Clinical Breast Examination

What is a Clinical Breast Examination?

A Clinical Breast Examination (CBE) is a physical examination performed by a doctor to detect any abnormalities in the breast tissue. It is an essential component of a comprehensive breast health evaluation and is often used with mammography and other imaging techniques.


Purpose of Clinical Breast Examination

The primary purpose of a CBE is to detect breast abnormalities that may indicate breast cancer or other benign conditions. It is particularly useful in assessing:

  • Lumps or masses in the breast
  • Changes in the size, shape, or texture of the breast or nipple
  • Skin changes, including dimpling, puckering, or redness
  • Discharge from the nipple


Who Should Have a Clinical Breast Examination?

CBEs are recommended for women as part of regular health check-ups. Guidelines for CBE vary by country and organisation, but it is generally recommended that:

  • Women aged 40 and above should have an annual CBE as part of their routine health care.
  • Women at higher risk of breast cancer may need to start regular screenings earlier and may undergo CBE more frequently.


Breast Changes During Pregnancy

Pregnancy brings about a series of significant changes in a woman's body, including various alterations in breast tissue. These changes prepare the breasts for breastfeeding and can vary widely among women.


Common Breast Changes During Pregnancy

  • Increased Breast Size: One of the earliest signs of pregnancy is an increase in breast size. Breasts can grow significantly, sometimes by a full cup size or more, due to hormonal changes that prepare the breasts for lactation.
  • Tenderness and Sensitivity: Many women experience breast tenderness or sensitivity. This can occur as early as one to two weeks after conception and is often one of the first symptoms of pregnancy. The breasts may feel sore when touched or when making sudden movements.
  • Darkening of the Areolas: The areolas (the area around the nipples) usually darken and increase in diameter. This change is believed to help the newborn find the nipple for breastfeeding.
  • Appearance of Veins: As pregnancy progresses, the blood supply to the breasts increases to support the milk-producing glands. This increased blood flow can make veins under the skin of the breasts more visible.
  • Colostrum Production: From the second trimester onward, some women may begin to produce colostrum, a thick, yellowish fluid that is the precursor to breast milk. It is common for small amounts of colostrum to leak from the nipples.
  • Stretch Marks: As breasts enlarge, some women may develop stretch marks due to the rapid stretching of the skin.


Physiological Reasons Behind Breast Changes

These changes are primarily driven by hormones such as oestrogen, progesterone, and prolactin:

  • Oestrogen stimulates the growth of the milk ducts.
  • Progesterone supports the formation and growth of milk-producing cells within the breasts.
  • Prolactin plays a crucial role in milk production.

Additionally, the release of human placental lactogen during pregnancy contributes to breast growth and readiness for lactation.


Managing Breast Discomfort During Pregnancy

  • Wear Supportive Bras: A well-fitting, supportive maternity bra can help alleviate breast discomfort. It's often useful to get fitted by a professional, as breast size can change throughout pregnancy.
  • Use Gentle Skincare: Applying lotions or oils formulated for pregnancy can help manage dry, itchy skin and may reduce the severity of stretch marks.
  • Avoid Irritants: Choosing bras from soft, natural fibres without underwires can prevent irritation and discomfort.
  • Warm or Cold Compresses: Applying warm or cold compresses can relieve breast pain and swelling.
  • Stay Hydrated and Maintain a Healthy Diet: Adequate hydration and nutrition can help maintain skin elasticity and overall breast health.


Family History

A detailed family history of breast cancer or other related cancers significantly influences the risk assessment process. A strong family history may suggest a genetic predisposition to breast cancer, which can guide the frequency and methods of screening.


Impact:

  • Patients with a family history of breast cancer may require earlier and more frequent screening.
  • Genetic counselling and testing for BRCA1, BRCA2, or other relevant mutations might be recommended.


Breast Asymmetry

Breast asymmetry refers to a difference in the size, shape, or position of the breasts. While some degree of asymmetry is normal, significant changes or sudden onset might indicate underlying issues.


Clinical Relevance:

  • New or pronounced asymmetry warrants further evaluation to rule out breast cancer or other conditions.
  • Imaging tests like mammography or ultrasound are often used to further investigate asymmetrical breasts.


Biopsy

If any suspicious areas are identified during the CBE or if there are concerning findings in a patient with significant family history or breast asymmetry, a biopsy may be necessary. A biopsy involves removing a small sample of breast tissue for laboratory analysis to determine if cancer or other abnormal cells are present.


Preparing for a Clinical Breast Examination

Preparing for a CBE involves several straightforward steps to ensure the examination is as effective and comfortable as possible:

  • Schedule Timing Wisely: For premenopausal women, it is often recommended to schedule the CBE about a week after the menstrual period ends when breasts are usually less tender and swollen. This timing can make the examination less uncomfortable.
  • Avoid Certain Products: On the exam day, avoid using deodorants, powders, lotions, or perfumes on or around the breasts and underarms. These products can leave a residue that might be mistaken for abnormalities during the exam.
  • Dress Appropriately: Wear a two-piece outfit so that only the top needs to be removed, making the process easier and more comfortable.
  • Prepare Mentally and Physically: Be ready to discuss any breast changes or problems, as well as any family history of breast cancer. Feel comfortable to ask questions about the examination process and any findings.
  • Know Your History: Be prepared to inform your doctor about your personal and family medical history, any medications you are taking, and any previous breast examinations and their results.


Clinical Breast Examination Procedure

  • Visual Inspection: The doctor examines the breasts with the patient sitting up, looking for skin changes, asymmetry, or nipple changes.
  • Manual Examination: With the patient lying down, the provider uses the pads of the fingers to gently feel the breast tissue in a systematic pattern, such as using a circular motion, covering the entire breast from the collarbone to the bra line and from the armpit to the breastbone.
  • Nipple Examination: The examiner checks for discharge by gently squeezing the nipple.


The examination usually takes about 10 to 15 minutes and should be conducted privately, respecting the patient's comfort and dignity.


Effectiveness of Clinical Breast Examination

CBE can be an effective tool for detecting breast abnormalities, especially in regions where mammography is not readily available. Some studies suggest that CBE may detect palpable breast cancers missed by mammography. However, the effectiveness of CBE can vary based on the doctor's skill and experience.


Limitations of Clinical Breast Examination

While useful, CBE has several limitations:

  • Sensitivity and Specificity: CBE is less sensitive than mammography. It may miss smaller tumours that imaging techniques can detect.
  • False Positives/Negatives: CBE may result in false positives, leading to unnecessary anxiety and additional testing. Conversely, a false negative result may delay the diagnosis of breast cancer.
  • Variability: The accuracy of CBE can vary significantly depending on the examiner's experience and technique.


What if a Clinical Breast Examination is Delayed?

The primary risk of delaying CBE is the possibility of delaying the detection of breast cancer or other abnormalities. Early detection is crucial in managing breast cancer effectively, as it is generally more treatable in its early stages.


A delay in diagnosis could result in detecting the disease at a more advanced stage, potentially limiting treatment options and adversely affecting prognosis.


For women with a family history or other risk factors for breast cancer, delaying regular CBEs can lead to increased anxiety and stress over undetected changes in breast health.