II. Efficacy: Clinical Breast Exam

  1. USPTF does not recommend for or against CBE or SBE
    1. Insufficient evidence to date
    2. Contrast with Mammogram which is USPTF B rating
    3. (2002) Am Fam Physician 65(12):2537-44 [PubMed]
  2. Sensitivity of Clinical Breast Exam
    1. CBE detects 3-24% of cancers missed by Mammography
      1. Especially in Women younger than age 50
  3. Limitations of Clinical Breast Exam
    1. High False Positive Rate
      1. As few as 4% of abnormal CBE are Breast Cancer
      2. Bobo (2000) J Natl Cancer Inst 92:971-6 [PubMed]
    2. Misses >40% of cancers diagnosed by Mammography
    3. Requires practice for confidence and proficiency
      1. Technique accounts for 29% variance in sensitivity
      2. Fletcher (1989) J Gen Intern Med 4:277-83 [PubMed]
  4. References
    1. Baines (1997) J Natl Cancer Inst Monogr 22:125-9 [PubMed]
    2. Sirovich (1999) Surg Clin North Am 79(5):961-90 [PubMed]

III. History: Focused

IV. Exam: Timing

  1. Lactation: Nurse or pump before exam
  2. Optimal during Follicular Phase (Estrogen only)
    1. Less engorgement
    2. More comfortable
    3. Preferably between days 5-10

V. Exam: High risk areas for Breast Cancer

  1. Upper Outer Breast
    1. Most common location for Breast tumors
  2. Sub-Areolar (Deep to Areola)
    1. Second most common location for Breast tumors

VI. Technique: Sitting Position Exam

  1. Advantages of Sitting Position
    1. Axillary fat pad moves forward, exposes nodes
    2. Duplicates upright position of shower exam
    3. Skin retraction highlighted on Pectoralis contract
  2. Observation (From front and side in every position)
    1. Focus points on observation of Breast
      1. Symmetry
      2. Skin retraction or dimpling
      3. Skin Color and texture
      4. Nipple and Areola
    2. Positions
      1. Arms at side
      2. Arms over head (exposes lateral, inferior Breast)
      3. Hands on hips
        1. Contracts Pectoralis Muscle
        2. Accentuates Cooper Ligament tumor involvement
  3. Examine Lymph Nodes
    1. Supraclavicular
    2. Infraclavicular
    3. Axillary

VII. Technique: Supine Position Exam

  1. Focus points on palpation of Breast
    1. Background nodularity (fibroadenomas)
    2. Asymmetry
    3. Dominant mass
    4. Nipple Discharge
  2. Positioning
    1. Ipsilateral arm abducted, flexed
      1. hand behind head
  3. Palpation patterns
    1. Wedge Pattern
      1. "Spokes of a wheel" OR "Hands of a Clock"
      2. Palpate in radial pattern around Breast
    2. Circular Pattern
      1. Spiral pattern from nipple to outer Breast
    3. Vertical Strip
      1. Similar to plow lines on a field
  4. Technique
    1. Use pads of the 1st 3 fingers
    2. Start with light, then medium, then deep pressure

VIII. Interpretation

  1. Benign mass findings
    1. No skin change
    2. Smooth, soft, mobile lesion with well defined margins
  2. Malignant mass findings
    1. Hard, immobile lesion with irregular margins

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