CLINICAL BREAST EXAMINATION FOR THE MAMMOGRAPHER; Part 1: The Exa

Happy Thanksgiving to all my Canadian readers. Up here in the great white north, we are all getting ready to over-stuff ourselves on overstuffed fowl and pumpkin pie dripping with whipped cream. I, for one, am thankful that I only do that once a year (maybe twice if you count Xmas). I am comatose for 3days after "the meal".


The laws they are a-changing for the allied health care professionals. Our practice is expanding and therefore the things we did informally now have to gain some structure. October`s techtalk is the first in a 3part series regarding our approach to patient assessment dealing with clinical breast exam. The first part deals with `how`, the subsequent parts deal with education, reporting, barriers and responsibilities.


Enjoy and pass it on, knowledge is power. 


Anne 

OBJECTIVES:


With the imminent signing into law of bill 172, full patient assessment comes into our scope of practice. With that in mind, the mammographers responsibilities in regards to Clinical Breast Exam broaden somewhat.


I will present recommendations in three areas, the clinical breast examination itself, interpretation/ reporting/follow-up, and overcoming barriers to performance. Some recommendations can be implemented immediately within clinical settings, and mammographers are encouraged to lead this effort. Others will require partnerships between the clinical community and health care organizations to establish systems, increase awareness, and gather necessary information to achieve outcomes.


CLINICAL BREAST EXAMINATION 


The premise underlying CBE is that visually inspecting and palpating of the breast and surrounding tissue can detect breast abnormalities. CBE is considered to include a continuum of integrally related components, from the examination itself, to interpretation and reporting of findings, to patient follow up. The recommendations for performance in this article represent general standards that can be immediately disseminated and adopted based on current evidence.


Neither CBE nor mammography is a substitute for the other as an independent examination for detecting breast abnormalities. When a suspicious mass is found on CBE, it must be evaluated and explained even if mammography examination does not show an abnormality.


The Examination: 

A. Adopt standards for CBE that include a stepwise progression of elements consisting of clinical history, visual inspection, and palpation.

Lead responsibility for implementation: clinicians.

B. Encourage widespread dissemination of standards for CBE.

Lead responsibility for implementation: health care organizations.

Studies have assessed the influence of test characteristics (such as search pattern, palpation, pressures, duration), patient characteristics (such as tissue density, and nodularity), and tumor characteristics (such as size, depth, mobility) on the CBE’s sensitivity and specificity. CBE techniques have been described and illustrated in several recent reviews; figures from one of several reviews are used to illustrate the recommendations presented here. These studies provide some basis for recommendations concerning the specific way CBE is performed. Not all aspects of visual inspection and palpation have been studied in controlled settings, however, and thus the following recommendations rely in part on the clinical expertise and the premise that visual inspection and palpation of every area of the breast and surrounding tissue will lead to identification of more breast masses.

FIGURE 1 Position of Patient and Direction of Palpation for the CBE. The top figure shows the lateral portion of the breast, and the bottom picture shows the medial portion of the breast. Arrows indicate the vertical strip pattern of examination. 

FIGURE 2 Palpation Techniques. Pads of the index, third, and fourth fingers (inset) make small circular motions, as if tracking the outer edge of a dime.

FIGURE 3 Levels of Pressure for Palpation of Breast Tissue Shown in a Cross-sectional View of the Right Breast. The examiner should make three circles with the finger pads, increasing the level of pressure (subcutaneous, mid-level, and down to the chest wall) with each circle. 

Clinical History:
A clinical history that identifies the patient’s personal and family health history is useful in assessing risk of breast cancer. Some women will not report symptoms until asked, and a clinical history provides an important opportunity to seek out this information. This health history can direct attention to potentially relevant symptoms and provides important context for interpreting findings. The clinical guidelines and policy statements of many organizations concerning the performance of screening CBE emphasize the importance of a woman’s individual risk for breast cancer. Furthermore, information on clinical history can help guide follow up. The clinical history also provides an opportunity for the health care provider to explain the benefits and limitations of the examination, its elements, the time involved, and the related events that occur after the examination (interpretation, reporting, and follow up).


The clinical history should: 

• Identify screening practices for breast health, when they were performed, and results. These practices include breast self-examination (BSE), prior CBE, and prior screening and diagnostic mammograms.
• Ask about any breast changes and how they were identified. This includes changes in appearance of skin or nipples, presence of lumps, pain (focal versus general and constant versus cyclic), itching, or staining of garments or bed sheets that would indicate spontaneous nipple discharge.
• Assess risk by asking about age and personal history, including benign breast disease, biopsy, cancer, cosmetic or other breast surgery, history of hormonal therapy, and/or oral contraceptive use, obstetric history, family history, and health promotion habits (e.g., exercise, nutrition).

