It is important to obtain a current list of medications used, including hormone therapy and herbal medications such as phytoestrogens. The gestational history should take into consideration the possibility that the patient may be pregnant or has a prior history of miscarriage or abortion. A personal history of exposure to radiation, especially in the treatment of childhood malignancies, is associated with a higher incidence of developing breast cancer (5). The goal of breast evaluation is to determine clearly whether the symptom represents a benign breast condition or may be indicative of a neoplastic process.
Physical Examination Breast tumors, particularly cancerous ones, usually are asymptomatic and are discovered by the patient or through physical examination or screening mammography. Typically, the breast changes slightly during the menstrual cycle. During the premenstrual phase, most women have increased innocuous nodularity and mild engorgement of the breast. Rarely these characteristics can obscure an underlying lesion and make examination difficult. Findings should be carefully documented in the medical record to serve as a baseline for future reference.
Inspection Inspection is performed initially while the patient is seated comfortably with her arms relaxed at her sides. The breasts are compared for symmetry, contour, and skin appearance. Edema or erythema is identified easily, and skin dimpling or nipple retraction is shown by having the patient raise her arms above her head and then press her hands on her hips, thereby contracting the pectoralis muscles (Fig. 21.1). Palpable and even nonpalpable tumors that distort Cooper’s ligaments may lead to skin dimpling with these maneuvers.
Figure 21.1 Raising the arm reveals retraction of the skin of the lower outer quadrant caused by a small palpable carcinoma. (From Kruper L, Giuliano AE. Breast disease. In: Berek JS, Hacker NF, eds. Berek & Hacker’s Gynecologic Oncology, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2010:615, with permission.)
Palpation While the patient is seated, each breast should be palpated methodically. Some physicians recommend palpating the breast in long strips, but the exact palpation technique used is probably not as important as the thoroughness of its application over the entire breast. One very effective method is to palpate the breast in enlarging concentric circles until the entire breast is covered. A pendulous breast can be palpated by placing one hand between the breast and the chest wall and gently palpating the breast between both examining hands. The axillary and supraclavicular areas should be palpated for enlarged lymph nodes. The entire axilla, the upper outer quadrant of the breast, and the axillary tail of Spence are palpated for possible masses. While the patient is supine with one arm over her head, the ipsilateral breast is again methodically palpated from the clavicle to the costal margin and from the sternum to the latissimus dorsi laterally. If the breast is large, a pillow or towel may be placed beneath the scapula to elevate the side being examined; otherwise, the breast tends to fall to the side, making palpation of the lateral hemisphere more difficult. The major features to be identified on palpation of the breast are temperature, texture and thickness of skin, generalized or focal tenderness, nodularity, density, asymmetry, dominant masses, and nipple discharge. Most premenopausal patients have normally nodular breast parenchyma. The nodularity is diffuse but predominantly in the upper outer quadrants, where there is more breast tissue. These benign parenchymal nodules are small, similar in size, and indistinct. By comparison, breast cancer usually occurs in the form of a nontender, firm mass with irregular margins. A cancerous mass feels distinctly different from the surrounding nodularity. A malignant mass may be fixed to the skin or to the underlying fascia. A suspicious mass is usually unilateral. Similar findings in both breasts are unlikely to represent malignant disease (6).