BREAST EXAMINATION: NEW ADVANCES AND RECOMMENDATIONS

A comprehensive breast screening program to detect breast cancer in asymptomatic women includes monthly breast self examination (BSE); periodic clinical breast exams by a physician; and screening mammography.

YOU SHOULD EXAMINE YOUR BREASTS ONCE A MONTH. If you have not reached menopause, perform monthly breast self examination shortly after the end of each menstrual period.

By examining your breasts regularly, you will become familiar with the background nodularity that is characteristic for your breasts, and will be able to recognize any changes. Be sure to take enough time to examine both breasts thoroughly. I suggest you chose a comfortable, private place where to perform your breast self examination without being distracted.

WOMEN MUST CONTINUE BREAST SELF EXAMINATION DURING PREGNANCY AND LACTATION AND MAKE SURE THAT THE PHYSICIAN PERFORMS A BREAST EXAM ON A MONTHLY BASIS DURING PREGNANCY. The main problem with breast cancer during pregnancy is delay in diagnosis that results in women being diagnosed with cancer at a later, more advanced stage. Early detection is your best defense. Breast examination helps detect cancer at an earlier and more curable stage. Studies show that well conducted breast self examination can detect about 50% of asymptomatic cancers, many of which (3-45%) had been missed by mammography.

 

WARNING SIGNS WITH BREAST SELF EXAMINATION:

• any changes such as a new lump or hard knot found in the breast or armpit, particularly if it doesn't shrink after your next period.
  
• any change in the size, shape, swelling or symmetry of your breast
  
• skin irritation, redness or roughness of the breast skin or nipple; or nipple tenderness or pain
  
• nipple discharge (fluid coming from your nipple other than breast milk), particularly if the discharge is bloody, clear and sticky, dark, or it occurs without squeezing your nipple
  
• Nipple retraction: turning or drawing inward or pointing in a new direction.

IMPORTANT: Benign and malignant lumps frequently have similar appearance and have a wide variability of sizes, hardness, mobility, and locations in the breast. Detecting a lump or a localized hardness may require further evaluation. Rarely can a breast cancer be diagnosed by examination alone. If in doubt, please get a second opinion and do not fall into denial..

EXAMINATION TECHNIQUE.

The following recommendations incorporate practices from the MAMMACARE METHOD which have been validated by independent investigations on breast examination.

REFERENCES:

(1)Fletcher SW. How best to teach women breast self-examination. Ann Intern Med. 1990;112:772-779. (2)Campbell HS. Improving physicians' and nurses' clinical breast examination. Am J Prev Med. 1991;7:1-8. 3) Barton MB, et al: Does This Patient have Breast Cancer? JAMA 1999;282:1270-1280.

PROPER PATIENT POSITIONING TO ACHIEVE FLATTENING OF THE LATERAL(Upper-outer) AND MEDIAL PARTS OF THE BREAST IS ESSENTIAL for an adequate examination, particularly in women with large breasts. This can generally be achieved in the lying down (supine) position: (A): To flatten the lateral part of the breast, bend your knees and roll your hips to the opposite side keeping your shoulders flat on the table; and raise your arm to place your hand on your forehead. Placing a pillow under the shoulder may further help spread the breast tissue against your chest wall. The standing up position is generally unnecessary but you may keep it as an additional option when needed to check this area. (B): To flatten the medial part of the breast, lie on your back and place your elbow at the level of your shoulder, as shown on Figure 1.

THE ENTIRE BREAST SHOULD BE SYSTEMATICALLY EXAMINED, covering a rectangular area between the clavicle (collar bone) and the bra line; and between the center of the sternum and the mid-axillary line; plus the supraclavicular and axillary regions to detect lymph nodes. Approximately half of breast cancers are found in the tail of the breast (lateral or upper outer quadrant towards the armpit). One third of all breast cancers are found in the area behind the nipple.

FOLLOW A SYSTEMATIC VERTICAL SEARCH PATTERN OF EXAMINATION(lawnmower technique). The vertical rows examined should overlap in order to comprise the entire breast. Do not lift your fingers while feeling your breasts to avoid missing any areas. Figure 1 shows the vertical search pattern of examination of the lateral and medial portion of the breast, respectively.

