 With breast cancer becoming increasingly prominent in the news, more

women are aware of the disease’s risk factors, treatments, and diagnostic
measures
 By staying informed and performing breast self-examinations regularly,
women can take control of their health and seek medical care when they
notice a change in their breasts

.
 No matter how informed a woman is, she can still feel anxious during
breast examinations, even if she hasn’t noticed a problem
 That’s because the social and psychological significance of female breasts
goes far beyond their biological function
 The breast is more than just a delicate structure; it’s a delicate subject
 Keep this in mind during your assessment
 It will let you proceed carefully and professionally, helping your patient feel
more at ease

                   L

 Each breast has a centrally located nipple of pigmented erectile tissue

ridged by an areola that’s darker than the adjacent tissue

Differences in Areola Pigmentation

The pigment of the nipple and areola vary among people of different races, getting darker as
skin tone darkens.
Whites have light-colored nipples and areola, usually pink or light beige
People with darker complexion, such as Blacks and Asians, have medium brown to almost
black nipples and areola

SUPPORT STRUCTURES
 Beneath the skin are glandular, fibrous, and fatty tissue that vary with age,
weight, gender, hereditary and other factors such as pregnancy
 A small triangle of tissue, called the TAIL OF SPENCE, projects into the axilla
  Attached to the chest wall musculature are fibrous bands, called COOPER’S
LIGAMENTS, that support each breast

           

LOBES AND DUCTS

 In women, each breast is surrounded by 12 to 25 glandular lobes containing
alveoli that produce milk
 The lactiferous ducts from each lobe transport milk to the nipple
 In men, the breast has a nipple, an areola, and mostly flat tissue bordering
the chest wall

                      

LYMPH NODES
 The breast also hold several lymph node chains, each serving different
areas
 The pectoral lymph nodes drain lymph fluid from most of the breast and
anterior chest
 The brachial nodes drain most of the arm
 The subscapular nodes drain the posterior chest wall and part of the arm
 The midaxillary nodes, located near the ribs and the serratus anterior
muscle high in the axilla, are the central draining nodes for the pectoral,
brachial, and subscapular nodes
                   

 In women, the internal mammary nodes drain the mammary lobes

 The superficial lymphatic vessels drain the skin

 In both men and women, the lymphatic system is the most common route
of spread of cells that cause breast cancer

 A woman’s breasts make many transformations throughout the life cycle

  Their appearance starts changing at puberty and continues changing during
the reproductive years, pregnancy, and menopause
                
                        
CHANGES DURING PUBERTY
 Breast development is an early sign of puberty in girls
 It usually occurs between ages 8 and 13
 Menarche, the start of the menstrual cycle, typically occurs about 2 years
later
 Development of breast tissue in girls younger than age 7 in Caucasians and
age 6 in blacks may be abnormal, and the patient should be referred to a
health care practitioner

 Breast development usually starts with the breast and nipple protruding as
a single mound of flesh, commonly called the breast bud stage
 The shape of the adult female breast is formed gradually
 During puberty, breast development is commonly unilateral or
asymmetrical

CHANGES DURING THE REPRODUCTIVE YEARS

 During the reproductive years, a woman’s breasts may become full or
tender in response to hormonal fluctuations during the menstrual cycle

 During pregnancy and lactation, breast changes occur in response to

hormones from the corpus luteum, the placenta, and the pituitary gland
 The areola becomes deeply pigmented and increases in diameter
 The nipple becomes darker, more prominent, and erect
 The breasts enlarge because of the proliferation and hypertrophy of the
alveolar cells and lactiferous ducts
 As veins engorge, a venous pattern may become visible

 In addition, striae may appear as a result of stretching, and Montgomery’s

tubercles may become prominent
                
CHANGES AFTER MENOPAUSE
 After menopause, estrogen levels decrease, causing glandular tissue to
atrophy and be replaced with fatty deposits
 The breasts become less dense and smaller than they were before
menopause
 As the ligaments relax, the breasts hang loosely from the chest
 The nipples flatten, losing some of their erectile quality
 The ducts around the nipple may feel like firm strings

 You’ll typically begin your health history by asking the patient about her
reason for seeking care
 You’ll then want to ask the patient questions about her personal and family
medical history as well as her current health

 Common complaints about the breasts include breast pain, nipple

discharge and rash, lumps, masses, and other changes 
 Complaints such as these – whether they come from women or men –
warrant further investigation

Male Concerns
Keep in mind that men also need breast examinations and that the incidence of breast cancer
in males is rising. Men with breast disorders may feel uneasy or embarrassed about being
examined because they see their condition as being unmanly. Remember that a man needs a
gentle, professional hand as much as a woman does.

