Clinical Breast Examination and Breast Self-Examination



Historically, clinical breast examination (CBE) was a used as a diagnostic tool both to recognize and to diagnose breast cancer. CBE is no longer used to diagnose breast cancer, but rather is currently used as a screening test that can identify areas that might be breast cancer. Many of the observations that students are taught regarding CBE are more appropriate to advanced cancers that were common a century ago than to the smaller cancers seen in current practice. While CBE is less sensitive than mammography, it is nonetheless the primary mode of detecting the 15% of breast cancers that are missed by mammography.

Palpation of the supine patient is the essential step to detect almost all cancers that can be detected by CBE. Underlying ribs are the surface against which tissue is palpated. Observing where ribs can or cannot be felt through breast tissue is a useful way to compare different areas of the breasts of a woman and to compare the breasts one to another woman.

Breast self-examination (BSE) is an attempt to have women identify their own cancers at an early stage. Although there are many reasons to anticipate that BSE should work, randomized trials of BSE with increasingly sophisticated procedures for retraining and sustaining BSE practice have found that, although there is increased identification of benign breast abnormalities, there is no increased identification of cancer, and no improvement in breast cancer specific survival.

Silicone models are widely used to teach both CBE and BSE skills. Nonetheless, there are no data to support claims that these complicated and time-consuming methods of specific patterns and depths of palpation are the optimal way to teach or perform CBE or BSE.


