Breast self-examination

Definition

A breast self-exam is the regular examination of one's own breasts to detect lumps or other changes that may need to be further evaluated as part of screening for breast cancer .

Purpose

In its early stages breast cancer has few symptoms. However, the earlier that breast cancer is detected, the more treatment options are available and the greater the likelihood of recovery. It is estimated that about 10 to 20% of breast cancers that are detected in a self-exam or a clinical breast exam are

not detectable by x-ray-film mammography. It is particularly important for women at increased risk for breast cancer to perform self-exams.

It has generally been recommended that all women perform monthly breast self-exams, beginning in their 20s and continuing throughout life. However, research has shown that general awareness about one's breasts is more important than monthly self-exams and that women who detect their own breast cancers usually do it while bathing or dressing rather than in the course of a regular self-exam. Therefore, as of 2008, the American Cancer Society (ACS) no longer recommended that all women perform monthly breast self-exams. Instead the ACS recommends that women who choose not to perform self-exams should still observe their breasts on a regular basis and be aware of how their breasts look and feel.

Women should also be aware of the benefits and limitations of self-exams. Most lumps or other changes are not cancerous, but any detected change in the breasts should be examined by a healthcare provider.

Precautions

Studies have not shown that breast self-exams alone reduce deaths from breast cancer. Self-exams should not replace clinical breast exams and mammograms as a screening for breast cancer.

Scar tissue that forms after a biopsy on a breast can make self-exams difficult. Women who have had biopsies should ask their physician how to feel the difference between scar tissue and abnormal changes.

Description

Women who choose to perform breast self-exams should do so on approximately the same day of every month, picking a day that is easy to remember. For menstruating women, a few days after the end of a period, when the breasts are the least swollen and tender, is ideal. By regularly examining their breasts women become familiar with their normal feel and thus are more able to detect subtle changes. If a woman chooses not to perform breast self-exams or to perform them only occasionally, she should still develop an awareness of the feel and appearance of her breasts, so as to notice anything out of the ordinary.

What to look for The earliest symptom of breast cancer is often a thickening or lump in or near the breast or under the arm. A breast self-exam searches for a lump or other change that seems to be different from the rest of the breast tissue. Breast tissues are of different consistencies. Glandular tissue usually has a firm feel.

It may feel somewhat rope-like, bumpy, or lumpy. In contrast the fat tissue surrounding the glands feels soft. The difference between the two types of tissue is usually easier to feel in the upper and outer region of the breast near the armpit. It may be easier to distinguish the two tissues just before the start of a menstrual period.

If a lump or change is detected in one breast, the other breast should be examined in the same place. If the two breasts feel the same, then the lumpiness is probably normal. With practice women can detect the difference between the normal feel of their breasts and any change.

In early stages of breast cancer the lump may move freely under the skin when pushed with the fingers. In later stages the lump may adhere to the chest wall of the skin and cannot be moved. Only occasionally is a cancerous lump painful.

Other symptoms of breast cancer that may be observable include:

• any change in the look or feel of the breast, nipple, or areola (the darker area around the nipple)
• a change in the size, shape, or contour of the breast
• a change in the appearance of the skin of the breast or nipple, such as a puckering or dimpling, an irritation, or a change in color or texture
• ridges or pitting in the breast
• a clear or bloody nipple discharge or tenderness
• a nipple that is pulled in, inverted, or indented
• nipple pain
• breast skin or a nipple that is red and swollen, warm or scaly
• hard, small, and perhaps slightly tender lumps in the underarm region.

Performing a self-exam

There are several methods for conducting a breast self-exam. A healthcare provider can determine whether a woman is performing a self-exam correctly. Women with breast implants may want to have the surgeon identify the edges of the implants for them, so that they can be aware of what they are feeling during a self-exam. Some people believe that implants push the breast tissue out and make it easier to examine.

Following an extensive review of the medical literature and experimental examinations using silicone models and patients with small noncancerous lumps, the ACS published a protocol for breast self-exams in

QUESTIONS TO ASK YOUR DOCTOR

• Am I at high risk for breast cancer?
• Should I perform monthly breast self-exams?
• What exactly should I look for?
• Am I performing my breast self-exam correctly?

2007. Self-exams are performed lying down. This position spreads the breast tissue evenly over the chest wall, making it as thin as possible so that it is easier to feel all of the tissue. Lying down with the right arm behind the head, the woman does the following:

• The pads of the three middle fingers of the left hand examine the right breast with overlapping, dime-sized, circular motions, feeling for any lumps.
• The exam moves from spot to spot, beginning under the arm and moving straight down the side until only the ribs are felt.
• The exam then moves up the breast to the collarbone.
• The exam continues in this down-and-up pattern across the breast to the middle of the chest bone (the breastbone or sternum).
• Each spot is examined with three different pressures before moving on to the next area.
• Light pressure is used to feel the tissue next to the skin.
• Medium pressure is used to feel deeper tissue.
• Firm pressure is used to feel the tissue closest to the chest and ribs.
• With the left hand behind the head, the right fingers pads are used to repeat the exam on the left breast.