USE THE PADS (NOT TIPS) OF THE 3 MIDDLE FINGERS HELD TOGETHER, MAKING SMALL AND OVERLYING CIRCLES as if tracing the outer edge of a dime while feeling for a lump, as illustrated on Figure 2.

MAKE THREE (3) CIRCLES AT EACH SPOT, increasing the pressure with your finger pads to three levels(superficial, intermediate, and deep) with each circle.

PALPATION OF THE NIPPLE is performed in the same manner as the rest of the breast; but in addition, push the nipple into the hollow beneath it to look for any unusual resistance, hardness or lump behind the nipple.

SQUEEZING THE NIPPLE TO EXPRESS DISCHARGE IS RARELY USEFUL. Of the women with otherwise normal BSE findings, only 2% of women with spontaneous discharges were diagnosed as having cancer, while none (0%) of women with discharges only apparent by expression were diagnosed as having cancer.

INSPECTION OF THE BREASTS
There is inadequate data to support inspection of the breasts in a variety of positions other than lying down, particularly if palpation is normal, with the rare exception of cases of nipple retraction or other visible nipple abnormalities. Inspection in other positions needs to be done only if the woman has symptoms or if an abnormality is discovered during palpation of the breast.

I RECOMMEND YOU PERFORM THE BREAST EXAM WITH YOUR BARE HAND AND SUPPLEMENT IT BY USING A TOUCH ENHANCER ("TE") DEVICE. A Touch Enhancer not only can increase the effectiveness of a breast examination but most importantly, could motivate women and their health providers to improve their examination technique.

The sense of touch is enhanced when the friction between the examining fingers and the surface of the skin is reduced. This is the basis for recommending that women use a soapy hand to examine their breasts in the shower; and for using an cloth sheet interposed between the examining hand and the breast. A double layered TE is even better in eliminating the friction associated to the circular motion of the fingers over the breast as one of the plastic layers of the TE slides with the fingers pads over the other layer of the device, without directly touching the skin.

There are three touch enhancer devices: the Sensability pad; the Carol Angel Touch Enhancer ("CATE", or "CAT Enhancer"); and the Anibal Rodriguez Touch Enhancer ("ARTE" , or "ART Enhancer").

THE SENSABILITY PAD is commercially available . I find that the Sensability pad works well but there is room for improvement in terms of availability and cost to women.

THE CAROL ANGEL TOUCH ENHANCER (CATE); and the ANIBAL RODRIGUEZ TOUCH ENHANCER (ARTE) are as effective as the Sensability pad and could potentially reach a larger segment of the female population because of their wider availability and substantially lower cost. The names are my tribute to my beloved daughter, Carol Lehrer Rubin; and to Professor Anibal Rodriguez Velasco, a renowned physician who has inspired hundreds of gynecologists in Chile.

THE CAROL ANGEL TOUCH ENHANCER is preferably made using a home Hefty OneZip storage bag. While other bags made of vinyl, rubber, silk or other materials may be even better, a Hefty OneZip storage bag size 17 cm x 20 cm works fine and is readily available in supermarkets.

HERE IS HOW YOU CAN MAKE YOUR OWN CAT ENHANCER: Turn the bottom of the storage bag inside out into the bag, forming a smooth pouch that admits the examiner's fingers and extends to a distance of about one centimeter below the zip lock end of the bag. A small amount of plain water or oil may be placed inside the bag for lubrication purposes, closing the bag with the zipper provided.

THIS IS HOW TO MAKE THE ANIBAL RODRIGUEZ TOUCH ENHANCER:
1.-I prefer using an exam glove made of vinyl polymer such as the SensiCare glove (Maxxim Medical); or Triflex glove (Allegiance Healthcare Corp) because of their extra smooth inside. The glove must first be turned inside out, exposing the smooth side. Next, put the glove on your hand and apply a small amount of KY jelly or water to lubricate the pads of the examining fingers 3.- Partially pull the glove off the palm of your hand, covering your examining fingers with a second layer of glove. You can prevent the formation of wrinkles that may interfere with the exam by stretching the globe with your opposite hand. Notice that the gloved finger pads slide with minimal friction over the second layer of the glove, greatly enhancing your sense of touch.