Breast examination

Question 1

what percentage of cases of breast cancer are now curable?

Answer 1

around 80%

Question 2

why has the mortality of breast cancer reduced?

Answer 2

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
Whilst surgery alone will cure 50% of all breast cancer regardless of what other treatments they have, it has no impact on systemic micrometastatic disease, hence the importance of medical adjuvant therapies.
Better surgery in the last 50 years hasn’t enhanced survival but has improved quality of life for survivors

Question 3

why is breast cancer more common in 1st world countries?

Answer 3

alcohol, contraception, having babies later, not breast feeding, obesity

Question 4

what is the distribution of breast cancers at presentation?

Answer 4

30% asymptomatic through screening
60% early symptomatic breast cancer
5% locally advanced breast cancer
5% metastatic 
Lung, lytic bone, brain (hypercalcaemia, jaundice, ascites due to peritoneal)

Question 5

how is breast cancer diagnosed?

Answer 5

Clinical examination
Mammogram 
Ultrasound 
Biopsy 
Staging

Question 6

how would you introduce a breast exam?

Answer 6

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 7

what should you ask the patient to do first after gaining consent and observing from standing?

Answer 7

ask patient to sit on the couch infront of you

Question 8

what are you looking for when that patient is sitting infront of you?

Answer 8

Observe the breast.
Look for:
Asymmetry
Skin tethering
Nipple retraction
Discoloration
Ask the 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 9

what is the next step after observing when sitting?

Answer 9

ask the patient to lie back a about 45 degrees

Question 10

what must be done before palpating the breasts

Answer 10

ASK
gain consent
ask if they are tender anywhere

Question 11

where should you be looking while palpating breasts?

Answer 11

at the patients face to look for signs of discomfort

Question 12

how would you palpate breasts?

Answer 12

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 13

what should you feel for if you find a lump?

Answer 13

Size: measure with a calliper or ruler
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

Question 14

what should you do if you cant find the lump the patient is complaining of?

Answer 14

ask the patient to show you where they felt it

Question 15

how should you examine nipple discharge?

Answer 15

Ask her to show you, don’t express it for her

Don’t squeeze the nipple if this is not a symptom

Question 16

how should you examine the axillary region?

Answer 16

put patient forearm to your forearm (left and left or right and right), then use other hand to palpate in the axillary region, usually a cavity, obese patients will not have this however

Question 17

what should be done at the end of the osce examination?

Answer 17

allow patient to redress and thank them BEFORE addressing the examiner

Question 18

how is breast cancer treated?

Answer 18

Surgical:
Breast conservation or mastectomy 
Selective axillary clearance - axillary clearance leads to arm swelling so avoided 
Adjuvant therapies:
Bisphosphonates
endocrine therapy
Chemo
Radiotherapy
targeted biologicals