Male breast cancer and gynecomastia:

Be sure to examine a man’s breasts thoroughly during a complete physical assessment. Don’t
overlook palpation of the nipple and areola in male patient; assess for the same changes you
would in a woman. Breast cancer in men usually occurs in the areolar area.

Gynecomastia is abnormal enlargement of the male breast. It may be a benign finding, or it

may be caused by medications, cirrhosis, malnutrition, neoplasms, illicit drug use, alcohol
consumption, or a hormonal imbalance

Breasts in boys and older men:

Adolescent boys may have temporary stimulation of breast tissue caused by the hormone
estrogen, which is produced in males and females. Breast enlargement in boys usually stops
when they begin producing adequate amounts of the male sex hormone testosterone during
puberty. Older men may experience gynecomastia as a result of age-related hormonal
alterations or an adverse effect of certain medications

Evaluating Breast Lump

If you find a breast lump during your assessment, note the following characteristics. All
breast lumps should be further evaluated with a mammography, ultrasound, fine-needle
aspiration, or core biopsy
CHARACTERISTICS BENIGN MALIGNANT
Appearance Breasts show no change Breast is dimpled, scaly, or puckered, with
an orange-peel appearance or accentuated
veins
Consistency  Lump is firm to soft Lump is firm and hard
Demarcation  Lump is well demarcated Lump is poorly defined
Mobility  Lump is easy to move Lump is fixed in breast tissue

Tenderness  Breast is usually non tender but Breast may be non tender or tender, based
may be tender before on advancement of cancer
menstruation
Nipple changes Nipple shows no changes Nipple may be inverted, retracted, or itchy
with bloody, yellow, green, or clear
discharge
Number  Single or multiple lumps may be in Usually a single lump
one or both breasts
Location  Lump may occur anywhere in Lump ma occur anywhere in breast, but
breast more commonly occurs in upper outer
quadrant

 To investigate these complaints, ask about the symptom’s onset, duration

and severity
 What day of the menstrual cycle do the signs and symptoms appear, if
applicable?
 What relieves or worsens them?

 Ask the patient if she has ever had breast lumps, a biopsy, or breast
surgery, including enlargement or reduction
 Also ask if she has a history of breast disease or trauma
 If she has had breast cancer, fibro-adenoma, or fibrocystic disease, ask for
more information, such as whether she underwent surgery, chemotherapy,
or radiation treatment
  Inquire about the patient’s menstrual cycle, including what age it started,
and record the date of her last menses
 If the patient has been pregnant, ask how many pregnancies and live births
she has had
 How old was she each time she became pregnant?
 Did she have complications?
 Did she breast-feed?

 Ask the patient if any family members have had breast disorders, especially
breast cancer
 Also ask about the incidence of other types of cancer
 Having a close relative with breast cancer greatly increases the patient’s
risk of having the disease
 Teach the patient how to examine her breasts and the importance of
regular breast examinations and mammograms

Scheduling Breast Examinations

The American Cancer Society recommends the schedule shown here for regular breast examinations.
Depending on their needs, some patients may follow schedule that have been modified by their
doctors. Women with a family history of or a genetic predisposition for breast cancer – as well as
women who have a personal history of cancer – may need earlier or more frequent screening tests
and examinations. Women at high risk for breast cancer should also have an annual magnetic
resonance imaging scan

Age Breast self-examination Mammography Clinical breast

examination
20 to 39 Monthly, 7 to 10 days after Not recommended Every 3 years
menses begin
40 and Monthly, 7 to 10 days after Yearly  Yearly 
older menses begins

