Continuing Education Activity

Breast cancer is the most prevalent malignancy among female populations and is responsible for the second-highest number of cancer-related deaths in American women. This activity reviews breast self-examination and highlights the role of the healthcare team in educating patients who are undergoing breast cancer screening.

Objectives:

• Gain knowledge and understanding of the practice of self-breast examination.
• Identify the indications of breast self-examination.
• Describe the preparation and technique in regards to breast self-examination.

Introduction

Breast cancer is the most prevalent malignancy among female populations and is responsible for the second-highest number of cancer-related deaths in American women.[1] The need for early detection has manifest several screening initiatives intent on curtailing morbidity and mortality associated with the disease. Breast Self-Examination was initially proposed as an intuitive, inexpensive, non-invasive, and universally accessible means of promptly identifying early-stage breast neoplasms. Unfortunately, this potential screening tool's positive aspects cannot be considered without the evidence contradictory to its value. Any evaluation of breast self-examination must include that current medical literature does not support the efficacy of the practice and that general implementation is discouraged by most medical societies and academies.

International groups have suggested that breast self-examination programs may benefit specific populations in low-resource countries; however, this idea also remains under consideration. Despite studies refuting the utility of breast self-examination, proponents and breast cancer awareness organizations continue to encourage the controversial practice and seek to educate the public on proper implementation.[2][3]

Anatomy and Physiology

In the context of self-examination, the discussion of breast anatomy should focus on gross and superficial components with attention to associated lymphatics and with an understanding of variability among individuals, age groups, stages of development, and timing within menstrual and gestational cycles.

Breast tissue extends superiorly from the level of the second and third ribs, inferiorly to the inframammary fold, and transversely from the sternum to the midaxillary lines. A peninsula of breast tissue may project into the axilla; this is known as the tail of Spence. Two fascial layers enclose the breast tissue properly, the superficial layer beneath the dermis and the deep layer overlying the pectoralis major muscle fascia. Lobes and lobules of branched tubule-alveolar epithelial glands constitute the functional breast parenchyma supported by the more prevalent stromal elements, mainly adipose tissue.[4] The lobes converge into a progression of lactiferous ducts and sinuses that terminate at the nipple-areolar complex. External stimulation, such as an infant sucking, activates the heavily innervated structures prompting nipple erection through smooth muscle contraction and initiating milk letdown in nursing mothers.[5] Montgomery's glands present superficially on the areola as papular elevations, serving as sebaceous glands and releasing an oily substance that protects the nipple and areola. Breast tissue is anchored to the overlying dermis by bands of connective tissue known as the suspensory ligaments of Cooper.[6] These connections, along with the retro-mammary bursa, support the breast’s position while allowing free movement over the underlying thoracic walls.

The breast’s lymphatic system, which is the primary conduit for metastatic dissemination of breast cancer, is composed mostly of axillary and supraclavicular lymph nodes.[4]

Breast development begins in puberty as epithelial proliferation and increased adipose deposition results in hormonally induced breast enlargement. During pregnancy, the breast prepares for lactation with tissue growth, venous dilation, and darkening of the nipple-areolar complex. After weaning of the infant, involution of breast tissue occurs as glandular and stromal proliferations regress, and the breasts return to approximate pregestational size.

Menopause results in breast tissue atrophy, decreased breast volume, and relaxation of Cooper's Ligaments, resulting in diminished suspension and breast ptosis.[4]

Indications

The indications for breast self-examination remain controversial, and recommendations vary among screening task forces, medical academies, advocacy organizations, and regional world health groups. The practice was established in the 1950s, before the advent of mammography, and doubts about its effectiveness and the nature of its overall health impact were present at its inception.[7] Self-examination could provoke anxiety if a false positive cancer diagnosis were to occur. Breast self-examination was first formally evaluated in a 2002 Shanghai study that demonstrated no survival benefit and increased identification of benign lesions with ensuing unnecessary biopsies.[8]

In response to these findings and similar outcomes in Russian investigations, a 2009 USPSTF (United States Preventive Service Task Force) guideline was adopted, with a Grade D recommendation against Breast Self-Examination. The recommendation cited harms associated with the procedure, including frivolous imaging, unnecessary biopsies, and "psychological' harms related to false-positive results.[8] Resistance to abandoning the practice is rooted in the high incidence of breast cancer, positive anecdotal experiences reported by patients and practitioners, and the intention to empower women through self-diagnosis. Recognizing the importance of early breast cancer detection and desiring to include patients in personal health advocacy, several organizations have proposed breast awareness to supplant breast self-examination as a potential screening device. This concept encourages women to become acquainted with their breasts in order to become more cognizant of any changes without practicing regularly scheduled, ritualistic self-examinations. There is currently no evidence to validate the breast awareness model as an effective strategy for improving cancer-related outcomes or confirmation that it eliminates the unfavorable sequelae associated with breast self-examination.[8][9]

