History

History should include the characteristics of symptoms and their timing in relation to menstrual cycles. Breast pain is most commonly caused by fibrocystic changes. Other causes include mastitis, which usually produces sudden pain, with signs of inflammation. Pendulous breasts can cause pain. Hidradenitis suppurativa can manifest as breast nodules and pain; signs of infection and possible concomitant involvement of the axilla should be evaluated. One should be alert for history suggesting thoracic arthritis, chest wall inflammation, breast or axillary infection, cholecystitis, or cardiac ischemia.

The presence or absence of lumps should be ascertained, and whether they wax and wane with the menstrual cycle (suggesting fibrocystic changes). Lumps associated with nipple discharge, particularly unilateral bloody discharge, are worrisome.

Symptoms of nipple discharge should be elicited. The overall rate of malignancy is low (probably around 1%). If the discharge is nonbloody, the risk of cancer is lower. Purulent discharge may be caused by mastitis or a breast abscess. Milky discharge may persist after childbearing and can occur with some medications (see “Treatment”). An endocrine workup (for prolactin excess) may be needed if symptoms are sustained or are associated with menstrual problems. Prior biopsies, prior treatments, and use of hormones should be ascertained.

Risk factors for cancer should be assessed whether symptoms are present or the visit is for screening only. These include age, menarche before age 12 years, menopause after age 55 years, and first live birth at age 30 years or older. Information should be obtained about previous biopsies (whether ductal hyperplasia and, if so, whether atypical), and the number of first-degree relatives with breast cancer (and at what age their cancer was detected). The Gail Model Risk Assessment Tool may be used to help calculate risk from these history questions.⁸ A computer disk for use of the Gail model is available from the National Cancer Institute to use in calculating this. Such estimates can aid in decision making, particularly about chemoprevention.

Physical Examination

There is an overall consensus that clinical breast examination (CBE) is useful in screening as well as in evaluation of a lump, although there has been debate on this issue. Four screening clinical trials included both mammography and CBE, four others evaluated mammography only, but no trial studied CBE alone without mammography. In a comparison of studies including both screening modalities, the range of cancers detected by CBE but not by mammography was 3% to 45%. Although the sensitivity of mammography is greater than that of CBE, there is a residual diagnostic value of CBE that favors its continued use in screening.⁹

Careful, systematic palpation has been shown to increase detection of breast lumps. Patient position, palpation of breast boundaries, and examination pattern and technique are important variables in CBE.⁹

The physical examination should include inspection and palpation. Inspection of the breasts can be done with the woman sitting with hands on her hips; some advocate inspection also with the patient sitting with her hands on top of her head, pushing downward. The examiner looks for lumps, asymmetry, or skin dimpling.

The breasts should be palpated for evaluation of texture and detection of masses. The supine patient position is preferable because CBE requires flattening breast tissue against the patient’s chest, and the distance from skin to chest wall is minimized with the patient supine. The patient’s ipsilateral hand should be brought up to head level for examination of the lateral aspect of the breast; the elbow should be at shoulder level for examination of the medial part of the breast.

The examination pattern should be systematic. It is important to include the area bordering the clavicle, and laterally toward the axilla, so as to ensure examination of all breast tissue. One preferred method is to start at the axilla in the midaxillary line and then cover the breast by palpating in parallel lines, in vertical strips to the sternum. A rectangular area bordered by the clavicle, the midsternum, the midaxillary line, and the bra line should be covered (Fig. 1). Small circular motions should be made at each step using the pads of the index, third, and fourth fingers, with gradated pressure (Fig. 2).

Figure 1 Position of the patient and direction of palpation for clinical breast examination.

Palpation is on the lateral (top) and medial (bottom) portions of the breasts. Arrows indicate vertical strip pattern of examination.

(From Barton MB, Harris R, Fletcher SW: Does this patient have breast cancer? The screening clinical breast examination: Should it be done? How? JAMA 1999;282:1270-1280.)

