Breast Examination

Gain informed consent after explaining the examination ± the use of a chaperone. The patient will need to undress to the waist and will be examined through four different postures.

1. Patient Sitting (arms by sides)
   • asymmetry of colour and contour (lumps / dimples)
   • nipple level / retraction (eczema / ulcer)
   • areolar pigmentation
   • peau d’orange (± varicosities)
2. raise arms above head
   1. is one breast less mobile than the other?
   2. accentuates lumps / dimples
   3. tethering of skin?
3. Supine (nipple highest point on chest)
   1. ask patient to find lump herself and then begin on the opposite side to affected breast using the flat of the fingers to palpate always watching for signs of tenderness and taking a mental note of the size, site, shape, consistency, and mobility (deep / skin) of any lump
      1. palpate the four quadrants of the breast systematically
      2. palpate also directly behind the nipple
      3. palpate the other breast
4. Sitting up (again)
   1. gently grasp lump between fingers and move horizontally and vertically
      1. note any nipple or other secretion
   2. ask the woman to press on her hips and repeat the manoeuvre
      1. this tenses the serratus anterior muscle
   3. bending forward
      1. large pendulous breasts fall away and reveal the axillary tail for better examination
   4. now check for axillary lymph nodes
   5. and do not forget the supraclavicular fossa (± neck), bilaterally
5. finally, mentally step back and look more holistically by examining the:
   1. liver
   2. back (bones)
   3. chest X-Ray

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Breast Cancer – clinical

History:

• risk factors – plus any h/o trauma, change in shape of any lumps or any discharge
• relationship to menstrual cycle (and other symptoms) – how long?
• previous breast problems (e.g. microscopic calcification)
• metastases – systemic complaints e.g. weight loss, bone pain
• pregnancies, lactation, menarche, menopause
• drugs – OCP, hormone therapy, tamoxifen, radiotherapy, etc.

Investigations

• FBC and LFTs
• CXR
• mammography
• ultrasound
• Fine-needle aspiration biopsy → excision biopsy (hormone-receptor assay)
• bone scan
• liver CT scan

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Breast Cancer – management

Be forthright with the patient but at the same time impress upon them that the specifics of management will have to wait until the results of the biopsy.

• Lumpectomy
• Segmentectomy (Quadrantectomy)
• Simple (Patey’s) Mastectomy (Modified Radical Mastectomy)
  • ± sentinel node biopsy
  • ± axillary dissection
  • ± radiotherapy
  • ± adjuvant therapy
    • chemotherapy: node positive
    • hormone therapy: oestrogen positive

Breast Cancer – prognosis

• localised to breast → 75-90% 5-year survival
• localised to breast + local nodes → 40-50% 5-year survival → 25% 10-year survival
  • (because of micrometastases at presentation)