Breast exam

Question 1

Breast cancer facts

Answer 1

Increasing incidence at present at about 1% per year, (90-110/100 000 since 1970s).

1 in 8 women

55 000+ cases in the UK last year.

13 000 deaths.

Age range 18-90+. Average is 62.

Question 2

Why is incidence rising?

Answer 2

Alcohol consumption
Post menopausal obesity
Increased longevity
Deferred and reduced child bearing
Reduced breast feeding
Oestrogen medications, (OCP, HRT)

Question 3

Why is mortality falling in breast cancer?

Answer 3

screening is better

Question 4

why is incidence rising?

Answer 4

Alcohol consumption
Post menopausal obesity
Increased longevity
Deferred and reduced child bearing
Reduced breast feeding
Oestrogen medications, (OCP, HRT)

Question 5

Why is mortality falling?

Answer 5

Screening: cancer being detected at an earlier stage when more likely to be cured

Antioestrogens: result in 25-30% improved survival

Chemotherapy, biologicals (trastuzumab), bisphosphonates

Question 6

What are the types of clinical presentation for breast cancer?

Answer 6

30% Asymptomatic, picked up through screening or incidentally on a CT scan for other illness
60% Early symptomatic breast cancer.
3-5% Locally advanced breast cancer
3-5% Metastatic

Question 7

What are the mainstays of breast diagnosis?

Answer 7

Clinical examination,
Mammography
Ultrasound
Biopsy
Staging

Question 8

Non Malignant Breast Problems

Answer 8

Benign, hormonal nodularity

Breast pain

Cysts

Itchy nipples/milky discharge

Sepsis

Question 9

other causes of breast lumps

Answer 9

Benign breast change
Fibroadenoma
Cyst
Sebaceous cyst
Papilloma
Fat necrosis/haematoma
Mastitis/abscess
Cancer
Sarcoma, lymphoma, metastases
Implant related: (capsule, rupture, edge or crease)

Question 10

what can cause benign breast change

Answer 10

Sometimes known as fibrocystic change.
Age range, puberty to menopause but usually younger end of range.
Often tender/painful
Cyclical variation
Feels like rubbery nodularity
Management: reassure

Question 11

presenting complaint

Answer 11

Duration of symptoms
Tenderness/not
Cyclical nature
Pregnancy/breast feeding
Size increasing?
Nipple discharge/bleeding
Previous history of breast problems (cysts, previous cancer)

Question 12

generAL factors

Answer 12

Use of oestrogens
General health
Drug history, especially clopidogrel, warfarin and apixaban
Family history of breast or ovarian cancer
Menopausal status
Breast implants present?

Question 13

presenting symptoms?

Answer 13

Painless lump/thickening
Nipple discharge
Nipple in-drawing
Distortion
Paget’s disease
Axillary nodes

Question 14

step 1 of exam

Answer 14

Introduce yourself and check the patient’s identity

A chaperone MUST!! Be present

Clean your hands!

Patient to be undressed to the waist (a gown round the shoulders gives some dignity)

Explain what you are doing to the patient as you go along.

Question 15

step 2 breast exam

Answer 15

Patient sits on couch facing you.
Observe the breast.
Look for:
Assymetry
Skin tethering
Nipple retraction
Discoloration

Question 16

step 3

Answer 16

Ask woman to lift her arms above her head and look again.

Ask woman to put her arms on her hips and push in: look again

Question 17

step 4

Answer 17

Ask woman to lie back at about 45 degrees.
Ask if you may palpate her breasts.
Ask if they are tender and tell her you will stop if it is hurting

Press breast vertically down onto the ribs. Do not pinch
Be thorough-quadrants /circular/ axillary tail
Watch her facial reactions.
Arms raised helps if large breasted

Question 18

if you find a lump?

Answer 18

Size: measure with a calliper or ruler
Assess: Mobility/fixity relative to skin, ribs and underlying muscle
Site in breast and proximity to nipple
Symmetry: Compare with the other side
Skin tethering
Consistency: hard/rubbery/soft/cystic/fluctuant
Smooth or irregular surface