1. Dr. Ruth Westra Applied Anatomy September 17, 2007
Breast Exam
Dr. Ruth Westra
Applied Anatomy
September 17, 2007

2. Goals/Objectives Discuss Asymptomatic Female/Male Breast Assessment
Practice on Silicone Models
Demonstrate Proficiency with clinical breast exams on a professional patient model at the Duluth Family Medicine Residency

3. Anatomy Milk producing glands arranged into lobules
Glands connected by series of ducts to form a common drainage path at the nipple
Nipple surrounded by the areola
Fibro-elastic and fatty tissue provide support
Lymphatic tissue with ~90% drain into the ipsilateral axilla and 10% drain into the Internal Thoracic nodes
Lymphatic Drainage: Internal Thoracic nodes not accessible for the exam. Lymphatics usually the first site of metastasis

4. EPIDEMIOLOGY
The lifetime risk for developing Breast Ca in US women is 1 in 7
Majority of women who develop breast Ca are over age 50
Majority of women with Breast Ca have no obvious risk factors
BREAST CANCER IS THE MOST COMMON CANCER AMONG WOMEN AND THE SECOND LEADING CAUSE OF CANCER DEATHS IN WOMEN TODAY.

5. RISK FACTORS Age Gender Race Prior History of Breast Cancer
Family History of 1st Degree Relative
Prolonged/Uninterrupted Exposure to Estrogen
Increasing Age
Gender: Far more common in women then men….while uncommon breast ca can occur in men so discrete masses should be evaluated. Also, men may develop gynecomastia secondary to medications (spirinolactone, digoxin, cimetidine, ketoconazole, ACE inhibitors, tricyclic antidepresessants and more)
Race: White women are slightly more likely to develop breast cancer than African-American women. African-American women are more likely to die of this cancer..?faster growing. Asian, Hispanic and American indian women have a lower risk of breast can
Family History of 1st Degree Relative-especially if young age (BRCA1 or BRCA2 mutations
Estrogen: early age of menarche, never having been pregnant, older age at first pregnancy, older age at menopause

6. GAIL MODEL
Breast Cancer Risk Assessment Tool to calculate 5 year and lifetime risk for breast cancer based on several factors
Relative Risk for each factor produces a composite score
FACTORS: Age, Race, Number of First-degree relatives with a history of breast cancer, age at first birth or nulliparity, age at menarche, number of breast biopsies, and a history of atypical hyperplasia
Gail Model=A computer program that uses personal and family history to estimate a woman’s chance of developing breast cancer.

7. SCREENING GUIDELINES
Clinical Breast Exams (CBE) part of periodic health exam every three years from women in 20s and 30s and yearly for women 40 and over.
Yearly mammogram starting at age 40 and continuing for as long as a woman is in good health.
Breast self-exam (BSE) is an option for women starting in their 20s
Women at increased risk should talk with their doctors about the benefits and limitations of screening earlier.
American Cancer Society
USPSTF=US Preventative Service Task Force

8. Taking Care of Your Breasts
Clinical Breast Exam (CBE)
Mammogram
Breast Self-Exam (BSE)
CBE: Age q 3 years; Age 40 or older q year
Mamogram: Age 40 and older yearly
BSE: Age 20 and older monthly
“While both CBE and BSE are part of routine care, there are no studies that demonstrate either technique, when performed as stand-alone examinations, actually improves clinical outcomes
(such as detecting cancer at earlier stage or positive impact on cancer related morbidity or mortality)
*Mammography has evidence base to support its routine screenting tool for early detection of malignancy.

