Clinical breast exam (CBE)

DEFINITION: A clinical breast exam (CBE) is a screening test for cancer and other breast conditions intended to detect palpable masses and other indications of possible malignancy at an early stage of progression. A CBE is done by a clinician (physician, nurse practitioner, or physician’s assistant). It includes the inspection and palpation of the axillary and supraclavicular lymph nodes and breasts for masses and tenderness, examination for skin changes of the breast, and evaluation for nipple discharge.

Cancers diagnosed:Breast cancer, including cancer in the milk ducts or lobules and cancer that is invasive to surrounding breast tissue; less commonly, breast cancer may originate outside the ducts or lobules, as with inflammatory breast cancer and Paget's disease of the breast.

Why performed: Breast cancer is the most commonly diagnosed cancer in US women. The National Cancer Institute (NCI) estimated in 2024 that in the United States, 13 percent of women would develop breast cancer at some time in their lives, based on data from 2017-19, and early diagnosis is key to effective treatment. Breast cancer is the second leading cause of cancer death in US women. In 2024, the NCI estimated that over 310,700 women in the United States would be diagnosed with breast cancer and approximately 42,250 people would die of the disease that year.

Positive findings on a clinical breast exam that may be indicative of cancer require further tests. Clinical breast exam plus mammography has demonstrated a diagnostic advantage over mammography alone, although false-positives may be more likely, as reported by Maria Tria Tirona in the American Family Physician (2013). In 2024, the US Preventive Services Task Force updated its recommendations on breast cancer screening, advising women to begin being screened for breast cancer ever other year starting at age forty. Previously, routine mammography screening of women aged forty to forty-nine was left to individuals to decide. Mammography is typically used for screening in women who are forty years and older and may be used diagnostically in younger women who are symptomatic. Clinical breast examination has not been found to be valuable for screening younger women because of limitations posed by their denser breast tissue. Ultrasonography has been used along with clinical breast examination for screening of high-risk young women, as has magnetic resonance imaging (MRI), but this use of MRI is controversial because of its high cost.

Patient preparation: Before conducting a breast examination, the clinician reviews the patient’s history and any concerns, including whether they perform breast self-examination (BSE), any history of lumps or nipple discharge, any history of breast surgeries, and family history of breast cancer. Family medical history is most significant if a first-degree relative (or relatives) developed breast cancer while premenopausal. Some women may come for a CBE with a known high risk for breast cancer, including a diagnosis of high-risk status from genetic screening for the BRCA1 and BRCA2 gene mutations.

If the patient will be under anesthesia for another procedure, health care providers are required to give patients the opportunity to provide written informed consent before performing sensitive exams, including breast exams. Patients may request a chaperone be present in the room during the procedure and may also decline the presence of additional staff.

Steps of the procedure: Before the examination, the clinician informs the patient of the steps to be performed. Clinical breast examination begins with visual inspection of the breasts. Adequate lighting is important to distinguish subtle changes. Flexation of the pectoral muscles with the patient’s hands on her hips, followed by examination of the breasts as the patient lifts her hands high above her head, will help determine the presence of dimpling or retractions, inverted nipples, and other skin changes.

Following visual examination, the lymph nodes should be palpated for any swelling, masses, or tenderness, including those above and below the clavicle and the axillary nodes. It is recommended that this be done while the patient is sitting. Following examination of the lymph nodes, the patient lies supine with her arm high above her head to flatten out the breast tissue and facilitate examination. Palpation should include the full margins of the breast tissue, including the tail of Spence, the area of breast tissue that extends from the upper outer quadrant toward the axilla, which is the site where most malignancies develop. It is important that the entire breast margin be palpated with the flats of the fingers moving in dime-size circles in a systematic fashion so that no area is missed. Common areas that are missed in self and clinical breast exams include the tissue that extends up to the clavicle and the area directly underneath the nipple. Each area should be palpated using light, medium, and then firm pressure.