Breast Cancer Breast Tissue Interval Cancer Nipple Discharge Clinical Breast Examination 
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  1. 1.
    Lewis D, Rienhoff WF. A study of operations for the cure of cancer of the breast. Ann Surg. 1932;95:336–400.PubMedCrossRefGoogle Scholar
  2. 2.
    MacCarty WC. Efficiency in diagnosis of neoplasms. SG&O. 1922;35:209–215.Google Scholar
  3. 3.
    Haggard WD, Douglass HL. Tumors of the breast. A study of two hundred and fifty-five cases. J Am Med Assoc. 1923;80:445–449.Google Scholar
  4. 4.
    U.S. Preventive Services Task Force. Screening for Breast Cancer., November 2009.
  5. 5.
    Coleman EA, Feuer EJ, NCI Breast Cancer Screening Consortium. Breast cancer screening among women 65 to 74 years of age in 1987–88 and 1991. Ann Int Med. 1992;117:961–966.PubMedGoogle Scholar
  6. 6.
    Chagpar AB, McMasters KM. Trends in mammography and clinical breast examination: a population-based study. J Surg Res. 2007;140:214–219.PubMedCrossRefGoogle Scholar
  7. 7.
    Campbell HS, Fletcher SW, Lin S, Pilgrim CA, Morgan TM. Improved physicians’ and nurses’ clinical breast examination: A randomized controlled trial. Am J Prevent Med. 1991;7:1–8.Google Scholar
  8. 8.
    Goodson WH III, Moore DHII. Causes of physician delay in the diagnosis of breast cancer. Arch Intern Med. 2002;162:1343–1348.PubMedCrossRefGoogle Scholar
  9. 9.
    Greenwald P, Nasca PC, Lawrence CE, et al. Estimated effect of self-examination and routine physician examinations on breast-cancer mortality. New Eng J Med. 1978;299:271–273.PubMedCrossRefGoogle Scholar
  10. 10.
    Huguley CM, Brown RL. The value of breast self-examination. Cancer. 1981;47:989–995.PubMedCrossRefGoogle Scholar
  11. 11.
    Senie RT, Lesser M, Kinne DW, Rosen PP. Method of tumor detection influences disease-free survival of women with breast carcinoma. Cancer. 1994;73:1666–1672.PubMedCrossRefGoogle Scholar
  12. 12.
    Muscat JE, Huncharek MS. Breast self-examination and extent of disease: A population based study. Cancer Detect Prev. 1991;15:155–159.PubMedGoogle Scholar
  13. 13.
    Reeves MJ, Newcomb PA, Remington PL, Marcus PM. Determinants of breast cancer detection among Wisconsin (United States) women, 1988–1990. Cancer Causes Control. 1995;6:103–111.PubMedCrossRefGoogle Scholar
  14. 14.
    Holleb AL, Venet L, Day E, Hoyt S. Breast cancer detection by routine physical examination. New York State Med J. 1960;60:823–827.Google Scholar
  15. 15.
    Gilbertsen VA, Kjelsberg M. Detection of breast cancer by periodic utilization of methods of physical diagnosis. Cancer. 1971;28:1552–1554.PubMedCrossRefGoogle Scholar
  16. 16.
    Murimoto T, Komaki K, Mori T, et al. The quality of mass screening for breast cancer by physical examination. Surgery Today Jpn J Surg. 1993;23:200–204.CrossRefGoogle Scholar
  17. 17.
    Baines CJ, Miller AB, Bassett AA. Physical examination, its role as a single screening modality in the Canadian National Breast Screening Study. Cancer. 1822;1989(63):1816–.PubMedCrossRefGoogle Scholar
  18. 18.
    Venet L, Strax P, Venet W, Shapiro S. Adequacies of breast examinations by physicians in mass screening. Cancer. 1971;28:1546–1551.PubMedCrossRefGoogle Scholar
  19. 19.
    Hicks MJ, Davis JR, Layton Jm, Present AJ. Sensitivity of mammography and physical examination of the breast for detecting breast cancer. J Am Med Assoc. 1979;242:2080–2083.CrossRefGoogle Scholar
  20. 20.
    Rodes ND, Lopez MJ, Pearson DK, Blackwell CW, Lankford HD. The impact of breast cancer screening on mortality. Cancer. 1986;57:581–585.PubMedCrossRefGoogle Scholar
  21. 21.
    Bobo JK, Lee NC, Thames SF. Finding from 752,081 clinical breast examinations reported to a national screening program from 1995 through 1998. J Nat Cancer Inst. 2000;92:971–976.PubMedCrossRefGoogle Scholar
  22. 22.
    Kolb TM, Lichy J, Newhouse JH. Comparison of performance of screening mammography, physical examination, and breast ultrasound and evaluation of factors that influence them: An analysis of 27,825 patient evaluations. Radiology. 2002;225:165–175.PubMedCrossRefGoogle Scholar
  23. 23.
    Banjec C, Decker K, Chiarelli A, et al. Contribution of clinical breast examination to mammography screening in the early detection of breast cancer. J Med Screen. 2003;10:16–21.CrossRefGoogle Scholar
  24. 24.
    Ostereicher N, Lehman CD, Seger DJ, Buist DSM, White E. The incremental contribution of clinical breast examination to invasive breast cancer detection in a mammography screening program. Am J Roent. 2005;184:428–432.Google Scholar
  25. 25.
    Shapiro S, Strax P, Venet L. Periodic breast cancer screening in reducing mortality from breast cancer. J Am Med Assoc. 1971;215:1777–1785.CrossRefGoogle Scholar
  26. 26.
    Hansel DM, Cooke JC, Parsons CA. The accuracy of mammography alone and in combination with clinical examination and cytology in the detection of breast cancer. Clin Radiol. 1988;39:150–153.Google Scholar
