Breast self-examination and clinical breast examination (CBE -- breast examination done by a health care provider) are useful in the early detection of breast changes and breast cancer. The following lists represent the most common signs, symptoms and examples of physiological changes but is not all-inclusive.

Visual Changes

• General changes
• Nipple changes
• Skin changes

Palpable Changes

A palpable change is a discrete lump or thickening of the breast that can be felt upon physical examination (BSE or CBE). This is the most common symptom of breast cancer. The lump may be tender but most often it is painless. Any abnormality, lump or thickening found during a BSE should be reported to a physician right away. Palpable changes include:

• a lump or mass
• an area of (tissue) thickening
• an expressible discharge
• axillary lymph node enlargement

Other Changes

• any expressible nipple discharge that is bloody

Breast self-examination (BSE) can save your life. Statistics show that most breast cancers are actually discovered by women themselves. If more women practiced routine BSE, death from breast cancer might be reduced by as much as 18 percent because BSE-detected tumors usually are discovered when the tumor is in its early, more curable stages. In addition to checking your own breasts, you should have your gynecologist, internist, or family physician examine them on a regular basis (e.g., yearly or as recommended by your personal physician).

BSE is easy to learn and to do. Ideally, BSE should be conducted once a month. If a woman is still menstruating, she should inspect her breasts approximately seven to ten days after the beginning of menstruation, when they are not swollen and tender. If she is no longer menstruating, she should still perform regular monthly examinations; the first day of each month is often an easy-to-remember schedule.

Breast self-examination consists of visual inspection and palpation (feeling).

Visual Inspection

To inspect your breasts, visually stand in front of a mirror in a well-lighted room and carefully observe all sides of your breasts for unusual characteristics. Note any differences in the size or shape of your breasts. You are looking for discharge from your nipples, sudden nipple inversion (If your nipples were previously erect), a skin rash, scaling, redness, puckering, retraction of the skin that could mean that a growth is pulling the overlying skin inward or a change in skin texture "orange peel" skin, referred to as peau dí orange). Some women have prominent veins in their breasts. This condition is not cause for alarm if it is a normal state of a woman's breasts. Changes in the appearance of these veins are important. If you notice any of these variations in your breast appearance, you should immediately report them to your doctor.

To identify any changes in the shape of your breasts, observe yourself in 3 positions:

1. straight forward with your hands at your sides,

2. hands raised and clasped behind your head with hands pressed forward and

3. hands pressed firmly on your hips with shoulders and elbows pulled forward.

As you assume the last two positions, you should be able to feel your chest muscles tense. The outline of your breasts should have a smooth curve in all positions.

Palpation (Feeling)

The most important part of the examination -- feeling your breasts -- can be done while you are standing or lying down. Many women prefer the privacy of the shower for this inspection. The soap and water make their skin feel slippery and their fingers smoothly glide over their breasts, making it easier for them to detect any textural changes underneath. Lying down is the best approach.

The area you need to examine begins at the middle notch of your collarbone, moving under the collarbone to your mid-underarm, down to your bra line. Follow your bra line to the middle of your breastbone and back to the middle notch of your collarbone.

Use the flat portion of your three middle fingers from the first joint down to the fingertips, placing them on your breast tissue in a flat bowing position. You should never remove your hands from your breast during the examination (so you do not lose track of where you have examined and miss an area). It is recommended that you use three pressures during your breast self-exam: light (barely moving the top layer of skin), medium (going halfway through the thickness of breast tissue) and firm (deep pressure going to the base of the breast next to the ribs).

Palpation Performed While Lying Down: If you perform the inspection while lying down, lie flat on your back with your left arm over your head and a pillow or rolled towel under your left shoulder. This position flattens your breasts and will make it easier to examine them. Lying down is the best approach. Use the vertical strip pattern (also the best technique), circular or wedge pattern described below and repeat the procedure on your right side.

You need to lie down on the opposite side of the breast you will be examining; pull your knees up slightly and rotate the shoulder of the breast you examine to the flat of the surface you are lying on. Place your hand palm up on your forehead. Stay in the side-lying position until you reach your nipple, then rotate flat on your back and place your arm at your side to finish your exam.

Palpation Performed While Standing: Begin the inspection by raising your left arm and using the flat, cushioned part of your fingers of your right hand (not the fingertips) to feel your left breast. Place your fingers at the outer edge of your breast and slowly press or compress the breast tissue gently down to the chest wall beneath.

There are several patterns that you can use for examining your breasts:

1. The Vertical Strip Pattern

Start at the top of your chest and palpate your breasts in a vertical pattern, carefully compressing the breast tissue, strip by strip, until all breast tissue has been inspected (10-16 vertical strips are recommended). The vertical strip pattern is the best approach.

