Tbc: @ec@in@c@ue

/
--
o@ @r@o@ @:x@@c@nc,n

Arthur I. Holleb, M.D.

More than 90% of breast cancer is cial attention to the area immediately
discovered by the patient. A systema above the clavicle. The latter area is a
tized examination of the breasts will frequent site of metastasis from pri
improve the rate of detection of early mary breast cancer. Metastatic nodes
breast cancer by physicians and should are often located just above the most
result in a higher cure rate. medial portion of the clavicle.
A superficial and rapid examination
of the breast with the patient sitting Inspection
will often miss tumors of considerable The patient is seated facing the ex
size and will give the examiner a mea aminer. Lighting must be adequate.
ger impression of the breast structure. With the patient's arms resting at her
Not only may cancer remain undiscov side, the physician inspects the contour
ered, but also the physician is unable to of the breast beginning at the axillary
prepare adequate records for later com fold and extending to the midline. (Fig.
parative examinations. 1.) Areas of flattening of the normal
Routine breast examination should curve, bulges and skin dimpling are
be systematized so that all breast tissue looked for.
is palpated. At least two positions are The patient is then asked to raise her
required for the patient—erect and arms as high as she can. Elevation of
supine. The procedures recommended the arms will not only expose the ex
are relatively standardized, but may be treme lateral portions and the under
modified in sequence according to the surface of the breast but the maneuver
preference of the examiner. The three itself will often emphasize the surface
anatomic sites to be investigated are: flattening and make skin dimpling more
(1) the supraclavicular areas; (2) the evident. (Fig. 2.) The skin is examined
breasts (including nipples and areolae); for redness, edema (orange peel ap
and (3) the axillae. The initial phase is pearance) and dilated veins.
inspection and palpation. Unilateral elevation of the nipple line
should be noted. Surface changes such
Supraclavicular Areas as ulceration or superficial erosion are
The examiner should palpate method looked for. It is important to note direc
ically the upper, middle and lower cer tional change in the axis of the nipple
vical lymph node chains and give spe because the nipple is often pulled to
ward a tumor. The nipple “¿pointing― to
Dr. Holleb is Associate Medical Director and
A ssistant Attending Surgeon, Memorial Hospital a breast cancer may be the first change
for Cancer and Allied Diseases, New York, N.Y. detected on inspection and may help to

7
 Fig. 1

Fig. 5

focus attention on a specific breast

quadrant during palpation.

Palpation
Routine breast examination should
not be done when the patient is immedi
ately premenstrual. Engorgement may
preclude adequate evaluation of the
findings.
Although palpation is best done with
Fig. 2
the patient supine, there is no contra
indication at this stage of the examina
tion to perform palpation while the pa
tient is sitting before you. The arms
should be elevated during palpation to
distribute the breast tissue over the
chest wall. The examiner should not
rely entirely on the findings when the
patient is in the erect position.
When the patient is supine, she is
asked to place both hands under her
head and to let her elbows lie flat. If
the breast is pendulous, it is helpful to
place a small pillow beneath the shoul
der on the side to be examined so that
the breast tissue is more evenly dis
tributed on the chest wall and less re
dundant laterally. (Fig. 3.)
The examiner palpates gently by
using four fingers and a slightly ex
tended hand. The motion may be rotary

8
or transversely linear; the breast may
be examined, quadrant by quadrant, or
by decreasing concentric circles toward
the nipple. The nipple is then placed be
tween the index finger and the thumb,
and gentle pressure applied to elicit
discharge, determine elasticity and
fixation at the base. Special
should be given to the upper outer
quadrants where breast cancer is most
commonly located.
During palpation one notes the gen
eral character of the breast tissue, e.g.,
smooth, granular, nodular, etc. If a
mass is encountered, the size, config
uration, and consistency are reported.
Fixation to skin, breast tissue
toralis fascia are determined. By plac
ing the thumb and index finger on
either side of the mass and gently com
pressing the intervening skin one may
elicit skin dimpling in some patients
with carcinoma. (Fig. 4.) At times,
only a flattening or sense of resistance
is noted.
With the patient sitting, skin dim
pling may also become apparent when
the breast is elevated with the examin
ing hand, or when the pectoral muscles
are contracted. The latter maneuver is
performed by asking the patient to
press her hands against her hips.
Transillumination
Having discovered a mass
breast or nipple discharge, the physi
cian may obtain additional information
by shining a concentrated beam of light
through the breast in a darkened room.
This procedure may tell whether a
mass is solid or cystic with translu
scent fluid. It will also aid in locating
a dilated terminal duct in the patient
with nipple discharge. Transillumina
tion is only an aid in diagnosis. It is
not definitive as a technique.
The AxilIae
The examiner, facing the patient,
supports the patient's arm with his
own, abducts the patient's arm and
places the examining hand flat against
the chest wall and high in the axilla.
The fingers press against the chest wall
and rotate gradually extending inferi
orly. (Fig. 5.)
attention
Breast Self-Examination
PHYSICIANANDPATIENTROLE.About
ten million women in the United States
have seen a film prepared by the Amer
ican Cancer Society which teaches the
technique of self-examination of the
breast. The film is designed to encour
age earlier diagnosis of breast cancer,
or pec recognizing the fact that the patient
herself totally unaided more frequently
discovers the breast mass.
The position for breast self-examina
tion is similar to that used by the phys
ician. The patient is supine and a small
pillow is placed under the right shoul
der. The left hand is brought across the
chest wall and with the flat of the fin
gers the entire right breast is palpated,
quadrant by quadrant. The procedure
is then repeated for the left breast.
The patient is also instructed to sit
before her mirror and view her breasts
first with arms at her sides and then
with arms elevated. She is advised to
look for the signs mentioned earlier.
The teaching of breast self-examina
in the tion is best done in the physician's of
fice immediately after physical exami
nation. The physician can point out the
areas of normal thickening such as the
inframammary ridge and other details
to avoid an alarm reaction when breast
self-examination discloses thickening
which is not clinically significant.
The patient should be advised to ex
amine herself only once a month and
at a time in her menstrual cycle when
the breasts are not engorged or tender.
She should be reassured about the find
ings of her own examination, advised
not to panic and instructed to see her
physician for confirmation of findings.