 Some breast changes are a normal part of aging, so be sure to ask the
patient how old she is
 If she has noticed a breast change, ask her to describe it in detail
 Exactly where on the breast is the change? When did it occur? Does she
have pain, tenderness, discharge, or rash?
 Has she had changes or pain in her underarm area?
  Does the problem come and go, or is it always present?
 Ask the patient what drugs she uses regularly, such as birth control pills,
contraceptive patches, or vaginal ring with estrogen
 Hormonal birth control methods can cause breast swelling and tenderness
 Ask about her diet, especially caffeine intake
 Caffeine has been linked to fibrocystic disease of the breasts
 Ask the patient whether she is under a lot of stress, smokes, or drinks
alcohol
 Discuss the possible link between those factors and breast cancer
 Note the patient’s weight
 If the patient is overweight, explain the link between increased weight and
breast cancer development, and refer her to information on weight control

BMI and Breast Cancer Risk

Extra weight can be bad for your patient’s health in more ways than one. Women who have a
body mass index (BMI) of 30 or higher have an increased risk of developing breast cancer,
especially after menopause. This is because fat tissue produces small amounts of estrogen,
and higher levels of estrogen increases the risk of breast cancer. The outlook is even worse
for women with a BMI of 40 or higher who develop breast cancer, they’re three times more
likely to die from the disease

 Having a breast examination can be stressful for a woman

 To reduce your patient’s anxiety, provide privacy, make her as comfortable
as possible, and explain what the examination involves
 If possible, perform the examination 7 to 9 days the onset of menses in a
premenopausal patient

 Before examining the breasts, make sure the room is well lighted
 Have the patient disrobe from the waist up and sit with her arms at her
sides
 Keep both breasts uncovered so you can observe them simultaneously to
detect differences

INSPECTION
  Breast skin should be smooth, un-dimpled, and the same color as the rest
of the skin
 Check for edema, which can accompany lymphatic obstruction and may
signal cancer
 Note breast size and symmetry
 Asymmetry may occur normally in some adult women, with the left breast
usually larger than the right
 Inspect the nipple, noting their size and shape
 If a nipple is inverted, dimpled, or creased, ask the patient when she first
noticed the abnormality
 Lifelong nipple inversion may be normal, but any changes of the nipple call
for further evaluation

 Next, inspect the patient’s breasts while she holds her arms over her head,
and then again while she has her hands pressed against her hips
 Having the patient assume these positions will help you detect skin or
nipple dimpling that might not have been obvious before

 If the patient has large or pendulous breasts, have her stand with her hands
on the back of a chair or the examination table and lean forward
 This position helps reveal subtle breast or nipple asymmetry

PALPATION
 Before palpating the breasts, ask the patient to lie in a supine position, and
place a small pillow under her shoulder on the side you’re examining
 This causes the breast on that side to protrude

Palpating the Breast

Use your three middle fingers to palpate the breast systematically. Rotating your fingers gently
against the chest wall, move in concentric circles. Make sure you include the tail of Spence and the
subareolar area in your examination

EXAMINING THE NIPPLE

If a lump was discovered in the breast, examine the nipple for discharge
Gently squeeze the nipple between your thumb and index finger. Note the color, amount, and
consistency of any discharge

                     
                 

 Have the patient put her hand behind her head on the side you’re
examining
 This spreads the breast more evenly across the chest and makes finding
nodules easier
 If her breasts are small, she can leave her arm at her side

 To perform palpation, place your finger pads flat on the breast and
compress the tissue gently against the chest wall, palpating outward from
the nipple with a circular, wedged, or vertical strip method
 For a patient with pendulous breasts, palpate down or across the breast
with the patient sitting upright

Breast Palpation Methods

 As you palpate, note the consistency of the breast tissue

 Normal consistency varies widely, depending in part on the proportions of
fat and glandular tissue
 Check for nodules and unusual tenderness 
 Tenderness may be related to cysts, normal hormonal changes, infection,
or very rarely, cancer
 However, nodularity, fullness, and mild tenderness are also premenstrual
symptoms
 Be sure to ask your patient where she is in her menstrual cycle

