1. Breasts and Regional Lymphatics

2. Structure and Function
Surface anatomy
Location of breasts on chest wall
Axillary tail of Spence
Nipple and areola

3. Structure and Function
Preadolescent
Developmental care
Adolescent
Puberty
Pregnant female
Aging female
Menopause
Male breast
Breast Bud Stage
Breast/Areola Enlarge
Areola/Nipple form 2ndary Mound
Mature Breasts

4. Breast Cancer 2nd leading cause of cancer death in women
Second to lung cancer
NCI-Lifetime risk for a women to develop breast cancer 12%
The 10-year risk for breast cancer:
at age 40: 1 and 69
at age 50: 1 and 42
at age 60: 1 and 29

5. Breast Cancer Risk Factors
Increased age (>40)
Personal or family history of breast cancer or disease
Early onset menarche (before age 13)
Late-age menopause (after age 50)
Nulliparous (never having borne a child)
Late first pregnancy (after age 30)
Recent use of oral contraceptives

6. Inherited Risk Factors- BRCA 1 or BRCA 2 Mutation
Diagnosed with breast cancer before age 50 and/or ovarian cancer at any age
Have close family member (on mother’s or father’s side) diagnosed with breast cancer before age 50, ovarian cancer at any age, or male breast cancer at any age.
Half of all women with hereditary risk inherited it from father’s side.
Myriad Genetic Laboratories

7. BRCA 1 and BRCA 2 Mutation Women with BRCA mutation have:
33%-50% risk of developing breast cancer by age 50
56%-87% risk by age 70
27%-44% chance of developing ovarian cancer by age 70
Men with BRCA mutation have:
-6% risk of developing breast cancer
Myriad Genetic Laboratories

8. Screening-Average Risk
American Cancer Society (2003)
Film Mammogram
Annually after 40 years old
Clinical Breast Examination (CBE)
Every 3 years for age 20-40
Breast Self-Examination (BSE)
Option for women starting at age 20
Women 20 years of age or older need to report any breast changes to a health care provider immediately
“It is acceptable for women to choose not to do BSE or to do BSE irregularly.”

9. Screening- Average Risk
US Preventive Services Task Force (USPSTF) (2009)
Film Mammogram
Not recommended in women years old
Biennial for women years old
Insufficient evidence for recommendation in women ≥75
Clinical Breast Examination (CBE)
Insufficient evidence for recommendation
Breast Self-Examination (BSE)
Not recommended

10. Health History Assess patient’s risk factors
Assess socioeconomic status
Fixed or low-income may be less likely to pursue CBE and mammography
Consider importance of teaching SBE
Provide with resources for free/low cost screening
If already performs self breast exam:
Assess methods and times performs in relations to menstrual cycle

11. Health History Presence of: Pain or tenderness Discharge
Distortion or retraction
Rash or scaling of nipple
Change in size of breast or swelling
Lump
Onset- When first noticed?
Duration- Always present or come and go?
Characteristics- Changed in size, shape, or with menstrual cycle?
Associated Symptoms?

12. Health History Medication Use: Caffeine Intake Level of activity
Oral contraceptives
Diuretics
Steroids
Estrogen
Caffeine Intake
Level of activity
Alcohol intake
Weight

13. Breast/Axilla Inspection
General appearance
Symmetry
Skin
Smooth and even in color.
Reddness
Bulging or dimpling
Edema (peau d’orange)
Skin or vascular lesions
Axillary rash or infection 2 1 3

14. Breast/Axilla Inspection
Nipple
Position
Protrude, flat, or inverted
Skin lesions
Dry scaling, fissures, ulcerations, bleeding, or dc
Supernumerary nipples

15. Maneuvers to screen for retraction

16. Breast/Axilla Palpation
Palpate Lymph nodes in Axilla
Down chest wall, middle of axilla (central)
Anterior border (pectoral)
Posterior border (subscapular)
Inner aspect of upper arm (lateral)
One or more soft, small (<1cm), nontender nodes are often felt
Nodes that are large (>1cm), firm or hard, matted together, or fixed to the skin suggest malignancy

17. Breast/Axilla Palpation
Position
Supine with pillow under side to be palpated
Arm above head
Palpation technique
Use pads of first three fingers and make gentle rotary motion
Vertical stripping pattern recommended
Apply light, medium and deep palpation
Cover entire breast, including the periphery, tail, and axilla
Vertical Stripe
Spokes
Concentric Circle

18. Breast/Axilla Palpation
Nipple
No mass, induration, or dc
Expected findings
Nulliparous- firm, smooth, elastic
Post pregnancy-softer and looser
Premenstrual engorgement-enlargement, tenderness, nodularity, prominent lobes, inframammary ridge
Bimanual palpation
For large pendulous breasts

19. Detection of a Breast Lump
Location
Size
Shape/Distinctness
Consistency
Mobility
Nipple retraction
Overlying skin
Tenderness
Lymphadenopathy

20. Breast Masses Fibroadenoma- Benign fibrous tumor Cysts Cancer
Age up to 55
Round, disc like or lobular, well delineated, mobile, usually non-tender, usually firm but may be soft.
Cysts
Age 30-50
Round, soft to firm, well delineated, mobile, tender
Cancer
Age 30-90
Irregular, firm to hard, not clearly delineated, may be fixed, usually non-tender, retraction may be present

21. Male Breast Exam Inspect chest wall for enlargement, lumps or swelling
Gynecomastia
Palpate nipple area for lumps or enlargement
Palpate axillary lymph nodes
Breast tissue without enlargement, masses, or swelling. Axillary lymph nodes nonpalpable.

22. Breast Self-Examination
Step 1:
Begin by looking at your breasts in the mirror with your shoulders straight and your arms on your hips.
Here's what you should look for:
breasts that are their usual size, shape, and color
breasts that are evenly shaped without visible distortion or swelling
If you see any of the following changes, bring them to your doctor's attention:
dimpling, puckering, or bulging of the skin
a nipple that has changed position or an inverted nipple (pushed inward instead of sticking out)
redness, soreness, rash, or swelling
Step 2: Now, raise your arms and look for the same changes.
Step 3: While you're at the mirror, gently squeeze each nipple between your finger and thumb and check for nipple discharge (this could be a milky or yellow fluid or blood).

23. Breast Self-Examination
Step 4: Next, feel your breasts while lying down, using your right hand to feel your left breast and then your left hand to feel your right breast. Use a firm, smooth touch with the first few fingers of your hand, keeping the fingers flat and together.
Cover the entire breast from top to bottom, side to side—from your collarbone to the top of your abdomen, and from your armpit to your cleavage.
Follow a pattern to be sure that you cover the whole breast. You can begin at the nipple, moving in larger and larger circles until you reach the outer edge of the breast. You can also move your fingers up and down vertically, in rows, as if you were mowing a lawn. Be sure to feel all the breast tissue: just beneath your skin with a soft touch and down deeper with a firmer touch. Begin examining each area with a very soft touch, and then increase pressure so that you can feel the deeper tissue, down to your ribcage.
Step 5: Finally, feel your breasts while you are standing or sitting. Many women find that the easiest way to feel their breasts is when their skin is wet and slippery, so they like to do this step in the shower. Cover your entire breast, using the same hand movements described in Step 4.

24. Sample Charting