  27. 27.
    Boyd NF, Sutherland HJ, Fish EB, et al. Prospective evaluation of physical examination of the breast. Am J Surg. 1981;142:331–334.PubMedCrossRefGoogle Scholar
  28. 28.
    Marsh SK, Archer TJ. Accuracy of general practitioner referrals to a breast clinic. Ann Roy Coll Surgeons Engl. 1996;78:203–205.Google Scholar
  29. 29.
    Goodson WHIII, Grissom NA, Moore DHII, Dribas FM. Streamlining clinical breast examination. J Natl Cancer Inst. 2005;97:1476–1477.PubMedCrossRefGoogle Scholar
  30. 30.
    Pennypacker HS, Pilgrim CA. Achieving competence in clinical breast examination. Nurse Pract Forum. 1993;4:85–90.PubMedGoogle Scholar
  31. 31.
    Mahoney L, Csima A. Efficiency of palpation in clinical detection of breast cancer. Canadian Med Assoc J. 1982;127:729–730.Google Scholar
  32. 32.
    Haagensen CA. Carcinoma of the breast. J Am Med Assoc. 1948;138:195–205.PubMedGoogle Scholar
  33. 33.
    Robles-De-La-Torre, Hayward V. Force can overcome object geometry in the perception of shape through active touch. Nature. 2001;412:445–448.CrossRefGoogle Scholar
  34. 34.
    Spence C. Multisensory attention and tactile information-processing. Behavioral Brain Res. 2002;135:57–64.CrossRefGoogle Scholar
  35. 35.
    Petrakis NL, Mason L, Lee R, et al. Association of race, age, menopausal status, and cerumen type with breast fluid secretion in nonlactating women, as determined by nipple aspiration. J Natl Cancer Inst. Apr 1975;54(4):829–834.PubMedGoogle Scholar
  36. 36.
    Cheattle GL. The importance of early symptoms in diseases of the breast. Br Med J. 1927;2:47–48.CrossRefGoogle Scholar
  37. 37.
    Goodson WHIII, Miller TR, Sickles EA, Upton RA. Lack of correlation of clinical breast examination with high-risk histopathology. Am J Med. 1990 Dec;89(6):752–756.PubMedCrossRefGoogle Scholar
  38. 38.
    Goodson WHIII, Moore DHII. Overall clinical breast examination as a factor in delayed diagnosis of breast cancer. Arch Surg. 2002 Oct;137(10):1152–1156.PubMedCrossRefGoogle Scholar
  39. 39.
    Groenendijk RPR, Bult P, Tewarie L, et al. Screen-detected breast cancers have a lower mitotic activity index. Brit J Cancer. 2000;82:381–384.PubMedCrossRefGoogle Scholar
  40. 40.
    Porter GJR, Evans AJ, Burrell HC, et al. Interval breast cancers: prognostic features and survival by subtype and time since screening. J Med Screen. 2006;13:115–122.PubMedCrossRefGoogle Scholar
  41. 41.
    Evans AJ, Kutt E, Record C, et al. Radiological and pathological findings of interval cancers in a multi-centre, randomized, controlled trial of mammographic screening in women from age 40–41 years. Clin Radiol. 2007;62:348–352.PubMedCrossRefGoogle Scholar
  42. 42.
    Brekelmans CT, van Gorp JM, Peeters PH, Collette HJ. Histopathology and growth rate of interval breast carcinoma. Characterization of different subgroups. Cancer. 1996;78:1220–1228.PubMedCrossRefGoogle Scholar
  43. 43.
    Zackrisson S, Janzon L, Manjer J, Andersson I. Improved survival rate for women with interval breast cancer – results from the breast cancer screening programme in Malmo, Sweden 1976 – 1999. J Med Screen. 2007;14:138–143.PubMedCrossRefGoogle Scholar
  44. 44.
    Pagana TJ, Lubbe WJ, Schwartz SM, Sprechini GD. A comparison of palpable and nonpalpable breast cancers. Arch Surg. 1989;124:26–28.PubMedGoogle Scholar
  45. 45.
    Bassett LW, Liu TH, Giuliano AE, Gold RH. The prevalence of carcinoma in palpable vs impalpable mammographically detected lesions. Am J Radiol. 1991;157:21–24.Google Scholar
  46. 46.
    Reintigen D, Berman C, Cox C, et al. The anatomy of missed breast cancers. Surgical Oncol. 1993;2:65–75.CrossRefGoogle Scholar
  47. 47.
    Perdue PW, Galbo C, Ghosh C. Stratification of palpable and nonpalpable breast cancer by method of detection and age. Ann Surg Oncol. 1995;2:512–515.PubMedCrossRefGoogle Scholar
  48. 48.
    Lung JA, Hart NE, Woodbury R. An overview and critical analysis of breast cancer screening. Arch Surg. 1988;123:833–838.PubMedGoogle Scholar
  49. 49.
    Lopez MJ, Balckwell CW. Breast cancer detection by screening: the importance of long-term follow-up. Surgery. 1989;106:590–595.PubMedGoogle Scholar
  50. 50.
    Sener SF, Winchester DJ, Winchester DP, et al. Survival rates for breast cancers detected in a community service screening mammogram practice. Am J Surg. 2006;191:406–409.PubMedCrossRefGoogle Scholar
  51. 51.
    Loughry CW, Price TE, Morek WM, et al. Right and left breast volume distribution comparisons in normal and tumor containing breasts. Cancer Detect Prev. 1987;10:215–221.PubMedGoogle Scholar
  52. 52.
    Losken A, Fishman I, Denson DD, Moyer HR, Carlson GW. An objective evaluation of breast symmetry and shape differences using 3-dimensional images. Ann Plast Surg. 2005;55:571–575.PubMedCrossRefGoogle Scholar
  53. 53.