While the appropriateness of formal self-examination programs in the developed world has largely been discredited, it has been suggested that such initiatives have possible utility in low-resource countries where widespread access to mammography is limited. Data is absent on the effectiveness of breast self-examination in the developing world; however, many analysts are investigating opportunities for self-examination education and practice in these settings and whether they have a role in decreasing the health burden of breast cancer in these regions.[10][11]

Contraindications

There are no absolute contraindications to enacting a structured and formal breast self-examination program; however, the absence of observed mortality benefit and the documented occurrence of unfavorable outcomes when regular breast self-examination is performed invalidate the procedure as a legitimate screening tool and should discourage individuals from engaging in the practice routinely.

Equipment

The only equipment necessary to complete a comprehensive breast self-examination is a free-standing or wall-mounted mirror to perform the visual inspection. A pillow may be used to support the back or shoulder during the supine, tactile portion of the procedure.[12]

Personnel

Breast self-examination can be accomplished privately without the assistance of medical personnel or aids.

Preparation

Preparing to undertake a Breast Self-Examination involves optimizing the procedure setting to ensure an accurate, repeatable, and comfortable process. Due to expected changes in breast anatomy given the examination's relationship in time to the menstrual cycle, screening should occur at the same time monthly, ideally at the end of the patient's menses. If the patient is amenorrheic, the examination should proceed on the same selected day each month.[12] A safe, familiar environment, free from distractions and interruptions, should be chosen to ensure a relaxed, secure experience.

Technique or Treatment

The breast self-examination begins with tactile assessment as the patient searches for irregularities through palpation. A methodical, systematic approach is necessary to ensure a consistent and reproducible evaluation. To examine the right breast, the patient should orient herself by rolling on her left side and placing her right hand, palm up, on her forehead. This maneuver optimizes positioning by allowing the breast to lie flat against the thoracic wall. The middle fingertip pad should be used to perform small circles with light, medium, and deep pressure investigating varying depths of breast tissue. To complete the examination of the breast's outer half, up and down motions of palpation are performed medially from the axilla to the nipple and vertically from the clavicle to just below the bra line. As the fingers traverse the breasts, they must remain in contact with the skin to avoid missing any tissue plane. Assessment of the inner half of the breasts requires changing to a supine position, removing the hand from the forehead, and placing the inactive arm at a right angle on the examination surface. The same palpation technique is utilized for the inner breast, including the area of the nipple and sternum. The same patient positioning and maneuvers are implemented to examine the left breast but on the opposite side.[12]

A visual survey of the breast tissue requires an inspection from three angles, with arms at the side, arms raised above the head while bending forward, and hunched over with the hands placed on the hips. Each of these positions should be observed in a mirror from a direct view, right profile, and left profile. While typically one breast may be larger than the other, new disparities in size should be noted. The skin should be appraised for any rashes, erythema, puckering, dimpling, or textural anomalies resembling an orange peel (peau d’orange). The nipples must be monitored for scaling, erythema, pruritis, edema, discharge, or new inversion. Asymmetric venous distribution or dilation should also prompt further consideration.[12]

The Maurer Foundation for breast health education provides step-by-step breast self-examination instructions featuring patient-oriented language and graphical representation of each maneuver. Advocates for Breast Self-Examination emphasize the relationship of quality patient education to the screening tool's success and that trained medical professionals are ideal instructors for the procedure.[13][14] Still, countless examination guides from diverse media platforms are available to the public, and discerning which sources are accurate can be difficult. Healthcare teams must be transparent about the reliability of breast self-examinations, including the avenue by which it is taught.

Complications

Complications associated with breast self-examination are principally secondary to false-positive findings resulting in increased benign lesion identification, unnecessary imaging, biopsies, and anxiety provoked by a possible cancer diagnosis.

Clinical Significance

Early detection of breast cancer is essential to ensuring effective management plans with successful end-points. While the practice of formal Breast Self-Examination screening has not demonstrated improvement in patient outcomes, any patient-observed change or abnormality in the breast anatomy should be reported to the healthcare team for further evaluation.

Enhancing Healthcare Team Outcomes

Interdisciplinary teams incorporating physicians, nurses, allied health, and breast cancer advocacy groups must provide evidence-based education to individuals and communities to make informed decisions concerning patients' breast health. While it is indisputable how steadfast and well-intentioned certain champions of breast self-examination can be, the data supports the assertion that the procedure does not improve outcomes, can produce harmful, unintended consequences, and should not be endorsed as a viable breast cancer screening choice.[8]

Perhaps breast self-examination, or breast awareness, can be implemented effectively in certain developing countries where mammography access is limited; however, further research and bolstered community education must be pursued to realize this intention.