Clinical breast exam
A clinical breast exam (CBE) is an examination of your breasts by
a health professional, such as a doctor, nurse practitioner, nurse,
or physician assistant. For this exam, you
undress from the waist
up. The health professional will first look at your breasts for
abnormalities in size or shape, or changes in the skin of the
breasts or nipple. Then, using the pads of the fingers, the examiner
will gently feel (palpate) your breasts.
Special attention will be given to the shape and texture of the
breasts, location of any lumps, and whether such lumps are attached
to the skin or to deeper tissues. The area under both arms will also
The CBE is a good time for women who don't know how to examine
their breasts to learn the right way to do it from their health care
professionals. Ask your doctor or nurse to teach you and watch your
Breast awareness and self-exam
Beginning in their 20s, women should be told about the benefits
and limitations of breast self-exam (BSE). Women should be aware of
how their breasts normally look and feel and report any new breast
changes to a health professional as soon as they are found. Finding
a breast change does not necessarily mean there is a cancer.
A woman can notice changes by knowing how her breasts normally
look and feel and feeling her breasts for changes (breast
awareness), or by choosing to use a step-by-step approach and using
a specific schedule to examine her breasts.
Women with breast implants can do BSE. It may be useful to have
the surgeon help identify the edges of the implant so that you know
what you are feeling. There is some thought that the implants push
out the breast tissue and may make it easier to examine. Women who
are pregnant or breast-feeding can also choose to examine their
If you choose to do BSE, the following information provides a
step-by-step approach for the exam. The best time for a woman to
examine her breasts is when the breasts are not tender or swollen.
Women who examine their breasts should have their technique reviewed
during their periodic health exams by their health care
It is acceptable for women to choose not to do BSE or to do BSE
occasionally. Women who choose not to do BSE should still know how
their breasts normally look and feel and report any changes to their
doctor right away.
How to examine your breasts
Lie down on your back and place your right arm behind your head.
The exam is done while lying down, not standing up. This is because
when lying down the breast tissue spreads evenly over the chest wall
and is as thin as possible, making it much easier to feel all the
Use the finger pads of the 3 middle fingers on your left hand to
feel for lumps in the right breast. Use overlapping dime-sized
circular motions of the finger pads to feel the breast tissue.
Use 3 different levels of pressure to feel all the breast tissue.
Light pressure is needed to feel the tissue closest to the skin;
medium pressure to feel a little deeper; and firm pressure to feel
the tissue closest to the chest and ribs. It is normal to feel a
firm ridge in the lower curve of each breast, but, you should tell
your doctor if you feel anything else out of the ordinary. If you're
not sure how hard to press, talk with your doctor or nurse. Use each
pressure level to feel the breast tissue before moving on to the
Move around the breast in an up and down pattern starting at an
imaginary line drawn straight down your side from the underarm and
moving across the breast to the middle of the chest bone (sternum or
breastbone). Be sure to check the entire breast area going down
until you feel only ribs and up to the neck or collar bone
There is some evidence to suggest that the up-and-down pattern
(sometimes called the vertical pattern) is the most effective
pattern for covering the entire breast without missing any breast
Repeat the exam on your left breast, putting your left arm behind
your head and using the finger pads of your right hand to do the
While standing in front of a mirror with your hands pressing
firmly down on your hips, look at your breasts for any changes of
size, shape, contour, or dimpling, or redness or scaliness of the
nipple or breast skin. (The pressing down on the hips position
contracts the chest wall muscles and enhances any breast changes.)
Examine each underarm while sitting up or standing and with your
arm only slightly raised so you can easily feel in this area.
Raising your arm straight up tightens the tissue in this area and
makes it harder to examine.
This procedure for doing breast self-exam is different from
previous recommendations. These changes represent an extensive
review of the medical literature and input from an expert advisory
group. There is evidence that this position (lying down), the area
felt, pattern of coverage of the breast, and use of different
amounts of pressure increase a woman's ability to find abnormal
Newer technologies for breast cancer screening
Mammography is the current standard test for breast cancer
screening. MRI is also recommended along with mammograms for some
women at high risk for breast cancer. Other tests, such as
ultrasound, are now being studied as well.
Magnetic resonance imaging
For certain women at high risk for breast cancer, screening
magnetic resonance imaging (MRI) is recommended along with a yearly
mammogram. MRI is not generally recommended as a screening tool by
itself, because although it is a sensitive test, it may still miss
some cancers that mammograms would detect. MRI may also be used in
other situations, such as to better examine suspicious areas found
by a mammogram. MRI can also be used in women who have already been
diagnosed with breast cancer to better determine the actual size of
the cancer and to look for any other cancers in the breast.
