P D A T E

Breast cancer:
C L I N I C A L

history and examination

By Dr Corinne Jones,
Breast, Thyroid and Parathyroid Surgeon, Mercy Hospital and SJOG Subiaco. Tel 9370 9329.

A lthough breast cancer is a feared and all too common condition, there has been good progress
in this diagnosis and treatment so that the vast majority of new breast cancer patients can now
expect to live 10 years and beyond. Although it is impossible to be dogmatic, particular clinical
Table 2: System for Noting Breast
Symptoms and Signs
scenarios are worth noting and others should ‘ring alarm bells’. • Site – describe which breast in relation to
the clock face.
In WA there is good support for breast cancer looking for during examination (see Table 2). • Size – how big (mm); increasing or
patients through all stages of their cancer The most helpful positions to examine patients decreasing in relation to menstrual cycle.
journey, this usually begins with the GP through are; • Surface – smooth, poorly defined,
a valuable ‘health check up’ or response to a 1. sitting on the side of the bed with the hands mobility (‘flicks’ or is fixed to surrounding
patient’s breast symptoms. Many asymptomatic behind the head and then pushed into the hips tissue).
women go to their GP requesting advice and (Figs 1a & 1b), and • Skin changes – tethering, redness,
referral for breast screening through either
2. lying with the head of the couch at 45° and the purplish pink colour, oedema, nipple
BreastScreen WA or private imaging.
hands behind the head (see Fig 2a). in-drawing.
Pointers in the history The examining doctor looks and palpates for
• Pain – painful/painless, changes with the
Breast assessment involves taking a history that both swellings and skin changes bilaterally in
menstrual cycle.
builds a picture of the glandular status of the three regions; breasts, axillae and supraclavicular
• Nipple discharge – spontaneous,
breasts that helps provide possible causes for the regions.
squeezed, bloody, greenish to yellow,
patient’s breast symptoms and signs (see Table 1). clear.
Sitting the patient up with the hands behind the
While breast cancer can occur at any age, it is head and inspecting the breasts is a good way Suspected inflammatory breast cancers and
rare in teenagers and young women and is nearly of detecting subtle changes compared to lying cancers during pregnancy and lactation need
always present in elderly women not taking down. immediate diagnostic work up and breast
HRT who present with a lump; 80% of breast specialist referral. Beware of the apparent,
Breast cancer metastases can present locally as
cancers occur in women over 50 years of age. negative breast imaging results.
a palpable mass or skin colour change in the
(With 0.7–1.0% of all new breast cancers in men, Different findings are more prevalent at different
breast, axilla, supraclavicular region or on the
it is important to process all men with breast ages.
chest wall after masectomy.
symptoms through the same pathway as women.)
The significance of findings Pre-menopausal:
Following pregnancy and lactation there is a
paradoxical degree of breast glandular tissue Although it is impossible to be dogmatic, Small firm breasts; often lumpy due to
atrophy. The breasts become fatty, making particular scenarios are worth noting and others prominent glandular tissue.
it easier to detect abnormalities on clinical should ring alarm bells. Teenagers and young adults usually have benign
examination and imaging. Significance of skin changes: fibroadenomas.
Exogenous hormones in the pre-menopausal • Skin tethering – dimpling or puckering is Middle age brings more cysts, some
and menopausal setting can result in varying pathognomonic of underlying cancer. fibroadenomas, more atypical proliferative
symptoms of breast pain, swelling and lumps lesions.
• Skin and shape – changes in nipple areolar
that are often benign breast cysts. complex can be a retro-areolar cancer. Post menopausal:
Any history of a bloody nipple discharge • Skin colour – purplish to red and a mass is No HRT, fatty non-hormonally stimulated
requires breast imaging and cytology (if indicative of imminent cancer ulceration. breasts – most new lesions are cancers.
possible). The majority of cases are due to a
• Skin oedema and redness – diffuse or local, HRT use, hormonally stimulated breasts with
retroareola duct papilloma but 10% are due to
consider inflammatory cancer. more fibroglandular tissue – some lesions are
retroareolar ductal carcinoma in situ (DCIS)
cysts, some are cancers. n
which is often ‘occult’ on imaging. Negative
cytology does not mean there is no DCIS.
Pregnant or lactating women can get an isolated
bloody discharge related to rapid duct growth, as
well as a duct papilloma or DCIS. All patients
need surgical referral. Thirlmere Road,

Examination Mt Lawley 6050

Tel: 08 9370 9222
It is good to have a clear idea of what you are www.mercycare.com.au
Fig 1a Fig 2a

Table 1: Breast history

Hormone status of the breast
• Age and menopausal status.
• Parity – the nulliparous breast tends to
be more glandular at any age.
• Breast feeding – the breast is less
glandular. Fig 1b Fig 2b
• Hormones for contraception and to n Fig 1a: Initial inspection; look at the different fall of the breast to detect swellings and tethering; remember to look from
reduce menstrual flow: oral, implants the sides.
and coils – can alter glandular tissue. n Fig 1b: Sitting, hands pushing into the hips.
• HRT (oral, topical, creams) increases n Fig 2a: Detailed palpation, supine at 45 degrees; to examine the axillae, hold the arm loosely in one hand and examine
glandular tissue. with the other.
Previous breast conditions n Fig 2b: Compare breast shape lying down and sitting; most lumps are easier to palpate with the patient supine.
Family history of breast and ovarian cancer However lumps deep and close to the chest wall are easier to palpate with the patient is sitting and leaning slightly
forward.

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