1F Skills: Examination of the breasts
When you have completed this skills chapter you should be able to:
- Take an adequate history for breast conditions.
- Perform a good breast examination.
- Perform an examination of the supraclavicular and axillary lymph nodes.
The purpose of taking a family, past and present history is to assess whether there are any warning symptoms of serious breast conditions, especially cancer.
A. The importance of asking the woman’s age
Breast cancer becomes more common as a woman gets older. While breast cancer is rare under 20 years of age it becomes more common over the age of 40 years.
B. The importance of a positive family history of breast cancer
Has any member of the mother or father’s family or a sibling had breast or ovarian cancer? A positive family history, especially of her mother or sisters, increases the chance that the woman will develop breast cancer.
C. The importance of a past history of breast or ovarian cancer
A woman who has had breast cancer before has a much higher chance of having breast cancer again.
D. Any present history of breast changes or complaints
Always ask about:
- One breast becoming larger than the other or changing shape
- Any new breast lumps or lumps that are getting bigger
- Any nipple changes, especially watery or bloody nipple discharge, a nipple which becomes inverted (pulled in) or a new rash on the nipple or areola
- Any rash or redness of a breast
Examination of the breasts
E. Preparation for a breast examination
The woman should undress down to her waist and put on a gown. The examination must be done somewhere private and well lit. Always explain what you are going to do. It is very important to be able to have a good look at both breasts.
F. Step-by-step examination of the breast
The examination consists of both looking (inspection) and feeling (palpating). Wherever possible, the examination should be done in a standardized step-by-step manner. Once you have done a few breast examinations, it will become quite quick and easy.
G. Inspection of the breasts is usually done in three positions with the woman sitting up
Ask the woman to sit down on the examining couch facing you with her arms relaxed at her sides. Look at her breasts asymmetry, nipple inversion, skin changes and redness. You may even be able to see a breast lump.
Figure 1F-1: Position during inspection of breasts.
Next ask her to raise both her arms above her head. Look for any skin puckering (skin pulled in). This will help identify a lump that is attached to the skin.
Figure 1F-2: Position with arms raised while looking for a lump or skin puckering.
Finally ask the woman to put her hands on her hips and squeeze (push her hands towards each other). This will tighten her chest muscles. Look and see if an area of skin is puckering due to being attached (tethered) to underlying muscle. This may indicate the site of a breast lump.
Figure 1F-3: Position with hands on hips while looking for tethering to underlying muscle
H. Palpation for enlarged supraclavicular lymph nodes
While the woman is still sitting it is a good opportunity to palpate for enlarged lymph nodes. Start by palpating above her clavicles (collar bones) for an enlarged supraclavicular lymph node. Breast cancers towards the centre of the chest may spread to this site.
Figure 1F-4: Position for supraclavicular node examination.
I. Palpation for enlarged axillary lymph nodes
To examine the (axillae) armpits properly the woman must be relaxed. If she is very ticklish it helps to press more firmly. The best way to get a woman to relax her muscles is by asking her to extend her arms and rest them on your shoulders while you examine the armpits.
Figure 1F-5: Position while feeling in the armpits for nodes.
Feel in the two armpits at the same time for any lumps. This allows you to compare the two armpits which are shaped like pyramids. You should feel along the inside wall and towards the front (anterior) for lymph nodes. Remember to feel at the top of the armpit also. If you think you feel a lump, examine that armpit very carefully.
J. Palpation of the breasts
Finally lie the woman down flat on her back and examine one breast at a time. Ask her to raise that arm above her head on the bed. This will flatten the breast and make examination easier. It helps to think of the breasts being divided into strips and then examine each strip of breast from the centre of the chest outwards. The breast extends from the clavicle above to the 6th rib below and also towards the axilla. The whole area of the breast must be carefully examined. Always use the tips of your fingers (the most sensitive part of your hand) with the rest of your hand gently resting against the breast. Do not use cold hands.
Figure 1F-6: The breast is palpated in strips to make sure the whole breast is examined.
J. Palpate behind the nipples
Never forget to examine behind the nipples and surrounding areolae for any abnormalities such as skin changes, lumps or an inverted nipple. It is best to leave the nipple examination to the end once you have won the woman’s trust.
Figure 1F-7: The breast being examined using finger tips with a flat hand.
Examining a woman’s breasts provides an excellent opportunity to teach her how to examine her own breasts each month after the end of her period when her breasts are softer. This is something all women should learn and practice regularly as it increases the chance of detecting an early breast cancer which can be cured.
This skills chapter is adapted from the Bettercare book Breast Care: A health professional’s guide to the diagnosis and management of common breast conditions by Dr Edge and Prof Woods.