A thorough history and physical examination are essential components of the diagnostic evaluation of a breast abnormality. Key features of the history include details about the presenting symptom, history of previous breast disease, and risk factors for breast cancer including a menstrual history and other contributing past medical history. Initial questions should focus on the presenting symptom, whether it be a mass, nipple discharge, palpable adenopathy, pain, or abnormal imaging. Questions should be asked regarding the length of time the abnormality has been present, associated pain, change in size or texture of the breast over time, and the relationship of the pain or change in size of the breast or mass to the menstrual cycle. Additionally, it is important to ascertain whether the patient has noticed any associated nipple discharge, nipple changes, axillary adenopathy, or skin changes. If the patient reports nipple discharge, it is important to inquire about whether the discharge is spontaneous or happens only with manipulation. A patient may notice staining of spontaneous discharge on her bra or bedclothes.

Identification of risk factors responsible for increasing a woman’s likelihood of developing breast cancer is important in the daily practice of clinicians caring for women. Risk factors for developing breast cancer can be divided into several categories: gender, age, endocrine factors, family history, genetic or inherited factors, and previous breast disease. Female gender is the most common risk factor for breast cancer. Male breast cancer accounts for less than 1% of all breast cancer. A patient’s risk for developing breast cancer increases with age. A woman in the sixth decade has a 1 in 24 chance of developing breast cancer, compared with 1 in 257 for a woman in her third decade. Endocrine risk factors for breast cancer include endogenous estrogen exposure and exogenous exposure to estrogen and progesterone. Early menarche, late menopause, late parity, and nulliparity all increase exposure to endogenous estrogen. In women who have had hysterectomy, whether or not the ovaries have been removed should be documented. It may be difficult to accurately determine the date of menopause, and often questions about menopausal symptoms may be helpful. Recent studies have indicated that long-term hormone replacement therapy with estrogen and progesterone can increase risk for breast cancer.

Previous personal history of breast cancer increases risk for subsequent breast cancer by approximately 0.7% per year. Having had a breast biopsy also increases risk to a much smaller extent, and this risk is further elevated if the pathologic results returned atypical hyperplasia or lobular carcinoma in situ. Table 1 lists the pathologic classification of benign breast disease and the risk associated with each category. A family history of breast or ovarian cancer consistent with genetic or inherited breast cancer significantly increases risk. A history of prior thoracic irradiation in women in their second and third decades of life carries a risk of subsequent breast cancer of approximately 35% by age 40. A summary of risk factors is listed in Table 2. It is important to note, however, that 60% of women with newly diagnosed breast cancer have no identifiable risk factors. Thus, the decision to evaluate a breast abnormality should not depend on the presence or absence of risk factors. Moreover, the presence or absence of risk factors does not influence the probability that a breast abnormality is malignant.

The physical examination should be performed with respect for patient privacy and comfort without compromising the complete evaluation. The examination begins with inspection. The breasts are visually observed and compared with the patient upright for any obvious masses, asymmetries, and skin changes. The nipples are inspected for the presence of retraction, inversion, or excoriation. The patient is then asked to lift her arms for a more careful inspection of the lower half of the breasts. This maneuver also highlights any subtle retraction that is not readily visible with the arms relaxed. Palpation of the regional nodes should follow to include the cervical, supraclavicular, infraclavicular, and axillary nodal basins. Finally, the breast is palpated in a systematic manner with the patient upright with arms relaxed and supine with the ipsilateral arm raised above the head.

A dominant mass is defined as being three-dimensional, distinct from surrounding
tissues, and asymmetric relative to the other breast. True masses will persist throughout the menstrual cycle. If a dominant mass is identified, it should be measured, and its location, mobility, and character should be documented in the medical record. Diagnosis should not be delayed. If uncertainty remains regarding the significance of an area of nodularity in the absence of a dominant mass in a premenopausal woman, a repeat examination at a different point in the menstrual cycle may clarify the issue.

In patients who present with nipple discharge, the nipple discharge is often elicited during palpation of the breast. The character, color, and location of the discharging duct or ducts should be documented. If the discharge is not grossly bloody, a Hemoccult test may be used to detect occult blood. Pathologic discharge, which is defined as unilateral, uniduct, spontaneous, and/or bloody discharge, should be evaluated with surgical duct excision.

Breast cancer is very uncommon in men, accounting for less than 1% of all breast cancers. The most common breast problem in men is gynecomastia. Gynecomastia is a benign hypertrophy of breast tissue. In older men, the hypertrophy is often unilateral. The patient usually presents with a discoid mass symmetrically placed beneath the areola, which may be tender to palpation. There are myriad benign causes of gynecomastia. Many medications are associated with gynecomastia. Gynecomastia is easily distinguished from breast cancer in that breast cancer is asymmetrically located beneath or next to the areola, and may be fixed to the overlying dermis or the pectoral fascia. If breast cancer is suspected, imaging followed by biopsy should be pursued.

Patients referred from another facility should provide the actual radiographic images so that the consulting surgeon may examine the films as part of the complete patient evaluation. Films of inadequate quality should be repeated. Additional images should be performed as necessary depending on the specific complaint.