Which position is appropriate for palpating tissues during breast self examination?

Breast Self-Examination

Although monthly breast self-examination (BSE) was recommended for many years, it recently has been recognized to have limited value in detecting early cancer. Large randomized clinical trials have failed to demonstrate reduction in breast cancer-specific or all-cause mortality from BSE in populations at average risk. Organizations such as the ACS, American College of Obstetrics and Gynecology, and US Preventative Service Task Force (USPSTF) have found insufficient evidence to recommend for or against performance of BSE. The emphasis on monthly BSE has been replaced by the concept of “breast self-awareness” in which women become knowledgeable about the normal appearance and feel of their breasts but without a specific schedule or examination technique. We share the opinion still held by many, however, that BSE has value. Physicians should educate women to enhance their awareness to report any skin changes, dimpling, nipple discharge, or presence of new lumps or bumps. The limitation of using BSE as a screening tool is related to the increased number of biopsies performed for benign breast disease, which comes at a financial and emotional cost.

Women who chose to perform BSE should do so when their breasts are least likely to be tender or swollen, often a few days immediately after a menstrual period. The examination is best done in both supine and upright positions using the finger pads of the three middle fingers. Different pressure levels (light, medium, firm) are used to examine the breast. Although various techniques can be used, women should be consistent in their technique used. One of the easier techniques involves palpating the breasts in a circumscribed clockwise fashion and working from the nipple outward; alternatively, a vertical (up-down) pattern can also be used.

VIII. Efficacy and Accuracy of Breast Self-Exam

BSE has an overall sensitivity of 26%, which decreases with age from 41% for women ages 35 to 39 years old to 21% for women ages 60 to 74 years [85]. In the United Kingdom Trial of Early Detection of Breast Cancer, a nonrandomized community trial, there was no reduction in breast cancer mortality in the BSE communities compared to communities that did not perform BSE [86]. There have been two randomized controlled trials, one in Leningrad of women ages 40 to 64 years [87] and one in Shanghai of women ages 31 to 64 years [88], that have directly tested the effectiveness of BSE to reduce breast cancer mortality. In the Leningrad trial, all women also underwent yearly CBE. After 8 years of follow-up, the Leningrad study reported no difference in the number of breast cancers diagnosed in the BSE group versus the control group and no difference with regard to the size of primary tumors or incidence of metastasis or regional lymph nodes [89]. The Shanghai study reported similar results after 5 years of follow-up. In addition, the authors reported no difference in breast cancer mortality between the BSE trained group and the control group [89]. However, in both studies [87,88] there were increases in physician visits, referrals for further diagnostic evaluations, and excisional biopsies among women in the BSE group compared with those in the control group. Both studies reported a twofold greater number of benign breast lesions identified in the BSE group than in the control group, and the Leningrad study reported 50% more excisional biopsies in the BSE group.

In summary, although observational studies have shown that women who report regular practice of BSE present with smaller tumors than women who do not practice BSE, when the gold standard for evaluation of screening, the randomized controlled trial, is used to determine the efficacy of BSE, there is no substantial stage shift from late to earlier stage disease in women who report regular practice of BSE and no reduction in breast cancer mortality. In addition, from the Leningrad trial it appears that BSE plus CBE does not result in a reduction in breast cancer mortality compared with women who only receive annual CBE. Finally, performing BSE results in additional physician visits and diagnostic tests without identifying more breast cancers or earlier stage disease.

Breast Self-Examination6

Although monthly BSE was recommended for many years, it has been recognized that BSE has limited value in detecting early cancer. Organizations such as the American Cancer Society, American College of Obstetrics and Gynecology, and the U.S. Preventative Service Task Force have found insufficient evidence to recommend BSE. The emphasis on monthly BSE has been replaced by the concept of “breast self-awareness” whereby women older than 20 years become knowledgeable about the normal appearance and feel of their breasts, but without a specific schedule or examination technique. A physician should help educate the woman so that she can have the awareness to report any skin changes, dimpling, nipple discharge or presence of new lumps or bumps. Although medical attention should be sought for any of these findings, she can be reassured that most findings are not cancer.

Many women will want to know how best to examine their breasts. The techniques of BSE are included here for the purpose of patient education:

Stand with your arms at your sides in front of a mirror. Inspect both breasts for anything unusual, such as dimpling, redness, puckering, discharge from the nipples, or scaling of the skin.