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

(From Barton MB, Harris R, Fletcher SW: Does this patient have breast cancer? The screening clinical breast examination: Should it be done? How? JAMA 1999;282:1270-1280.)

Examination of the axillae for lymph nodes should follow breast examination. Examination along the chest wall is especially important. The position and size of any nodes should be recorded. The presence of lymphadenopathy should prompt referral to a breast specialist, although the significance of shotty nodes is unclear.

The character of breast lumps is particularly important. Characteristics that suggest cancer include a hard or gritty texture, immobility, an irregular border, and a size greater than 2 cm. A new dominant mass or a gritty or growing lump deserves evaluation by a breast specialist. Unfortunately, likelihood ratios for these signs indicating cancer are not very large, except for the presence of fixed lesions and lump size greater than 2 cm.⁹

After the history and physical examination, further assessment of breast lumps may include careful clinical follow-up, ultrasound, mammography, and biopsy. Guidelines for screening mammography are reviewed in the “National Guidelines” section.

Mammography

Mammography may be performed as an adjunct to the physical examination in evaluating breast lumps or as a screening tool. Mammography is not generally useful in women younger than 35 years who present with a lump.¹⁰ Ultrasonography may be useful in evaluating lumps in these younger women, although it is important to refer to a breast specialist for any lesion in doubt.

Evaluating Symptoms

Mammography is usually recommended as part of the evaluation in women older than 35 years who have a breast mass, to help evaluate the mass and to search for other lesions. It is an error to rely on negative mammogram results when there is a clinically suspicious lump. In such cases, the mammogram is a diagnostic adjunct to the surgeon, and negative findings should not preclude referral.

Mammographic findings that suggest cancer include increased density, irregular border, spiculation, and clustered irregular microcalcifications. Round, dense lesions on mammography might represent cystic fluid. Ultrasonography can often suggest a cystic lesion, and needle aspiration can confirm this.

Mammography findings are usually negative when mammography is used to evaluate breast pain, although it may be of reassurance value in this setting.

Screening

The age at which to begin mammography for screening is controversial. There have been eight major trials of mammography screening. The observed change in breast cancer mortality has varied widely among these studies. Differences in randomization techniques, quality of the mammograms, duration of follow-up, and evolving treatments for breast cancer during the trials have made it difficult to draw conclusions about mammographic screening. There have been several meta-analyses of the effect of mammographic screening. Differences in these derive from the time they were done, the presence or absence of follow-up data from individual trials, and the exclusion of certain trials in some meta-analyses.

A consensus has emerged that women between 50 and 69 years should be screened by mammography. Results of a meta-analysis¹¹ of breast cancer screening trials found a 26% reduction in breast cancer mortality over 7 to 9 years among women screened at ages 50 to 74 years.

For women first screened in their 40s, the magnitude of breast cancer mortality reduction is at best 18% after 10 to 18 years of follow-up.¹² Although some guidelines discuss starting mammographic screening earlier in women with a family history of breast cancer, data on the sensitivity of mammograms show no better cancer detection rates in this group.¹³ However, due to a higher pretest probability of breast cancer in those with a family history, the positive predictive value of mammograms is higher for those women (and therefore the false-positive rate is lower for them).

The number needed to be screened to prevent one death from breast cancer is estimated at between 1500 and 2500 for women screened in their 40s.¹⁴ In addition, nearly one half of women screened starting at age 40 years have at least one abnormal screening mammogram during the subsequent 10-year period, leading to additional mammographic views and biopsies for a significant number. Many of these abnormal screening studies prove to be false positives.

If the patient or physician finds a palpable lump, a diagnostic (four-view) mammogram, with or without ultrasound, may be used to help guide diagnosis. Again, mammography is not sufficient to exclude cancer in the evaluation of a palpable mass (see the discussions of ultrasonography and triple diagnosis).