    Kopans DB, Swann CA, White G, et al. Asymmetric breast tissue. Radiology. 1989;171:639–643.PubMedGoogle Scholar
  54. 54.
    Scutt D, Lancaster GA, Manning JT. Breast asymmetry and predisposition to breast cancer. Breast Cancer Res. 2006;8(2):R14:Epub 2006 Mar 20.PubMedCrossRefGoogle Scholar
  55. 55.
    Sanfilippo JS, Berman B, Spratt JS, et al. Establishment of a clinical teaching associates breast examination program for medical students. J Reproductive Med. 1986;31:245–248.Google Scholar
  56. 56.
    Haagensen CD. Self-examination of the breasts. J Am Med Assoc. 1952;149:356–360.PubMedGoogle Scholar
  57. 57.
    Foster RS, Lang SP, Costanza MC, et al. Breast self-examination practices and breast cancer. NEJM. 1978;299:265–270.PubMedCrossRefGoogle Scholar
  58. 58.
    Huguley CM, Brown RL, Greenberg RS, Clark WS. Breast self-examination and survival from breast cancer. Cancer. 1988;62:1389–1396.PubMedCrossRefGoogle Scholar
  59. 59.
    Feldman JG, Carter AC, Nicastri AD, Hosat ST. Breast self-examination, relationship to stage of breast cancer at diagnosis. Cancer. 1981;47:2740–2745.PubMedCrossRefGoogle Scholar
  60. 60.
    Foster RS, Costanza MC. Breast self-examination practices and breast cancer survival. Cancer. 1984;53:999–1005.PubMedCrossRefGoogle Scholar
  61. 61.
    Auvinen A, Elovainio L, Hakama M. Breast self-examination and survival from breast cancer. Breast Cancer Res Treat. 1996;38:161–168.PubMedCrossRefGoogle Scholar
  62. 62.
    Miller AB, Chamberlain J, Tsechkovski M. Self-examination in the early detection of breast cancer. A review of evidence, with recommendations for further research. J Chronic Dis. 1985;38:527–540.PubMedCrossRefGoogle Scholar
  63. 63.
    UK Trial of Early Detection of Breast Cancer group. 16-year mortality from breast cancer in the UK trial of early detection of breast cancer. Lancet. 1999;353:1909–1914.CrossRefGoogle Scholar
  64. 64.
    Semiglazov VF, Moiseyenko VM, Manikhas AG, et al. Role of breast self-examination in early detection of breast cancer: Russia/Who prospective trial St. Petersburg. . Cancer Strategy. 1999;6:1–7.Google Scholar
  65. 65.
    Thomas DB, Gao DL, Ray RM, et al. Randomized trial of breast self-examination in Shanghai: Final results. J Nat Cancer Inst. 2002;94:1445–1457.PubMedGoogle Scholar
  66. 66.
    Devi BCR, Tang TS, Corbex M. Reducing by half the percentage of late-presentation for breast and cervix cancer over 4 years: a pilot study of clinical downstaging in Sarawak, Malaysia. Ann Oncol. 2007;18:1172–1176.PubMedCrossRefGoogle Scholar
  67. 67.
    Adams CK, Hall DC, Pennypacker HS, et al. Lump detection in simulated human breasts. Percept Psychophys. 1976;20:163–167.CrossRefGoogle Scholar
  68. 68.
    Hall DC, Adams CK, Stein GH, et al. Improved detection of human breast lesions following experimental training. Cancer. 1980;46:408–414.PubMedCrossRefGoogle Scholar
  69. 69.
    Saunders KJ, Pilgrim CA, Pennypacker HS. Increased proficiency of search in breast self-examination. Cancer. 1986;58:2351–2537.CrossRefGoogle Scholar
  70. 70.
    McDermott MM, Dolan NC, Huang J, Reifler D, Rademaker AW. Lump detection is enhanced in silicone breast models simulation postmenopausal breast tissue. J Gen Internal Med. 1996;11:112–114.CrossRefGoogle Scholar
  71. 71.
    Fletcher SW, O‘Malley MS, Pilgrim CA, Gonzalez JJ. How do women compare with internal medicine residents in breast lump detection? J Gen Intern Med. 1989;4:277–283.PubMedCrossRefGoogle Scholar
  72. 72.
    Smith RL, Hanchak NA, Bloom H, et al. The effectiveness of postgraduate education on the clinical breast examination skills of primary care physicians. Am J Manag Care. 1996;2:989–995.Google Scholar
  73. 73.
    Trapp MA, Kottke TE, Vierkant JS, Kaur JS, Sellers TA. The ability of trained nurses to detect lumps in a set of silicone breast models. Cancer. 1999;86:1750–1756.PubMedCrossRefGoogle Scholar
  74. 74.
    Vetto JT, Petty JK, Dunn N, Prouser NC, Austin DF. Structured clinical breast examination (CBE) training results in objective improvement in CBE skills. J Cancer Educ. 2002;17:124–127.PubMedGoogle Scholar
  75. 75.
    Steiner E, Austin DF, Prouser NC. Detection and description of small breast masses by residents using a standardized clinical breast exam curriculum. J Gen Internal Med. 2008;23:129–134.CrossRefGoogle Scholar
  76. 76.
    Goodson WH III, Hunt TK Jr, Plotnik J, Moore DH II. Optimization of clinical breast examination. Am J Med (in press – April 2010).Google Scholar
  77. 77.
    Elmore JG, Barton MB, Moceri VM, et al. Ten-year risk of false positive screening mammograms and clinical breast examinations. NEJM. 1998;338:1089–1096.PubMedCrossRefGoogle Scholar

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© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Department of SurgeryCalifornia Pacific Medical Center Research InstituteSan FranciscoUSA

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