A well-done clinical breast examination takes at least several minutes. Studies have documented increased success in finding lesions when a minimum of five minutes is spent doing an examination, although studies have also documented that many clinicians spend less than two minutes, an inadequate amount of time, examining the breasts. Patients who are not used to examinations that take longer may be anxious and require reassurance that this is being done in order to be thorough, not as a result of suspicious findings. Furthermore, the use of increased pressure on the breasts throughout the exam has been associated with higher diagnostic accuracy, as reported in 2014 by Shlomi Laufer et al. in Studies in Health Technology and Informatics.

When a new breast lump is detected in a patient who is premenopausal, she will often be counseled to wait through one menstrual cycle and then return to the clinic for evaluation. In many cases, the lumps are and will spontaneously resolve. If a lump persists, the patient is referred to a breast surgeon who will evaluate the lump using biopsy, mammography, and, for women younger than thirty-five years old, diagnostic breast ultrasound. Mammography can help to evaluate the need for follow-up, but accurate diagnosis of a mass requires biopsy. A biopsy may be done in the office as a needle biopsy (either fine-needle or core needle) or surgically as an (lumpectomy) that is both diagnostic and may provide treatment. A fine-needle aspirational biopsy produces faster results, is less invasive, and costs less. However, a negative result for a needle biopsy is nondiagnostic, meaning that because of the high rate of false-negatives, further surgical evaluation is needed.

After the procedure: The clinician will reinforce the need for patient familiarity with the breasts and, for negative examinations, discuss intervals for regular screening mammography and make referrals if necessary. If any positive findings occur, then the need for further testing is discussed. Many patients need help arranging for additional testing, and many clinician offices will assist with scheduling of appointments rather than leaving patients to coordinate care when they may be emotionally distraught by the possibility of a cancer diagnosis.

Risks: Clinical breast examinations are associated with no direct physical risk. False negative results, however, can be misleading and delay diagnosis, while false positive results are very common and can result in invasive testing and significant emotional distress and anxiety as well as expense.

Results: The results of a clinical breast examination may be negative (no findings), in which case no action other than continuation of regular clinical screening is warranted. Findings that are positive may include a discrete mass, a thickened area, breast tenderness or pain, nipple discharge, and skin changes.

Discrete masses may be fixed or mobile and tender or nontender, and they may be in the breast tissue itself or in the axillary lymph nodes. They are carefully described as to shape, size, and location in the breast, including depth.

A thickened area of breast tissue may be detected bilaterally (in both breasts) or unilaterally (in one breast only). It will be evaluated further but is less likely than a discrete mass to be a cause for concern.

Breast tenderness may be bilateral or unilateral. It may be hormonal and vary over the course of a month, but if associated with skin changes it can be related to infection or possible malignancy. Breast tenderness is common with some hormonal contraception and with pregnancy. Episodic sharp breast pain has been found to be responsive, in many cases, to a decrease in caffeine intake.

Nipple discharge may be bilateral or unilateral and may be clear, reddish or bloody, milky, or greenish. It may occur spontaneously or only with manual expression. It may or may not have an odor. History of recent pregnancy as well as some medications (in particular, many antipsychotics) may cause a bilateral, nonsticky milky discharge called "galactorrhea." Bilateral discharge is usually benign. Secretions may be collected on a slide and examined under a microscope to help determine the need for further evaluation, including mammography, other imaging tests, and biopsy.

Skin changes may include uneven fullness or flattening, asymmetry that was not previously present, rashes and discoloration, areas of warmth and redness, retraction or dimpling of the skin, inversion of the nipple, crusting and erosion or ulceration of the nipple and areola, and the skin change described as peau d’orange, which looks like the surface of an orange with regularly spaced, shallow pitting. Skin changes are particularly associated with inflammatory breast cancer, which may cause red and swollen skin and a peau d’orange appearance, and with Paget's disease, which may cause an eroded and/or retracted nipple. Nipple inversion is of clinical concern only if it has not been present previously.

Bibliography

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