Raise your arms and clasp your hands behind your head. Press your hands forward. Look in the mirror for any changes in the breast tissue.

Put your hands down and place them on your hips. Bend slightly toward the mirror as you pull your shoulders and elbows forward.

Raise your right arm; using the pads of your left fingers, press into your right breast firmly, carefully, and thoroughly. Start at the upper outer edge and move in small circles, moving the circles slowly around the breast. Pay special attention to the breast tissue between the breast and the underarm. Use a massaging motion.

Gently squeeze your nipple and look for any discharge.

Repeat steps 4 and 5 while lying down with a small pillow under your right shoulder. Place your right arm over your head.

Repeat the examination on your left breast.

Examine each underarm while sitting or standing with your arm only slightly raised so that you can more easily feel in this area. Lifting the arm straight up will tighten the skin and make the examination more difficult.

Breast Awareness

Breast self-examination (BSE) was a mainstay for decades in breast cancer screening recommendations, but this recommendation changed for most organizations in the early 2000s when findings from a large RCT of BSE in women in Shanghai, China noted no difference in breast cancer mortality between women performing BSE versus controls. This trial randomized 266,064 Chinese women to receive instruction on BSE or a topic unrelated to breast cancer. During the time this study was conducted, women in China had access to mammography only for diagnostic evaluation of a clinical finding. Women in the BSE arm received intensive instruction in BSE technique. Compliance was encouraged through feedback and reinforcement sessions as well as monthly reminders. After 10 to 11 years of follow-up, with 135 breast cancer deaths in the instruction group and 131 in the control group, there was no statistically significant difference between the two arms in breast cancer mortality (RR, 1.04; 95% confidence interval [CI], 0.82–1.33; P = .72). In addition, no statistically significant difference in breast cancer incidence or stage was seen. However, the BSE group had a higher rate of false positives.33,34

Nonetheless, it is recognized that women are the most likely person to find a palpable breast cancer, with most being found during normal activities of daily living (e.g., showering, dressing). For this reason, BSE has been replaced with the concept of breast awareness, which recommends that women be familiar with their breasts and promptly report any change. Differing from BSE, breast awareness does not involve formalized instruction in the clinical setting or reminders (such as shower cards).

Screening

Screening strategies for breast cancer have traditionally included the triad of breast self-examination, clinical breast examination by a health care professional, and screening mammography in well women. Although widely promulgated as an important component of early detection, two large randomized trials of conventional breast self-examination versus observation failed to show any clinical advantage with breast self-examination. As a result, many experts now promote breast awareness rather than regular breast self-examination. The independent value of clinical breast examinations has not been rigorously assessed. Rather, it has been studied in conjunction with screening mammography, in which case the two interventions appear to decrease mortality from breast cancer by approximately 20% for average-risk women of all ages20 and by 25 to 30% in women older than 50 years. Considerable controversy continues over the value of screening mammography in women 40 to 50 years of age and those older than 70 years, as well as the optimal interval between mammograms for women aged 50 to 70 years. However, a large randomized trial of annual mammography screening in women aged 40 to 49 years showed a 25% reduction in mortality from breast cancer at 10 years but no further reduction over the next 12 years.A28,A28b Currently, the American Cancer Society (ACS) recommends annual screening mammography for women at standard risk for breast cancer starting at age 45 (with opportunity to begin at age 40) and biennial screening (with opportunity to continue annual screening) beginning at age 55 years. These ACS screening recommendations are for mammography only; the ACS does not recommend clinical breast examination for cancer screening among average-risk women at any age.21 In contrast, the U.S. Preventive Services Task Force and the American College of Physicians recommend that women between 40 and 50 years of age be counseled about the risks and benefits of screening mammography and that screening mammography can be used at 2-year intervals for women aged 50 to 74 years (Table 188-5).22,22b However, women aged 40 to 49 years with a two-fold increased risk for breast cancer have benefit-to-harm ratios for biennial screening mammography similar to average-risk women aged 50 to 74 years. A study of digital versus conventional film screen mammography failed to show an overall advantage for digital mammography but suggests that digital mammography may be more useful for women with dense breasts. A large national study of tomosynthesis found it to be less good than MRI.A28c The survival benefits of mammography come at the cost of false-positive results that lead to anxiety and further evaluation.23 According to various estimates, more than half of the women screened by mammography have false-positive results over 10 years of screening, and 7 to 9% get recommendations for breast biopsy. Other studies have estimated an overdiagnosis rate of 3.3% for invasive cancer and from 18 to 32% for carcinoma in situ. Another issue is that the radiation exposure from mammography is estimated to cause 2 to 11 deaths per 100,000 screened women.24 In general, screening is unlikely to be worthwhile for women with a life expectancy of less than 10 years. Furthermore, some analysts suggest that the reduction in breast cancer mortality after the introduction of screening mammography is mostly a result of improved therapy rather than earlier diagnosis.25

