Review of Systems for Physical Assessment of a Breast Lump
When evaluating a patient with a breast lump, focus your review of systems on breast-specific symptoms, risk factors for malignancy, and signs of metastatic disease.
Breast-Specific Symptoms
The most critical elements to assess are nipple discharge characteristics, skin changes, and associated breast symptoms. 1
Nipple Assessment
- Spontaneous versus induced discharge – spontaneous discharge is pathologic and warrants surgical referral 1, 2
- Color of discharge – bloody discharge is particularly concerning for malignancy 1
- Eczematoid changes or discoloration of the nipple – may indicate Paget's disease 1
- Nipple retraction or inversion – suggests underlying malignancy with tissue tethering 1
Skin and Breast Changes
- Skin erythema, dimpling, or retraction – indicates possible chest wall involvement 1
- Peau d'orange (skin edema) – suggests inflammatory breast cancer or advanced disease 1
- Skin ulceration or satellite lesions – signs of locally advanced cancer 1
- Pain characteristics – focal versus generalized, constant versus cyclic 1, 2
- Itching or staining of garments/bed sheets – may indicate spontaneous nipple discharge 1
Risk Factor Assessment
A thorough risk assessment directly influences the level of suspicion and urgency of workup. 1
Family and Genetic History
- First-degree relatives with breast cancer, including age at diagnosis and bilaterality 1
- Family history of ovarian, endometrial, or other malignancies – suggests hereditary cancer syndromes 1
Personal Medical History
- Previous breast biopsies or benign breast disease – certain lesions increase cancer risk 1
- Prior breast cancer – increases risk of contralateral disease 1
- Previous therapeutic chest wall irradiation – significantly elevates breast cancer risk 1
- History of collagen vascular disease – may contraindicate radiation therapy if breast conservation is considered 1
Hormonal and Reproductive History
- Date of last menstrual period and possibility of pregnancy – affects imaging choices and treatment planning 1
- Hormone replacement therapy, oral contraceptives, or fertility drug use – associated with mastalgia and may influence cancer risk 1, 2
- Obstetric history – nulliparity increases risk 1
Breast Implant History
- Presence and location of implants (submammary versus subpectoral) – affects imaging interpretation and surgical planning 1
Systemic Symptoms Suggesting Metastatic Disease
Screen for symptoms that could indicate advanced or metastatic breast cancer. 1
- Bone pain – suggests skeletal metastases
- Persistent cough or dyspnea – may indicate pulmonary involvement
- Abdominal pain or jaundice – concerning for hepatic metastases
- Neurologic symptoms – headaches, vision changes, or focal deficits suggest CNS involvement
- Unintentional weight loss or fatigue – nonspecific but concerning systemic symptoms
Lymph Node Assessment
Regional lymph node involvement is a critical prognostic factor. 1
- Axillary lymphadenopathy – size, mobility, and tenderness 1
- Supraclavicular or infraclavicular lymphadenopathy – indicates advanced disease 1
- Ipsilateral arm lymphedema – suggests extensive axillary nodal involvement 1
Prior Screening History
Document previous breast health screening practices and results. 1
- Breast self-examination practices – when performed and any changes noted 1
- Prior clinical breast examinations – timing and results 1
- Prior screening and diagnostic mammograms – dates and findings 1
- How the current breast change was identified – self-detected versus incidental finding 1
Critical Pitfall to Avoid
Never rely solely on the absence of symptoms to rule out malignancy – many breast cancers present as asymptomatic palpable masses without associated symptoms. 1 The physical examination findings and imaging results take precedence over symptom reporting, as even experienced clinicians show only 73% agreement on the need for biopsy among proven malignancies based on examination alone. 1, 3