not viewing the breasts from all sides during the single position can miss subtle asymmetries or skin changes. 1
Visual inspection takes only a short amount of time, with the remainder of the examination spent predominantly on palpation—this balance is essential for optimal cancer detection. 1