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Chapter 17 Breast Notes

Health Assessment Across The Lifespan (Regis University)

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Ch. 17: Breasts and Regional Lymphatics (p. 385-

Loretto Heights School of NursingRegis University
UNIT OBJECTIVES: Upon completion of this unit the student will be prepared to:
Review the basic anatomy of the breast.
Describe the composition of breast glandular tissue.
Relate the changes that occur in Cooper’s ligaments with cancer.
Describe the ways of documenting clinical findings from a breast exam.
Explain the anatomy of the breast lymphatic system.
Identify the developmental considerations of the male and female breast.
Describe the procedure for teaching breast self-
examination with rationale.
Identify diagnostic testing appropriate for the breast.
Demonstrate appropriate gathering of subjective data
(health history) of the breast.
Describe how to prepare a client physically and
psychologically for an examination of the breast.
Incorporate health promotion concepts and screenings
when performing a breast assessment.
Describe variations in health in the assessment of the
breast.
Demonstrate appropriate documentation of subjective
data for a breast assessment.

STRUCTURE AND FUNCTION

Breasts
 Mammary glands- present in both females & males
 Male breasts- rudimentary throughout life
 Female breasts- accessory reproductive organs whose function is
to produce milk for nourishing newborn
 Extensive lymphatic drainage
Surface Anatomy
 Location of breasts on chest wall
 Axillary tail of Spence (MOST breast cancer here and upper
outer quadrant)
 Nipple and areola
Internal Anatomy
 Glandular tissue, which contains Lobes, that contain Lobules, that
contain Alveoli (produce milk)
 Each lobe drains into a Lactiferous duct
o Ducts converge toward nipple where they form
ampullae/lactiverous sinuses that store milk
 Fibrous tissue that support breast
o Suspensory ligaments, aka Cooper’s ligaments
 Adipose tissue
o Lobes are embedded in adipose tissue
Four quadrants of breast (see image)
 Upper outer quadrant is site of most breast tumors
 Next most common in nipple area
Areas of malignancy-

Lymphatics

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 Lymph
o Most of lymph, more than 75%, drains into ipsilateral (same side) axillary nodes
 Axillary nodes-
o Pectoral/Anterior
o Subscapular/ Posterior
o Lateral
 All three drain into Central Axillary Nodes
 From the central axillary nodes, drainage flows UP to:
o Infraclavicular and supraclavicular nodes
 Smaller amount of lymphatic drainage flows directly up to infraclavicular group, deep
into chest, or into abdomen, or directly across to opposite breast
Male Breast
 Rudimentary structure consisting of a thin disk of undeveloped tissue underlying nipple
 Areola well developed, although nipple is small
 Gynecomastia: during adolescence, it is common for breast tissue to temporarily enlarge
 Patients with family history of male breast cancer have increased risk for breast cancer

Developmental Considerations: Adolescents

At puberty, estrogen stimulates breast changes.
 Five stages of breast development are correlated with
Female Tanner Staging.
o Breast buds first sign-Stage 2
 Occasionally one breast may grow faster than other,
producing a temporary asymmetry.
 Beginning of breast development precedes menarche by
about 2 years.
Cultural Competence
 Timing of puberty is influenced by genetic and
environmental factors.
 Research data indicate age differences in onset of
puberty according to different ethnic groups.
 Menses began at an average age of 12.16 years for
black girls and age 13 for white girls.
 Obesity contributes to the early onset of puberty.

Developmental Competence: Pregnant Woman

 Breast changes start during the second month of pregnancy and are an early sign for most women.
 Hormones stimulate the expansion of the ductal system and supporting fatty tissue and development
of the true secretory alveoli. Thus the breasts enlarge and feel more nodular.
 The nipples grow larger, darker, and more erectile. The areolae become larger and a darker brown
as pregnancy progresses, and the tubercles become more prominent.
 Colostrum- thick yellow fluid is precursor for milk, containing same amount of protein and lactose,
but practically no fat. It is rich with antibodies that protect newborn against infection, so
breastfeeding is important.
o Breasts produce colostrum for first few days after delivery, but it may be expressed as early as
the fourth month.
 Lactation, milk production, begins 1 to 3 days postpartum; whitish color is from emulsified fat and
calcium caseinate.

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Developmental Competence: Aging Woman

 After menopause, ovarian secretion of estrogen and progesterone decreases, causing breast
glandular tissue to atrophy.
 Decreased breast size makes inner structures more prominent.
 A breast lump may have been present for years but is suddenly palpable.
 Around nipple, the lactiferous ducts are more palpable and feel firm and stringy because of fibrosis
and calcification.
 Axillary hair decreases.