1 What are the three parts of breast screening that assist in the early diagnosis of breast cancer?

Breast self-examination (BSE) should begin at age 20 and be performed monthly. The breast is usually easiest to examine on the days immediately following the menstrual cycle. BSE can be frustrating to patients, particularly when they have fibrocystic change because they are not certain what they are feeling or supposed to feel. The technique of BSE should be taught early and reinforced regularly. If a palpable tumor develops, women who regularly perform BSE present with tumors 1 cm or smaller more frequently than women who do not perform BSE. Improvement in survival from breast cancer has not been demonstrated, however. Some women should not practice BSE because of the psychological trauma they suffer from repetitive false-positive findings. Those women need to rely on their physician to do a breast examination once or twice a year.

Clinical or physician breast examination (CBE) also should begin at age 20 and be performed annually for women at average risk for breast cancer. Although tumors between 0.5 cm and 1.0 cm occasionally can be detected by an experienced physician, tumors between 1.0 and 1.5 cm can be detected 60% of the time. As the tumor grows, 96% of tumors larger than 2.0 cm can be identified on physician physical examination. Clinical breast examination should be part of the primary care physician's health maintenance and screening program.

Screening mammography has had the most substantial impact on the early diagnosis of, and subsequent decrease in mortality from, breast cancer.

Breast Self-Examination

Breast self-examination (BSE) is no longer a recommendation of the American Cancer Society, although the society states that its potential use should be discussed along with risk and benefits for a woman starting in her 20s. The U.S. Preventive Service Task Force (USPSTF) in 2002 decided that the data is insufficient to recommend for or against BSE. Women should be aware of how their breast looks and feels and report changes to their health care provider immediately. The limitations of breast cancer self-screening are based largely on a study of 266,000 female factory workers in Shanghai, China. One group was instructed in BSE, and the control group was given instructions about lower back pain. Neither group had routine conventional breast imaging or clinical examination. In both cohorts, the size of the tumor and mortality for breast cancer was similar, whereas a higher rate of benign breast biopsies was seen in the BSE group.2 In another study of 27,421 women enrolled in a health plan in the Pacific Northwest, 75% reported performing BSE, with 27% being reported as having performed an adequate examination. Participants ultimately diagnosed with breast cancer were significantly less likely to report performing BSE. Tumor size and stage were also not association with the performance of BSE.3

With this in mind, the discussion should be made about the limitations and potential benefits of BSE. Women who are comfortable with BSE should have a systematic and monthly approach to looking at and examining their own breasts. Instruction may first include a discussion of risk factors for development of breast cancer with a patient, including patient age, family history (both paternal and maternal) for breast and ovarian cancer, menarche, menopause, obesity, alcohol consumption, and hormone replacement. During this discussion, mention should be made of the fact that most early-stage breast cancers do not produce symptoms. The most common sign is a painless mass. The technique of BSE should be reviewed with a health professional. The importance of noticing changes to the contour of the breast and possible development of swelling, dimpling, nipple retraction, skin thickening, and nipple discharge along with identifying a palpable finding should be brought to the attention the health care provider—along with the caveat that most findings will not be cancer. In the premenopausal setting, a lump that develops may be normal and appear and disappear with the menstrual cycle. A lump that persists past one or two cycles should be brought to the attention of a health care provider. A lump that persists for more than a few weeks in the postmenopausal setting should also be brought to a care provider's attention.