MRI scans use magnets and radio waves, instead of x-rays, to
produce very detailed, cross-sectional images of the body. The most
useful MRI exams for breast imaging use a contrast material
(gadolinium) that is injected into a small vein in the arm before or
during the exam. This improves the ability of the MRI to clearly
show breast tissue details.
MRI scans can take a long time -- often up to an hour. You have
to lie inside a narrow tube, which is confining and may upset people
with claustrophobia (a fear of enclosed spaces). The machine makes
loud buzzing and clicking noises that you may find disturbing. Some
places provide headphones with music to block this noise out.
Although MRI is more sensitive in detecting cancers than
mammograms, it also has a higher false-positive rate (when the test
finds something that turns out not to be cancer), which results in
more recalls and biopsies. This is why it is not recommended as a
screening test for women at average risk of breast cancer, as it
would result in unneeded biopsies and other tests in a large portion
of these women.
Just as mammography uses x-ray machines that are specially
designed to image the breasts, breast MRI also requires special
equipment. Breast MRI machines produce higher quality images than
MRI machines designed for head, chest, or abdominal MRI scanning.
However, many hospitals and imaging centers do not have dedicated
breast MRI equipment available. It is important that screening MRIs
are done at facilities that can perform an MRI-guided breast biopsy.
Otherwise, the entire scan will need to be repeated at another
facility when the biopsy is done.
MRI is more expensive than mammography. Most major insurance
companies will likely pay for these screening tests if a woman can
be shown to be at high risk, but it's not yet clear if all companies
will. At this time there are concerns about costs of and limited
access to high-quality MRI breast screening services for women at
high risk of breast cancer.
Ultrasound, also known as sonography, is an imaging method in
which sound waves are used to look inside a part of the body. For
this test, a small, microphone-like instrument called a transducer
is placed on the skin (which is often first lubricated with
ultrasound gel). It emits sound waves and picks up the echoes as
they bounce off body tissues. The echoes are converted by a computer
into a black and white image that is displayed on a computer screen.
This test is painless and does not expose you to radiation.
Breast ultrasound is sometimes used to evaluate breast problems
that are found during a screening or diagnostic mammogram or on
physical exam. Breast ultrasound is not routinely used for
screening. Some studies have suggested that ultrasound may be a
helpful addition to mammography when screening women with dense
breast tissue (which is hard to evaluate with a mammogram), but the
use of ultrasound instead of mammograms for breast cancer screening
is not recommended.
Ultrasound is useful for evaluating some breast masses and is the
only way to tell if a suspicious area is a cyst (fluid-filled sac)
without placing a needle into it to aspirate (pull out) fluid. Cysts
cannot be accurately diagnosed by physical exam alone. Breast
ultrasound may also be used to help doctors guide a biopsy needle
into some breast lesions.
Ultrasound has become a valuable tool to use along with
mammograms because it is widely available, non-invasive, and less
expensive than other options. However, the effectiveness of an
ultrasound test depends on the operator's level of skill and
experience. Although ultrasound is less sensitive than MRI (that is,
it detects fewer tumors), it has the advantage of being more
available and less expensive.
This test, also called a galactogram, is sometimes helpful in
determining the cause of nipple discharge. Most nipple discharges or
secretions are not cancer. In general, if the secretion appears
milky or clear green, cancer is very unlikely. If the discharge is
red or red-brown, suggesting that it contains blood, it might
possibly be caused by cancer, although an injury, infection, or
benign tumors are more likely causes.
In this test a very thin plastic tube is placed into the opening
of the duct at the nipple. A small amount of contrast material is
injected that outlines the shape of the duct on an x-ray image and
shows if there is a mass inside the duct.
A digital mammogram (also known as a full-field digital mammogram
or FFDM) is like a standard mammogram in that x-rays are used to
produce an image of your breast. The differences are in the way the
image is recorded, viewed by the doctor, and stored. Standard
mammograms are recorded on large sheets of photographic film.
Digital mammograms are recorded and stored on a computer. After the
exam, the doctor can view them on a computer screen and adjust the
image size, brightness, or contrast to see certain areas more
clearly. Digital images can also be sent electronically to another
site for a remote consult with breast specialists. While many
centers do not offer the digital option at this time, it is expected
to become more widely available in the future.