 A lump or mass that feels different from the rest of the breast tissue may
indicate a pathologic change and warrants further investigation by a
practitioner
 If you find what you think is an abnormality, check the other breast, too
 Keep in mind that the infra-mammary ridge at the lower edge of the breast
is normally firm and may be mistaken for a tumor
 If you palpate a mass, record these characteristics:
o Number of masses
o Size in centimeters
o Shape – round, discoid, regular, or irregular
o Consistency – soft, firm, or hard
o Mobility
o Delineation – well defined or not well defined
o Degree of tenderness
o Location, using the quadrant or clock method

Identifying Locations of Breast Lesions

     

 If the patient complains of a spontaneous nipple discharge (and isn’t

pregnant or lactating) or has any other abnormal findings on her history or
physical examination, perform a thorough examination of the nipple
 Compress the nipple and areola to detect discharge
 If discharge is present, assess the color, consistency, and quantity of the
discharge
 If possible, obtain a cytologic smear

 To obtain a smear, put on gloves, place a glass slide over the nipple, and
smear the discharge on the slide
 Spray the slide with a fixative, label it with the patient’s name and the date,
and send it to the laboratory, according to your facility’s policy

 To examine the axillae, use the techniques of inspection and palpation 

 With the patient sitting or standing, inspect the skin of the axillae for
rashes, infections, or unusual pigmentation

 Before palpating, ask the patient to relax her arm at her side
 Support her elbow with one of your hands
 Cup the fingers of your other hand, and reach high into the apex of the
axilla
  Place your fingers directly behind the pectoral muscles, pointing toward the
midclavicle

Palpating the Axilla

To palpate the axilla, have the patient sit or lie down. Wear gloves if an ulceration or
discharge is present. Ask her to relax her arm at her side, and support it with your
nondominant hand.
Keeping the fingers of your dominant hand together, reach high into the apex of the axilla.
Position your fingers so they’re directly behind the pectoralis muscles, pointing toward the
midclavicle. Sweep your fingers downward against the ribs and serratus anterior muscle to
palpate the midaxillary or central lymph nodes. Explain to the patient that it’s normal for this
exam to be mildly uncomfortable.

ASSESSING THE AXILLARY NODES

 First, try to palpate the central nodes by pressing your fingers downward
and in toward the chest wall
 You can usually palpate one or more of the nodes, which should be soft,
small, and nontender
 If you feel a hard, large, or tender lesion, try to palpate the other groups of
lymph nodes for comparison

 To palpate the pectoral and anterior nodes, grasp the anterior axillary fold
between your thumb and fingers and palpate inside the borders of the
pectoral muscles
 Palpate the subscapular or posterior nodes, stand behind the patient and
press your fingers to feel the inside the muscle of the posterior axillary fold

ASSESSING THE CLAVICULAR NODES

 If the axillary nodes are abnormal, assess the nodes in the clavicular area
 To do this, have the patient relax her neck muscles by flexing her head
slightly forward
 Stand in front of her and hook your fingers over the clavicle beside the
sternocleidomastoid muscle
 Rotate your fingers deeply into this area to feel the supraclavicular nodes
  The menstrual cycle, certain prescription drugs, pregnancy, and other
conditions can cause breast changes, therefore, you might have trouble
differentiating abnormal changes from those that are normal