The actual technique of BSE varies but should include the woman looking at herself in a full-length mirror, with her arms to her side, then over her head, and then to her side with flexion against the side to look for symmetry, dimpling, and retraction (Fig. 35-1). It should be noted that most women have a slight asymmetry in breast size, and this should be considered normal. A progressive change in size, whether an increase or decrease, in one breast should be brought to the attention of the health care provider. A BSE should also be performed lying down with the arm over the head to allow the breast tissue to splay out evenly over the chest The examination should be taught with using two or three fingers using a circular approach of light, moderate, and deep pressure going over the entire breast from the clavicle to the inframammary fold, laterally to the latissimus, medially to the sternum, and also including the low axilla. The entire breast should be examined either in a spoke-wheel fashion or vertical/horizontal blind or circular method, covering the entire surface area (Fig. 35-2). The timing of the BSE should be monthly, usually 1 week after menses in the premenopausal woman and on a set day of the month in the postmenopausal setting.

General Rules

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BSE should be done in a warm, comfortable, private place free from distractions. This allows women to be mindful of the exam, and the warmth allows the breast tissue to relax, facilitating the exam.

BSE should be conducted using the pads, not the tips, of the three middle fingers.

The right hand should be used to examine the left breast, the left hand to examine the right breast.

The woman should examine all tissue from the midaxillary line to the clavicle and to the sternum. Evidence suggests that a vertical pattern (Fig. 10-2) is most effective for covering the entire breast without missing any breast tissue.

Three levels of pressure should be applied: light, medium, and firm.

The breast should be examined in small “massaging” circles when using the patterns shown in Figure 10-2. The fingers should maintain contact with the breast at all times. Lifting the fingers could lead to an area being missed.

BSE should be performed both lying down, and in an upright position. The upright portion of the exam can be done in the shower. Additionally, a visual inspection should be done in front of a mirror.

A small amount of oil, soap, or powder may be applied to the fingers to reduce friction and allow the fingers to glide more smoothly over the skin.

The following areas should be examined thoroughly with each BSE:

Outside: armpit to collar bone, and below the breast

Middle: the breast itself

Inside: the nipple area

Although cancerous growths are most likely to be found in the upper, outer breast quadrant or behind the nipple, they can occur in any area of the breast, chest, or lymph network (Box 10-2); therefore, a thorough exam is essential.

Self-examination of the breasts

Few randomized trials regarding breast self-examination exist. A 2003 Cochrane systematic review included two large population studies from China and Russia. Twice as many biopsies with benign results were performed in the screening group compared with the control group (RR, 1.89; 95% CI, 1.79 to 2.00) (Gemignani, 2011). Several other studies did not show an advantage of breast self-examination in the rates of breast cancer diagnosis, breast cancer death, or tumor stage or size. Although this procedure has long been advocated, breast self-examination in itself does not decrease breast cancer mortality. However, research has shown that routine breast self-examination does play a role in detecting breast cancer compared with finding a breast lump by chance or simply knowing what is normal for each woman. For this reason, some societies continue to recommend some form of self-breast examination. ACOG recommends breast self-awareness, which for some patients includes performing a BSE and reporting changes to their physician. The ACS recommends educating women about the benefits and limitations of BSE and to report any changes. BSE is an option for women starting in their 20s. The USPSTF, however, recommends against teaching breast self-examination.

Women who choose to perform a BSE should do so when their breasts are least likely to be tender or swollen. In premenopausal women, a few days immediately after a menstrual period are the best time to detect changes in normal lumps or texture of the breasts. Postmenopausal women or women who have had a hysterectomy can perform BSE on the same calendar days each month if they choose. Breast changes that women should be aware of include development of a lump or mass, swelling of the breast, nipple abnormalities or discharge, and skin irritation or dimpling. The examination is best done in both supine and upright positions using the finger pads of the three middle fingers. Three different levels of pressure (light, medium, and firm) are used to examine the breast. Women should be consistent in their technique used. One of the easier techniques to follow is to palpate the breasts in a clockwise fashion beginning at the nipple and gradually circumscribing larger circles; however, some advocate the vertical pattern (up and down pattern) as the most effective for examining the entire breast without missing any breast tissue.

Diagnosis

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Women who regularly perform breast self-examinations may note changes in the breasts during the cycle. The breasts become more lumpy and tender before menses and less lumpy and less tender after menses.

Physician-administered breast examinations may reveal move-able, nonadhered, cystlike masses with clearly delineated borders in the breasts.

Fine-needle aspiration of the cyst can be used to both diagnose and treat fibrocystic changes.

Mammography may be used to differentially diagnose fibrocystic changes from breast cancer and other breast disorders.

Excisional biopsy of the tissue is used to differentially diagnose fibrocystic changes from breast cancer and other breast disorders.