9. CLINICAL BREAST EXAM Every 3 years for women age 20-39
Annually for women 40 and older
Adjuct to mammograms
CBE seeks to detect breast abnormalities or evaluate patient reports of symptoms to find palpable breast cancers at an earlier stage of progression. Treatment options for earlier-stage cancers are generally more numerous, include less toxic alternatives and are usually more effective than treatments for later-stage cancers. Recent debate has questioned the contributions of CBE to the detection of breast cancer in asymptomatic women…

10. CLINICAL BREAST EXAM
Detection for some cancers that are missed on mammography
Follow-up on “lumps” detected by women
Screening younger women
Screening women who do not follow mammography recommendations

11. EXAMINATION IN DETAIL Explain Exam Room Appropriate Draping Inspection
Position
Palpation

12. SEVEN P’s FOR EXAM Position Perimeter Palpation Pattern Pressure
Patient Education
Plan of Action
Some students like to remember by a mnemonic

13. Observation: Looking for Retraction Signs, Abnormal Contours, Skin Dimpling, Nipple Retraction and Deviation, Edema of the Skin, Paget’s Disease of the Nipple
Edema of the Skin: Peau d’orange (orange peel) sign-thickened skin with enlarged pores due to lymphatic blockage
Paget’s Disease of the Nipple: uncommon form of breast CA-starts as scaly, eczemalike lesion…may weep, crust or erode..evaluate any persistant dermatitis of the nipple

14. Positions: 1. Arms relaxed at side 2. Arms above Head 3. Hands on Hips

15. Superior aspect bounded by the clavicle
Inferiorly by the inframammary crease (bra line)
Medially by the sternum
Laterally by the axilla

16. Pressure: Light, Medium and Heavy

17. Pillow under arm for lateral aspect
Appropriate draping
Methods: 1. Vertical Strip 2. Pie or Radial Spoke Pattern 3. Circular Pattern
Palpate the AXILLA

18. PATIENT EDUCATION AND PLAN
Discuss your Exam with the patient
Check for patient understanding and agreement
Offer written material
Recommend appropriate screening
Document your Exam Findings
Document your Patient Recommendations

19. DOCUMENTATION location size shape consistency texture mobility
tenderness

20. PLAN
Document your Exam Findings
Document your Patient Recommendations

21. COMMON ERRORS IN CBE Missing the Auxiliary Tail Inconsistent Pressure
Pattern of Search does not extend to the Perimeter
Avoiding the Nipple/Areolar Complex

22. MAMMOGRAM GUIDELINES
Yearly mammograms starting at age 40 and continuing for as long as a woman is in good health.
American Cancer Society

23. BREAST SELF-EXAM Option starting at age 20 and older monthly
Women should report any breast change promptly
American Cancer Society: women in their 20’s should be told about the benefits and limitations of BSE
Women should be aware of their normal breast and report any new change.
Research related to the ability of CBE or BSE to reduce breast cancer deaths is limited…
USPSTF_The evidence is insufficient to recommend for or against teaching or performing routine breast self-examination (BSE)
Best time to examine when breasts are not tender or swollen. May still do the exam if pregnant, breast feeding or with breast implants. It is acceptable to choose not to do a BSE or to do BSE occasionally according to American Cancer Society

24. BREAST MASSES Fibroadenoma Cysts Breast Cancer
Three most common breast masses
Fibroadenoma: up to 55 usually single well delineated very mobile, usually nontender
Cysts: regress after menopause, usually single, round, well delineated, mobile often tender
Cancer: most common over 50, irregular or stellate, firm, not clearly delineated, may be fixed, usually nontender, may have retractions
Fibrocycstic Changes-common palpable nodular, ropelike densities usually and may be tender

25. Clinical Pearls
A clearly identifiable discrete mass requires a biopsy even if the mammogram is negative
Breast Cancer can occur in men
Breast Cancer can occur in young women
If you have uncertainty, seek input
Not all malignancies may generate an abnormal mammogram. So if you are able to palpate a discrete mass (not cystic) continue to pursue with biopsy.
Most masses are benign…secondary to fibro-cystic changes, cysts or transient changes during the cycle
Further lectures will follow during endo-repro regarding abnormal lesions and evaluations…when to evaluate by ultrasound, aspiration, biopsy, menstrual cycle and breast exams.

26. References www.cancer.org http://medicine.ucsd.edu/clinicalmed/
Bickley, L.S. Bate’s Guide to Physical Examination and History Taking Ninth Edition
Saslow et al. “Clinical Breast Examination: Practical Recommendations for Optimizing Performance and Reporting CA: A Cancer Journal for Clinicians Vol 54, No 6 Nov/Dec 2004
Sharon Anderson NP UMD Health Service