Breast Abnormalities
This chart shows you some common groups of findings for the chief signs and symptoms of the
breasts and axillae, along with their probable causes.
SIGN OR SYMPTOM AND COMMON SIGN OR SYMPTOM AND FINDINGS COMMON
FINDINGS CAUSE CAUSE
BREAST NODULE
BREAST DIMPLING Breast cancer Single nodule that feels firm, elastic, Adenofibroma
Firm, irregular, nontender and round or lobular with well-
lump defined margins
Nipple retraction, Extremely mobile, “slippery” feel
deviation, inversion, or No pain or tenderness
flattening Size varies from pinpoint to very
Enlarged axillary lymph large
nodes Grows rapidly
Usually located around the nipple or
Heat Mastitis the lateral side of the upper outer
Erythema quadrant
Swelling Breast cancer
Pain and tenderness Hard, poorly delineated nodule
Flulike signs and Fixed to the skin or underlying tissue
symptoms, such as fever, Breast dimpling
malaise, fatigue, and Nipple deviation or retraction
aching Located in the upper outer quadrant
(50% of cases)
BREAST PAIN Breast cancer Nontender
Tender, palpable lymph abscess Serous or bloody nipple discharge
nodes Edema or peau d’orange of the skin
Fever overlying the mass
Nipple discharge Axillary lymphadenopathy
Breast pain and Fat necrosis
enlargement of affected History of trauma to fatty tissue of
breast the breast (patient may not
Redness and warmth in remember such trauma)
the affected breast Tenderness and erythema
Intraductal Bruising
Unilateral breast pain or papilloma Hard, indurated, poorly delineated
tenderness lump that’s fibrotic and fixed to
Serous or blood nipple underlying tissue or overlying skin
discharge, usually only Nipple retraction
from one duct
Small, soft, poorly Fibrocystic
delineated mass in the Smooth, round, slightly elastic breast disease
ducts beneath the areola nodules or generalized “lumpiness”
Sebaceous without a discrete mass
Small, well-delineated cyst Increased size and tenderness just
nodule (infection) before menstruation
Localized erythema Clear, watery (serous), or sticky
Induration nipple discharge
Bloating
NIPPLE RETRACTION Breast cancer Irritability
Unilateral nipple Abdominal cramping
retraction and inversion
Hard, fixed, nontender
breast nodule
Nipple itching, burning, or
erosion
Watery or bloody nipple
discharge (typically
unilateral)
Altered breast contour
Dimpling or peau d’orange
Tenderness, redness, and
warmth
Mastitis 
Unilateral nipple
retraction, deviation,
cracking, or flattening
Firm, warm,
erythematous, tender,
swollen area
Possible fatigue, fever,
chills, and other flulike
symptoms
  A breast nodule, or lump, may be found in any part of the breast, including
the axilla
 Breast nodules may range in clinical significance from the benign lumps of
fibrocystic breast disease to a malignant mass of breast cancer

 Breast dimpling
o The puckering or retraction of skin on the breast
 Results from abnormal attachment of the skin to underlying tissue
 It suggests an inflammatory or malignant mass beneath the skin surface
and may represent a late sign of breast cancer

Dimpling and Peau d’ Orange

DIMPLING
Dimpling usually suggests an inflammatory or malignant mass beneath the skin’s surface. The
illustration shows breast dimpling and nipple retraction caused by a malignant mass above the areola
                                  

PEAU D’ ORANGE
Peau d’orange is usually a late sign of breast cancer, but it can also occur with breast or axillary lymph
node infection. The skin’s orange-peel appearance comes from lymphatic edema around deepened
hair follicles

                                      
                                 

 Nipple retraction, the inward displacement of the nipple below the level of
surrounding breast tissue, may indicate an inflammatory breast lesion or
cancer
 It results from scar tissue formation within a lesion or large mammary duct
 As the scar tissue shortens, it pulls adjacent tissue inward, causing nipple
deviation, flattening, and finally retraction

 Nipple inversion is the lack of protrusion of the nipple

 It typically occurs in puberty
 In an adult woman, it may impede breast feeding and predispose the
patient to mastitis and abscess formation

 Nipple discharge can occur spontaneously or can be elicited by nipple

stimulation
 It’s characterized as intermittent or constant, unilateral or bilateral, and by
color, consistency, and composition
 It can be a normal finding; however, nipple discharge can also signal serious
underlying disease, particularly when accompanied by  other breast
changes
 Significant causes include endocrine disorders, cancer, certain drugs, and
blocked lactiferous ducts

 Breast pain commonly results from benign breast disease, such as mastitis
or fibrocystic breast disease
 It may occur during rest or movement and may be aggravated by
manipulation or palpation
 Breast tenderness refers to pain elicited by physical contact

 Prominent veins in one breast may indicate cancer in some patients;

however, they’re considered normal in pregnant women because of
engorgement