Breast Care Cycle: 2. Conduct clinical breast exam
Clinical Breast Examination: Proficiency and Risk Management
This video covers the nine key elements of a comprehensive clinical breast exam, as determined by a national workgroup of breast screening experts and published in Clinical Breast Examination: Practical Recommendations for Optimizing Performance and Reporting, CA Cancer J Clin 2004;54:327-344.
The video is not intended to be used as a stand-alone training tool but rather as a supplement to a comprehensive training. The most effective training includes hands-on exam opportunities with feedback from a patient instructor and clinical faculty member. The CA Department of Public Health, Cancer Detection Section produced the Core Competencies of this CBE Video (2009).
The Ladies First Provider conducts the clinical breast examamination as part of the Ladies First annual exam office visit. Proper Clinical Breast Exam procedure is also detailed in the Lymph Node Exam Guide below.
Examination of the Lymph Nodes (PDF) is a guide for Primary Care Providers. This publication describes the proper lymph node examination technique, a crucial element in the comprehensive clinical breast examination (CBE).
Abnormal clinical breast exam results include:
- Observable breast changes such as nipple or areolar scaliness, bloody or serous discharge
- Skin dimpling or nipple retraction
- Color or texture changes
Some abnormal breast findings such as skin dimpling, nipple retraction, scaliness or discoloration may be warning signs of cancer. Dimpling and nipple retraction, for example, may suggest an underlying tumor. Additional tests are needed to diagnose these abnormal findings.
The clinical breast exam might reveal a discrete, palpable mass. Most palpable breast masses discovered during a clinical breast exam are not malignant. The most common types of benign masses include:
- Cysts: fluid filled masses in the breast
- Fibroadenomas: movable, solid, rounded lumps made up of normal breast cells
In general, benign, palpable masses have distinct margins and a smooth surface; they are mobile, soft or rubbery; and they may be tender. Malignant palpable masses are usually distinct from benign masses. They have indistinct and irregular margins; are firm and fixed; usually the area is not tender.
Detailed procedures for how to follow up breast findings can be found in the Algorithms section of this site. When a clinical breast exam reveals abnormalities, Ladies First patients should be referred for additional imaging testing such as a diagnostic mammogram or ultrasound.
Refer for mammogram
Once the full Ladies First screening exam is completed (inclucing cervical and cardiovascular portions), your office provides the patient with the referral forms necessary to schedule her own mammogram, and any laboratioy tests not done in the office.
Click here for a complete listing of mammography facilities for Ladies First patients.
Screening vs. diagnostic mammograms
A screening mammogram is used to detect breast changes in women who have no signs or symptoms of breast cancer. A diagnostic mammogram is similar to a screening mammogram, but the technician takes additional or specialized x-ray views of the breast. Imaging techniques such as magnification or cone compression may be recommended to look more closely at an area of concern. These images can help evaluate unusual breast changes such as a lump, pain in conjunction with thickening, nipple discharge or change. A diagnostic mammogram is also performed on women with breast implants.
When a mammogram reveals abnormalities, Ladies First patients should be referred for additional imaging testing such as diagnostic mammogram, added mammographic views or ultrasound.
All of these procedures are covered by Ladies First.
Conventional vs. digital mammography
Digital and conventional mammography are similar techniques. In conventional mammography, the image is stored directly on film, whereas in digital mammography, an electronic image of the breast is stored as a computer file. This digital information can be enhanced, magnified, or manipulated for further evaluation more easily than information stored on film. Except for the difference in how the image is recorded and stored, there is no other difference between the two types of mammograms.
Because digital mammography allows a radiologist to adjust, store, and retrieve digital images electronically, digital mammography may offer the following advantages over conventional mammography:
- Health care providers can share image files electronically, making long-distance consultations between radiologists and breast surgeons easier.
- Subtle differences between normal and abnormal tissues may be more easily noted.
- Fewer follow-up procedures may be needed.
- Fewer repeat images may be needed, reducing the exposure to radiation.
The FDA approved the use of digital mammography in January 2000. In September 2005, preliminary results from a large clinical trial that compared digital mammography with film mammography were published (1). These results showed no difference between digital and film mammograms in detecting breast cancer in the general population. However, digital mammography may be more accurate than conventional film mammography in women with dense breasts who are premenopausal or perimenopausal (i.e., women who had their last menstrual period within 12 months of their mammograms) or who are younger than age 50. Whether this improved accuracy will translate into a reduced risk of breast cancer death is not yet known.
Some health care providers recommend that women who have a very high risk of breast cancer, such as those with BRCA1 or BRCA2 gene alterations, have digital mammograms instead of conventional mammograms; however, no studies have shown that digital mammograms are superior to conventional mammograms for these women.
Digital mammography can be done only in facilities that are certified to practice conventional mammography and have received FDA approval to offer digital mammography. The procedure for having a mammogram with a digital system is the same as with conventional mammography.
(1)Pisano ED, Gatsonis C, Hendrick E, et al. Diagnostic performance of digital versus film mammography for breast cancer screening. New England Journal of Medicine 2005; 353(17):1773–1783. [PubMed Abstract]