Some evidence suggests that examining the breasts using this up-and-down pattern is the most effective way to avoid overlooking any breast tissue. It is normal to feel a firm ridge in the lower curve of the breast.

The breast self-exam is concluded by standing in front of a mirror with the hands pressed firmly down on the hips. This contracts the chest wall muscles, making any changes more easily observable. The breasts are visually examined for changes in the following:

• size
• shape
• contour
• dimpling
• redness or scaliness of the skin or nipple.

KEY TERMS

Biopsy —The removal of cells or tissue from the breast for examination by a pathologist.

Glandular tissue —The glands or lobules of the breast that produce milk.

Mammogram —An x ray of the breast to screen for or diagnose cancer.

Then while standing or sitting with one arm is raised slightly, the woman observes visually the underarmregion and feels the area with the fingers of the other hand. The exam is repeated on the other underarm.

Interactive tools are available online for teaching women how to perform breast self-exams. However, women should also receive instruction from their healthcare provider and have their technique reviewed periodically by a healthcare professional who regularly performs clinical breast exams.

Age-related changes

Women need to be aware of changes in their breasts that are related to aging:

• Breast tissue becomes less dense and more fatty.
• Tenderness and lumpiness may change.
• The breasts become smaller and less full.
• The breasts lose support and often flatten and sag.
• The number of mammary ducts is reduced.
• The areola becomes smaller and may almost disappear.
• Hair around the nipple is lost.

Complications

Frequent breast self-exams can cause a discharge from the nipple.

Results

A woman should immediately contact her healthcare practitioner if she notices any of the following during a breast self-exam:

• a lump that is new or feels unusual and different from other tissue in that or the other breast
• a lump that does not disappear after the next menstrual period
• a lump that changes or gets bigger
• a bloody discharge from the nipple
• a nipple that is turned unusually inward or inverted
• redness, crusting, dimpling, or puckering of the breast skin.

A mammogram can determine the exact location of a lump and look for other abnormalities in both breasts. A biopsy may be performed to remove cells and tissue to check for the presence of cancer.

Resources

BOOKS

Finkel, Madelon Lubin. Understanding the Mammography Controversy: Science, Politics, and Breast Cancer Screening. Westport, CT: Praeger, 2005.

Love, Susan M., and Karen Lindsey. Dr. Susan Love's Breast Book, 4th ed. Cambridge, MA: Da Capo Press, 2005.

Sutton, Amy L. Cancer Sourcebook for Women, 3rd ed. Detroit: Omnigraphics, 2006.

OTHER

American Cancer Society. “How to Perform a Breast Self-Exam.” Cancer Reference Information March 29, 2007 [cited February 29, 2008]. http://www.cancer.org/docroot/cri/content/cri_2_6x_how_to_perform_a_breast_self_exam_5.asp?sitearea=CRI&viewmode=print

“Breast Cancer.” NIH Senior Health October 26, 2006 [cited February 29, 2008]. http://nihseniorhealth.gov/breastcancer/toc.html.

“Breast Cancer Screening.” National Cancer Institute June 14, 2007 [cited February 29, 2008]. http://www.cancer.gov/cancertopics/pdq/screening/breast/Patient/page1.

“Breast Lumps: Next Step after Discovering Suspicious Breast Tissue.” Mayo Clinic May 17, 2006 [cited February 28, 2008]. http://www.mayoclinic.com/print/breast-lump/WO00031/METHOD=print.

“Breast Self-Exam.” National Women's Health Information Center August 2007 [cited February 28, 2008]. http://www.womenshealth.gov/faq/bsefaq.htm.

“Breast Self-Exam.” Susan G. Komen for the Cure [cited February 28, 2008]. http://cms.komen.org/Komen/AboutBreastCancer/EarlyDetectionScreening/BreastSelf-Exam/index.htm?ssSourceNodeId=298&ssSourceSiteId=Komen.

ORGANIZATIONS

American Cancer Society, 1599 Clifton Rd., NE, Atlanta, GA, 30329, (404) 320-3333, (800) ACS-2345, http://www.cancer.org.

National Breast and Cervical Cancer Early Detection Program, Centers for Disease Control and Prevention, Division of Cancer Prevention and Control, 4770

Buford Hwy. NE, MS K-64, Atlanta, GA, 30341-3717, (800) CDC-INFO, (770) 488-4760, cdcinfo@cdc.gov, http://www.cdc.gov/cancer/NBCCEDP/about.htm.

Susan G. Komen for the Cure., 5005 LBJ Freeway, Suite 250, Dallas, TX, 75244, (877) GO-KOMEN, http://ww3.komen.org/home/.

Margaret Alic Ph.D.