Visual Inspection:


Once the clinical history has been completed, the patient’s breasts should be visually inspected. To minimize awkwardness and potential misunderstandings, clinician should inform women in advance that a visual inspection will be performed and describe what is being assessed during this part of the examination. The patient should sit with her hands pushing tightly on her hips. This position contracts the pectoralis major muscles and enhances identification of asymmetries. Although adding multiple positions (e.g., hands over head and hands at sides) may further assist identification of asymmetries, it does not add substantively to the single position recommended and may reduce time devoted to palpation. When conducting the visual inspection, the provider must view the breasts from all sides and should:

• Assess symmetry in breast shape or contour (subtle changes or differences)
• Assess skin changes, particularly any skin erythema, retraction or dimpling, and nipple changes.
• Physical signs associated with advanced breast cancer have been summarized using the acronym BREAST:

1. Breast mass
2. Retraction
3. Edema
4. Axillary mass
5. Scaly nipple
6. Tender breast

If the clinician is seeing the patient on a regular basis, visual inspection allows the monitoring of changes in appearance over time when observations are compared with previously documented examination. Visual inspection takes only a short amount of time, with the remainder of the examination spent predominately on palpation.

Palpation:
Following the visual inspection, the examiner palpates each breast and nearby lymph nodes. To minimize awkwardness and the potential for misunderstanding, providers should inform women in advance that palpation will be performed and describe what is being assessed during this part of the examination. Palpation provides an opportunity for discussion of the normal variability of breast characteristics and the importance of women becoming familiar with the characteristics of their own breasts. Thoroughness is essential; palpation must examine all breast tissue as well as nearby lymph nodes. Appropriate palpation includes five key characteristics:

1. Position: Patients should be sitting for palpation of the axillary, supraclavicular, and infraclavicular lymph nodes. Patients should be lying down for breast palpation, with their ipsilateral hand overhead to flatten the breast tissue on the chest wall, thereby reducing the thickness of the breast tissue being palpated (Figure 1, pg 2). If this maneuver does not result in a relatively even distribution of breast tissue, the breast should be further centralized by placing a small pillow under the shoulder/lower back on the side of the breast being examined. The tissue being examined needs to be as thin as possible over the chest wall. The examiner must be able to see the full palpation area.
2. Perimeter: All breast tissue falls within a pentagon shape (as opposed to the traditional perception of the breast as a conical structure). The examiner should use the following landmarks to cover all of this area: down the midaxillary line, across the inframammary ridge at the fifth/sixth rib, up the lateral edge of the sternum, across the clavicle, and back to the midaxilla.
3. Pattern of search: The full extent of breast tissue should be searched using a "vertical strip" pattern (Figure 1, pg 2). (A systematic analysis demonstrated the superiority of the vertical strip search pattern over concentric circle and radial spoke patterns in thoroughness of coverage, as performed by women trained in BSE to examine themselves.) The search should be initiated at the axilla. If a mastectomy has been performed, the chest wall, skin, and incision should be included.
4. Palpation: The examiner should use the finger pads of the middle three fingers to palpate one breast at a time (Figure 2, pg 2). Palpate with overlapping dime-sized circular motions. Tissue at and beneath the nipple should be palpated, not squeezed. Squeezing often results in discharge as well as discomfort. Only spontaneous discharge warrants further evaluation. Breast tissue in the upper outer quadrant and under the areola and nipple should be thoroughly searched, as these are the two most common sites for cancer to arise.
5. Pressure: As each area of tissue is examined, three levels of pressure should be applied in sequence: light, medium, and deep, corresponding to subcutaneous, mid-level, and down to the chest wall (Figure 3, pg 2). Adapt the palpation to the size, shape, and consistency of tissue, and accommodate pressure to other factors such as breast size and the presence of breast implants. Providers sometimes lack confidence performing CBE in women with breast implants; implants correctly placed are located behind the tissue of the breast. Therefore, the steps for CBE are exactly the same as in women without implants.

The duration of the examination is intentionally not specified, for several reasons. First, while thoroughness is related to time spent performing CBE; performance time can decrease with increased proficiency. Additionally, a variety of patient factors, such as breast size, tenderness, lumpiness, body weight, and risk factors, can influence the time required to perform a proficient CBE. Therefore specifying a uniform time frame would be misleading more often than not and would inappropriately shift the focus of performance away from proficiency and thoroughness.


SUMMARY:


As laws change, medical teams form and shift, multi disciplinary education becomes normal and hybrid and fusion imaging becomes standard practice our responsibilities as clinicians expand and evolve. As professionals we are expected to rise to the challenges presented to us.


With education, practice and experience we can embrace these new proficiencies and continue to serve our patients with skill and renewed efficacy. Knowledge is power!