Breast Self-Examination There is controversy about recommending breast self-examination (BSE). There is no evidence that doing BSE improves survival rates from breast cancer (7). Staunch opponents of BSE argue that it doubles a woman’s risk of undergoing a breast biopsy for benign pathology (8). BSE increases breast health awareness and helps promote early detection of cancer (9–11). Most breast cancers are detected by women themselves (48%), followed by breast imaging (41%), and by physician clinical examination in only 11% (12). Although young women have a low incidence of breast cancer, it is important to teach BSE early so it becomes habitual. Organizations such as the American Cancer Society sponsor courses in BSE. Reassurance, support, and patient education may encourage women to overcome psychological barriers to routine BSE (13). Such instruction is available through electronic resources (14).
The following seven “P”s represent the essential components of breast examination:
Pads of fingers for palpation
Pattern of search
The woman should inspect her breasts while standing or sitting before a mirror, looking for any asymmetry, skin dimpling, or nipple retraction. Elevating her arms over her head or pressing her hands against her hips to contract the pectoralis muscles will highlight any skin dimpling. Finally, the woman should examine her breasts while bending over and leaning forward. While standing or sitting, she should carefully palpate her breasts with the fingers of the opposite hand. She should lie down and again palpate each quadrant of the breast as well as the axilla using the pads of the three middle fingers with three pressures—light, medium, and deep—covering the entire breast from the clavicle to the inframammary fold, from sternum to latissimus dorsi laterally. The area within the perimeter of the breast should be palpated, preferably using an up-and-down method called vertical stripe, rather than the concentric circular or radial methods, in which the edges of the breast tissue often are omitted. Many women feel anxious about performing breast examination. The examination may be performed while showering; soap and water may increase the sensitivity of palpation, and the privacy of the shower may provide a less anxiety-provoking environment.
It is helpful for all women to examine their breasts at the same time each month to develop a routine. Premenopausal women should examine their breasts monthly 7 to 10 days after the onset of the menstrual cycle. For postmenopausal women, selection of a specific calendar date is a helpful way to remember to perform a monthly BSE. Women should be instructed to report any abnormalities or changes to their physicians. If the physician cannot confirm the patient’s findings, the examination should be repeated in 1 month or after her next menstrual period.
Mammography Screen-film mammography was considered the best method for imaging the breast (15). Full-field digital mammography, which records mammographic images on a computer, is a modification of screen-film mammography (16). Some advantages of digital mammography include lower radiation exposure, ability to manipulate a computerized image for optimal viewing, and access to distance consultations through telemammography (17). Studies comparing the sensitivity of full-field digital mammography with screen-film mammography in detecting cancer had mixed results. The Digital Mammographic Imaging Screening Trial (DMIST) consisted of 49,528 asymptomatic women presenting for screening mammography, who underwent both digital and film mammography. Results suggested that while the overall accuracy of digital and film mammography for screening breast cancer is similar, digital mammography may be more accurate in women under the age of 50 years, women with radiographically dense breast, and premenopausal or perimenopausal women (18).
Slow-growing breast cancers can be identified by mammography at least 2 years before the mass reaches a size detectable by palpation. These tumors have a less aggressive biologic behavior than interval breast cancers (19–21). Mammography is the only reproducible method of detecting nonpalpable breast cancer, but its use depends on the availability of state-of-the-art equipment and a dedicated breast radiologist.