Cultural Competence: Breast cancer

 We all have certain tumor suppressor genes termed BRCA1 and BRCA2; women who inherit a
mutation on one or both have a significantly increased risk of developing breast or ovarian cancer
 Incidence of breast cancer varies in cultural groups-
 Morbidity rate of breast cancer incidence (out of 100,000 in 1998 to 2002) was 141.1 for whites,
119.4 for African Americans, 96.6 for Asians, 89.9 for Hispanics, and 54.8 for American Indians
 Mortality rate of breast cancer incidence (out of 100,000 in 1998 to 2002) was 25.9 for whites, 34.7
for African Americans, 12.7 for Asians, 16.7 for Hispanics, and 13.8 for American Indians
 Although incidence of breast cancer is 12% lower in African American women than in white women,
African American women had a 36% higher death rate that white women
 Asian, Hispanic, and American Indian women have a lower risk for development of breast cancer
 Use of mammograms in 2003 by women over 40 years old was 69.5% but…
o 63.1% among African American women
o 63.1% among Asians
o 57.6% among American Indian and Alaska Natives
o 65% among Hispanic women
 Factors contribute to breast health care access include low income, lack of health insurance,
geographic, cultural, and language barriers, and racial bias
 Additional statistics: http://www.cdc.gov/nchs/data/hus/hus14.pdf#076
 Some studies have found that diet rich in certain fats has strong promoting effect on breast cancer
and that breast cancer is less common in countries where diet is low in total fat, low in
polyunsaturated fat, and low in saturated fat
 Although the relationship of breast cancer to dietary fat is unclear at this time, it is known that
reducing intake of dietary fat in postmenopausal women has a subsequent reduced risk of invasive
breast cancer
 What are the current recommendations for breast screening mammograms?
o Age? Frequency? Who’s at risk?

SUBJECTIVE DATA – HH ?’s

 In Western culture female breasts signify more than their primary purpose of lactation
o Women are surrounded by messages that feminine norms of beauty and desirability are
enhanced by and dependent on size of breasts and their appearance
o More recently, women leaders have tried to refocus this attitude, stressing women’s self-worth
as individual human beings, not as stereotyped sexual objects
o Intense cultural emphasis is slow to change
 Matters pertaining to breasts affect woman’s body image and generate emotional responses
o This emotionality may take strong forms that you observe as you discuss woman’s history
o One woman may be acutely embarrassed talking about her breasts AEB lack of eye contact,
minimal response, nervous gestures, or inappropriate humor
o Another woman may talk wryly & disparagingly about size or development of her breasts
o A young adolescent is acutely aware of her own development in relation to her peers

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o A woman who has found a breast lump may come to you with fear, anxiety, and panic
 Although many breast lumps are benign, women initially assume worst possible
outcome, including cancer, disfigurement, and death
 While you are collecting subjective data, tune in to cues for these behaviors that call for a reasoned
and straightforward attitude
Breast Questions-
1. Pain- need to differentiate from other chest area pain
2. Lump
3. Discharge
4. Rash
5. Swelling
6. Trauma
7. History of breast disease
8. Surgery including implants, augmentation
9. Self-care behaviors
10. Perform breast self-examination and how often
11. Last mammogram
Axilla
1. Tenderness, lump, or swelling
2. Rash

Subjective Data: Additional history for preadolescent girl

 Have you noticed your breasts changing?
 How long has this been happening?
 Many girls notice other changes in their bodies too, that come with growing up
o What have you noticed?
 What do you think about all this?
Subjective Data:Additional history for menopausal woman
 Have you noticed any change in breast contour, size, or firmness?
 Change may not be as apparent to obese woman or to woman whose earlier pregnancies already
have produced breast changes
Subjective Data: Risk profile for breast cancer
 Breast cancer is second major cause of death from cancer in women
o However, early detection and improved treatment have increased survival rates
o The 5-year survival rate for localized breast cancer has increased from 78% in 1940s to 98%
today
o If cancer has spread regionally, survival rate is 88%

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OBJECTIVE DATA
Preparation for Physical Exam
 Position
o Draping
 Equipment Needed
o Small pillow
o Ruler marked in centimeters
o Pamphlet or teaching aid for BSE

The Breasts - Inspect

 General Appearance- size, shape, symmetry
 Skin
 Lymphatic Drainage areas
 Nipple
o Supernumerary nipple (third nipple) is normal variation, it is from the central epidermal
ridges develop (like other mammals)

The Axillae - Inspect and Palpate

 Skin
 Palpation technique
 Lymph node

The Breasts - Palpate

 Position
 Technique of palpation
o Use pads of fingers
 Can use circular motion, lawnmower pattern, radial pattern, etc. (Look at pictures)
o Best to do BOTH- sitting and lying down
o Expected breast tissue findings to vary acrossage groups
 Nipple
 Bimanual palpation

If any lump present, note:

1. Location
2. Size
3. Shape
4. Consistency
5. Mobility
6. Distinctness
7. Nipple retraction
8. Overlying skin
9. Tenderness
10. Lymphadenopathy

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Retraction Maneuvers
(Use to observe changes in contour, symmetry, retraction, & dimpling associated with CA)
 Observe breasts with hands at sides
 Lift arms overhead
 Push hands on hips
 Push palms together
 Lean forward (to see underside of large breasts)

TEACH BREAST SELF-EXAM (BSE)

