The breasts

Published on 02/03/2015 by admin

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Last modified 02/03/2015

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Chapter 14 The breasts

Blessed is the physician who takes a good history, looks keenly at his patient and thinks a bit.

Walter C Alvarez (1976)

Breast examination is a vitally important part of the general physical examination. Examinations for breast cancer should be done monthly by the patient and yearly by the doctor in those over the age 40 of years.

History

The history is important. Important questions to ask include the length of time any mass has been present, presence of pain, change in size or texture over time, relationship to menstrual cycle, and any nipple discharge. Ask about previous cyst aspirations.

Find out about risk factors for breast cancer including any family history of breast or ovarian cancer (and age affected), previous personal history of breast cancer, late menopause, late first pregnancy, mantle radiation, heavy alcohol use, and use of oestrogens post-menopausally. A personal history of atypical hyperplasia (ductal or lobular) increases the risk of breast cancer 3 to 5 times. However, three-quarters of patients presenting with a breast cancer have no known risk factors.

The breast cancer genes BRCA1 and BRCA2 are associated with a strong risk of breast (and ovarian) cancer, as well as breast cancer in men. For all women from the age of 50 years, screening mammography ¹ is generally recommended.

Examination

When it is done properly, the examination takes some time to perform (about 3 minutes per breast).² This must obviously be explained to the patient at the start. The patient should be offered a chaperone for the examination.

The examination is only just over 50% sensitive for carcinoma but specificity is as high as 90%. The likelihood ratio of a positive examination is 14.1 and the LR of a negative examination is 0.47.³

Inspection

Ask the patient to sit up with her chest fully exposed. There is controversy about the value of inspection of the breasts as part of the examination, but advanced cancers may be obvious at this stage. Look at the nipples for retraction (due to cancer or fibrosis; in some patients retraction may be normal) and Paget’s disease of the breast (where underlying breast cancer causes a unilateral red, bleeding skin).

Next inspect the rest of the skin. Look for visible veins (which if unilateral suggest a cancer), skin dimpling, and for peau d’orange skin (where advanced breast cancer causes oedematous skin pitted by the sweat glands).

A persistent erythematous plaque in the areola area may be contact dermatitis or skin irrigation, but if asymmetric or it has not responded to treatment this may be the malignancy Paget disease of the breast.

Ask the patient to raise her arms above her head and then lower them slowly. Look for tethering of the nipples or skin, a shift in the relative position of the nipples or a fixed mass distorting the breast (Figure 14.1).

Figure 14.1 Carcinoma of the right breast, showing elevation of the breast, dimpling of skin, and retraction of the nipple

Note whether there are any obvious visible masses in the axillae.

Next ask her to rest her hands on her hips and then press her hands against her hips (the pectoral contraction manoeuvre). This accentuates areas of dimpling or fixation.

Palpation

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