Because digital mammograms cost more than standard mammograms,
studies are now under way to determine which form of mammogram will
benefit more women in the long run. Some studies have found that
women who have FFDM have to return less often for additional imaging
tests because of inconclusive areas on the original mammogram. A
recent large study found that FFDM was more accurate in finding
cancers in women younger than 50 and in women with dense breast
tissue, although the rates of inconclusive results were similar
between FFDM and film mammograms. It is important to remember that a
standard film mammogram also is effective for these groups of women,
and that they should not miss their regular mammogram if digital
mammography is not available.
Computer-aided detection and diagnosis
Over the past 2 decades, computer-aided detection and diagnosis
(CAD) has been developed to help radiologists detect suspicious
changes on mammograms. This can be done with standard film
mammograms or with digital mammograms.
Computers can help doctors identify abnormal areas on a mammogram
by acting as a second set of "eyes." For standard
mammograms, the film is fed into a machine, which converts the image
into a digital signal that is then analyzed by the computer.
Alternatively, the technology can be applied to a digital mammogram.
The computer then displays the image on a video screen, with markers
pointing to areas it "thinks" the radiologist should check
It's not yet clear how useful CAD is. Some doctors find it
helpful, but a recent large study found it did not significantly
improve the accuracy of breast cancer detection. It did, however,
increase the number of women who needed to have breast biopsies.
Further research of this approach is needed.
Scintimammography (molecular breast imaging)
In scintimammography, a slightly radioactive tracer called
technetium sestamibi is injected into a vein. The tracer attaches to
breast cancer cells and is detected by a special camera.
This is a newer technique that most doctors still consider be
experimental. Some radiologists believe it is sometimes useful in
looking at suspicious areas found by regular mammograms, but its
exact role remains unclear. Current research is aimed at improving
the technology and evaluating its use in specific situations such as
in the dense breasts of younger women. Some early studies have
suggested that it may be about as accurate as more expensive MRI
Tomosynthesis (3D mammography)
This technology is basically an extension of a digital mammogram.
For this test, a woman lies face down on a table with a hole for the
breast to hang through, and a machine takes x-rays as it rotates
around the breast. Tomosynthesis allows the breast to be seen as
many thin slices, which can be combined into a 3-dimensional
picture. It may allow doctors to detect smaller lesions or ones that
would otherwise be hidden with standard mammograms. This technology
is still considered experimental and is not yet commercially
These tests may be done for the purposes of research, but they
have not yet been found to be helpful in diagnosing breast cancer in
Nipple discharge exam
If you are having nipple discharge, some of the fluid may be
collected and looked at under a microscope to see if any cancer
cells are in it. But even when no cancer cells are found in a nipple
discharge, it is not possible to say for certain that a breast
cancer is not there. If a patient has a suspicious mass, a biopsy of
the mass is necessary, even if the nipple discharge does not contain
Ductal lavage and nipple aspiration
Ductal lavage is an
experimental test developed for women who have no symptoms of breast
cancer but are at very high risk for breast cancer. It is not a test
to screen for or diagnose breast cancer, but it may help give a more
accurate picture of a woman's risk of developing it.
For this test, gentle suction is used to help draw tiny amounts
of fluid from the milk ducts up to the nipple surface, which helps
locate the milk ducts' natural openings on the surface of the
nipple. A tiny tube is then inserted into a duct opening. Saline
(salt water) is slowly infused into the tube to gently rinse the
duct and collect cells. The fluid is then withdrawn through the tube
and sent to a lab, where the cells are viewed under a microscope.
Ductal lavage is much more useful as a test of cancer risk rather
than as a screening test for cancer. It is not considered
appropriate for women who aren't at high risk for breast cancer. It
is not clear whether it will ever be a useful tool. The test has not
been shown to detect cancer early. More studies are needed to better
define the usefulness of this test.
Nipple aspiration also
looks for abnormal cells from the ducts. The device for nipple
aspiration uses small cups that are placed on the woman's breasts.
The device warms the breasts, gently compresses them, and applies
light suction to bring nipple fluid to the surface of the breast.
The nipple fluid is then collected and sent to a lab for analysis.
As with ductal lavage, the procedure may be useful as a test of
cancer risk but is not appropriate as a screening test for cancer.
The test has not been shown to detect cancer early.
Talk to your doctor
If you think you are at higher risk for developing breast cancer,
talk to your doctor about what is known about these tests and their
potential benefits, limitations, and harms. Then decide together
what is best for you.
For more information on imaging tests for early detection and
diagnosis of breast diseases, refer to the separate American Cancer
Society document, Mammograms
and Other Breast Imaging Procedures.