Breast examination

Questionnaire/history:

Risk factors for breast cancer:

Family history of breast cancer, ovarian cancer, or other hereditary breast and ovarian syndrome - associated cancer (e.g. prostate cancer, pancreatic cancer):

Indication for referral to a service with specialist skills in estimating breast cancer risk: (Note: First-degree relatives (FDRs) include mother, father, daughter, son, sister, brother and

second-degree relatives (SDRs) grandparent, aunt, uncle, niece, nephew, half-sister, half-brother) Female breast cancers only? - 1 FDR under 40 (age at diagnosis)? - 2 FDRs (any age at diagnosis)? - 1 FDR and 1 SDR (any age at diagnosis)? - 3 FDRs (any age at diagnosis)? - 3 SDRs (any age at diagnosis)? Male breast cancer?

- 1 first-degree male relative (any age at diagnosis)?

Bilateral breast cancer?

- 1 FDR under 50 for diagnosis of first cancer?

Breast and ovarian cancer? - 1 FDR with breast cancer and 1 FDR with ovarian cancer (any age at diagnosis)?

- 1 FDR with breast cancer and 1 SDR with ovarian cancer (any age at diagnosis)? - 1 SDR with breast cancer and 1 FDR with ovarian cancer (any age at diagnosis)?

NICE risk criteria for moderate risk:

- 1 FDR with breast cancer at age younger than 40 years?

- 2 FDRs or SDRs diagnosed with breast cancer at an average age of older than 50 years?

- 3 FDRs or SDRs diagnosed with breast cancer at an average age of older than 60 years?

NICE risk criteria for high risk:

- 2 FDRs or SDRs diagnosed with breast cancer at younger than an average age of 50 years (at least one must be an FDR)?

- 3 FDRs or SDRs diagnosed with breast cancer at younger than an average age of 60 years (at least one must be an FDR)?

- 4 FDRs or SDRs diagnosed with breast cancer at younger than an average age of 60 years (at least one must be an FDR)?

- Families containing 1 relative with ovarian cancer at any age and on the same side of the family:

--- 1 FDR (including the with ovarian cancer) or SDR diagnosed with breast cancer at age younger than 50 years?

--- 2 FDR or SDRs diagnosed with breast cancer at younger than an average age of 60 years?

--- Another ovarian cancer at any age?

- Families affected by bilateral cancer (each breast cancer has the same count value as one relative): --- 1 FDR with cancer diagnosed in both breasts at younger than an average age of 50 years?

--- 1 FDR or SDR diagnosed with bilateral cancer and 1 FDR or SDR diagnosed with breast cancer at younger than an average age of 60 years?

- Families containing male breast cancer at any age, and on the same side of the family at least: - 1 FDR or SDR diagnosed with breast cancer at age younger than 50 years? - 2 FDRs or SDRs diagnosed with breast cancer at younger than an average age of 60 years?

Known deleterious gene mutation?

Prior breast biopsy with specific pathology (e.g. atypical hyperplasia (lobular or ductal or lobular carcinoma in situ)? Early menarche (before 12 years)?

Late menopause (after 55 years)?

Nulliparity?

Prolonged interval between menarche and first pregnancy?

Not breastfeeding?

Menopausal hormone therapy with estrogen and progestin (decreased risk with estrogen alone)?

Certain ethnicities (eg, increased risk of BRCA mutation in Ashkenazi Jewish women)?

Higher body mass index?

Alcohol consumption?

Smoking?

Dense breasts on mammography?

Prior exposure to high-dose therapeutic chest irradiation in young women (10-30 years old)

Lump?

- When first noticed?

- Changed in size or in any other way?

- Any changes noted through the menstrual cycle?

Pain?

- Onset?

- Severity?

- Location?

- Radiation?

- Duration?

- Relationship to menstrual cycle, physical activity or recent trauma?

Skin changes?

Nipple changes?

Past medical history?

Current medication?

Drug allergies?

Examination:

Explanations given ('The examination will involve me first inspecting the breasts, then placing a hand on the breasts to assess the breast tissue. Finally, I’ll examine the glands of your neck and armpit. One of the female ward staff members will be present throughout the examination, acting as a chaperone, would that be ok? Does everything I’ve said make sense? Do you feel you understand what the examination will involve? Do you have any questions?)?

Consent obtained ('Are you happy for me to carry out the breast examination?')?

Instructions given (asked patient to undress down to the waist to adequately expose their breasts for the examination, provided patient with privacy to get undressed and offered a paper roll cover to allow exposure only when required. With the patient sitting on the side of the bed asked them to place hands on thighs to relax the pectoral muscles, then to press hands into hips to contract the pectoralis muscles and finally to place hands behind head and lean forward so that the breasts are pendulous.)?

Inspection - Scars? - Asymmetry (normal in most women)?

- Shape (eg ptosis, pseudootosis, parenchymal maldistribution, scars)? - Masses? - Nipple abnormalities (eg discharge, inversion)? - Skin changes (eg scaling, erythema, puckering, dimpling/Peau D’Orange)?

Palpation Breast Adjusted head of the bed to 45° and asked patient to lie down, asked patient to place the hand on the side being examined behind head to fully expose the breast, warmed hands before touching the patient, used flats of middle three fingers to compress the breast tissue against the chest wall as to feel for any masses, began with asymptomatic breast.

- Clock face method (each “hour” of the breast)?

- Spiral method (start at the nipple and work outwards in a concentric circular motion)?

- Quadrants method? Findings?

Texture?

Soft?

Nodular? Fibrocystic? Dense? Presence of inframammary ridge in large breasts?

Masses? - Position: - Which quadrant? - What “hour”? - How far away from the nipple? - Size (approximate dimensions of the mass (cm x cm))? - Shape (eg spherical, elongated, irregular? - Consistency (eg smooth, firm, stony rubbery)? - Overlying skin changes (eg erythema, puckering)? - Mobility (moves freely, moves with the overlying skin, moves with the prectorcal contraction (tense chest muscles))? - Fluctuance (mass fluid filled with holding the mass by its sides and then applying pressure with another finger to the centre of the mass sides bulging outwards?) Axillary tail

Findings? Nipple-areolar complex (Palpated using the flats of middle three fingers to compress the areolar tissue towards the nipple.) History of nipple discharge, but none is visible? Asked patient to attempt to express discharge from the nipple (if comfortable to do so)? Findings? Discharge? - Colour (eg milky; green, yellow, brown; blood-stained)? - Consistency (eg thick, watery)? - Volume? Elevation of breast Pathology visible? Lymph nodes Axillary (pectoral (anterior), subscapular (posterior), humoral (lateral), central (medial) and apical groups (palpated by holding the patient’s forearm in other hand and instructed to relax it completely, allowing to support the weigh)? Cervical? Supraclavicular? Infraclavicular? Parasternal? Diagnosis: No breast lump found? Bening breast lump? Suspected benign breast lump? Suspicious breast lump? Management: Findings explained to patient? Reassured? Advice for breast awareness given (including weblinks NHS Health A to Z and NHS England)? Advised to return in 2 weeks for re-examination? Non-urgent referral to breast clinic? 2 week wait referral to breast clinic? Other?