2. The Circular Pattern

Examine your breasts by moving your fingers in small circles around your breast, gradually working toward the nipple.

3. The Wedge Pattern

Approach your breast as if it were a circle divided into wedges. Then examine your breast wedge by wedge, working from the outer portion of your breast toward the nipple until the whole breast is examined.

Which pattern you choose is not as important as selecting one, using it consistently and allowing yourself enough time (8 to 10 minutes is recommended) for a thorough and deliberate examination. With all of these patterns, be sure to palpate the entire breast region, the areas above the breast and under the collarbone and the underarm, including the armpit itself. Sometimes lumps are discovered in this area. You are looking for any thickening, masses, swollen lymph nodes or unusual lumps under the skin, spontaneous nipple discharge (particularly if it is bloody) -- and especially a change from any previous examination. Changes might feel like firm, distinct bumps. Repeat this technique on your right side.

Post Mastectomy, Lumpectomy or Breast Reconstruction Self-Exam

It is almost impossible for a surgeon to remove all of the breast tissue even with a mastectomy. Breast cancer can still develop in the remaining tissue. If you have had a mastectomy, a lumpectomy or breast reconstruction, you should feel your chest area, paying close attention to the scar and tissue surrounding it.

Raise your arm on the unoperated side; or the opposite side if you have had surgery on both sides (bilateral); and using your opposite hand, place three or four fingers at the top of the scar. Press gently using the circular motion described above. Examine the entire length of the scar. You are looking for lumps, bumps, hard spots or thickenings. As with your breasts, familiarity with your scar(s) or reconstructed breast(s) will make it easier for you to recognize any changes and report them to your doctor.

What To Check For:

The best way to discover abnormal breast lumps is to know what is normal for your breasts; then, if a problem develops, you can spot it immediately. Remember, most women's breast have a bumpy texture and the upper portion is usually the lumpiest. Essentially, what you are looking for are persistent lumps that do not disappear or change size after menstrual cycles. These are dominant lumps, appearing suddenly and remaining. Abnormal breast lumps will vary in size, firmness and sensitivity. They may be hard or irregular with sharp edges. Still others appear as thickened areas with no distinct outlines. Some lumps are painful and tender. Pain is not ordinarily a sign of breast cancer, however, and may just indicate the development of a breast cyst. Sometimes, natural underlying anatomic structures, such as breast glands, the breastbone or ribs, can be mistaken for lumps. A firm ridge in the lower curve of each breast is normal. Do not worry about making a mistake. Always report suspected lumps to your doctor. It never hurts to be wrong but it can definitely be damaging and even fatal to ignore a cancer. The bottom line is: when in doubt, check it out!

Whether you perform BSE while standing or lying down, the important point is to make the decision to do a self-inspection each month. Any breast changes, unusual pain or tenderness or lumps you discover should be investigated further by your doctor. Along with your monthly BSE, you should have regular checkups (an 8 to 10 minute breast exam is recommended) by your family physician, internist or gynecologist. Be sure to have a clinical breast examination at least yearly or as often as advised by your physician.

Most breast lumps are benign, but for those that are malignant, mammography, BSE and physician surveillance can ensure early detection and a significantly higher cure rate.

Occasionally, the first sign of a tumor in the breast is enlargement of an axillary lymph node in the underarm area. However, many women normally have soft and movable nodes that may be enlarged.

Breast cancer can take many forms and it can produce many abnormalities. Any change(s) in the breast needs to be checked by the woman's health care professional. Women should remember that most changes are not signs of cancer. Most breast biopsies turn out to be benign.

Some general changes may include change in appearance or contour of the breast, such as asymmetry in size or shape.

Some nipple changes may include a spontaneous discharge from the nipple that is bloody, retraction of the nipple, scaly skin on or around the nipple.

Some skin changes may include dimpling, puckering or retraction of the skin that could mean that a growth is pulling the overlying skin inward (and may be more clear on raising the arm), change in skin color (redness) or texture ("orange peel" skin, referred to as peau dí orange).

Remember, a self-exam is NOT a substitute for periodic examinations
or mammograms by a qualified health care professional.

* Source and Suggested Resource: Excerpted with permission and adapted from: Berger, Karen
and Bostwick III, John: A Woman's Decision: Breast Care, Treatment, and Reconstruction, Quality
Medical Publishing, St. Louis, 1994. Additional Resource: Special Touch Breast Health Program
Trainer's Guide, American Cancer Society, California Division, Revised August 1995.