 Schedule of self-exam: Soon (7-10 days after start of period or use “birthday” date)
 Describe correct technique
 Supine or standing
 Shower is good time to check
 One arm behind head
 Fingerpads of 3 middle fingers
 Up-and-down or strip pattern
 Remember to inspect in front of mirror
 Have patient return demonstration

Breast Examination Objective Data:Aging woman

 On inspection, breasts look pendulous, flat, and sagging
 Nipples may be retracted but can be pulled outward
 On palpation, breasts feel more granular; terminal ducts around nipple feel more prominent and
stringy
 Thickening of inframammary ridge at lower breast is normal, and feels more prominent with age
 Reinforce value of BSE
 Women over 50 years old have increased risk of breast cancer
 Older women may have problems with arthritis, limited range of motion, or decreased vision that
may inhibit self-care
 Suggest aids to self-examination; for example, talcum powder helps fingers glide over skin

Sample Charting
FEMALE
 SUBJECTIVE: States no breast pain, lump, discharge, rash, swelling, or trauma. No history of breast
disease herself; does have mother with fibrocystic disease. No history of breast surgery. Never been
pregnant. Performs BSE monthly.
 OBJECTIVE
 Inspection: Breasts symmetric. Skin smooth with even color and no rash or lesions. Arm movement
shows no dimpling or retractions. No nipple discharge, no lesions.
 Palpation: Breast contour and consistency firm and homogeneous. No masses or tenderness. No
lymphadenopathy.
 ASSESSMENT
 Healthy breast structure
 Has knowledge of breast self-examination
MALE
 SUBJECTIVE: No pain, lump, rash, or swelling.
 OBJECTIVE
 No masses or tenderness. No lymphadenopathy.

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Abnormal Findings
Lactation Abnormalities:
 Clogged Duct- This is common when milk is not removed completely because of poor latching,
ineffective suckling, infrequent nursing, or switching to second breast too soon. There is a tender
lump that may be reddened and warm to touch. No infection.
 Breast Abscess- infection in breast
 Mastitis- This is uncommon; an inflammatory mass before abscess formation. Usually occurs in
single quadrant. Area is red, swollen, tender, very hot, and hard, here forming outward from areola
upper edge in right breast. The woman also has a headache, malaise, fever, chills, sweating, increased
pulse, flulike symptoms. May occur during first 4 months of lactation from infection or from stasis
from plugged duct.

Signs of Nipple Retraction and Inflammation:

 Dimpling- a shallow dimple (also called a skin tether) is a sign of skin retraction. Cancer causes
fibrosis, which contracts the suspensory ligaments. The dimple may be apparent at rest, with
compression, or with lifting of the arms.
o Nipple retraction- The retracted nipple looks flatter and broader, like an underlying crater.
A recent retraction suggests cancer, which causes fibrosis of the whole duct system and pulls
in the nipple. It also may occur with benign lesions such as ectasia of the ducts. Do not
confuse retraction with the normal long-standing type of nipple inversion, which has
no broadening and is not fixed.
 Deviation in Nipple Pointing- An underlying cancer causes fibrosis in the mammary ducts, which
pulls the nipple angle toward it.
 Edema (Peau d’Orange)- Lymphatic obstruction produces edema. This thickens the skin and
exaggerates the hair follicles, giving a pigskin or orange-peel look. This condition suggests cancer.
Edema usually begins in the skin around and beneath the areola, the most dependent area of the
breast.
 Fixation- Asymmetry, distortion, or decreased mobility with the elevated arm maneuver. Often seen
in cancer.

Breast Lumps:
 Benign “Fibrocystic” Breast Disease- Multiple tender masses that occur with numerous symptoms
and physical findings:
o Swelling and tenderness (cyclic discomfort)
o Mastalgia (severe pain, both cyclic and noncyclic)
o Nodularity (significant lumpiness, both cyclic and noncyclic)
o Dominant lumps (including cysts and fibroadenomas)
o Nipple discharge (including intraductal papilloma and duct ectasia)
o Infections and inflammations (including subareolar abscess, lactational mastitis, breast
abscess, and Mondor disease)
 Many women have some form of benign breast disease. Nodularity occurs bilaterally;
regular, firm nodules are mobile, well demarcated, and feel rubbery like small water
balloons. Pain may be dull, heavy, and cyclic as nodules enlarge. Some women have
nodularity but no pain and vice versa. Cysts are discrete, fluid-filled sacs. Dominant
lumps and nipple discharge must be investigated carefully. Nodularity itself is not
premalignant but produces difficulty in detecting other cancerous lumps.
 Fibroadenoma- benign tumors. Solitary nontender mass that is solid, firm, rubbery, and elastic.
Round, oval, or lobulated; 1 to 5 cm. Freely movable, slippery; fingers slide it easily through tissue.
Usually no axillary lymphadenopathy. Tends to be more discrete, mobile and regular border
than cancer.

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 Cancer- Solitary, unilateral, nontender mass. Single focus in one area, although it may be
interspersed with other nodules. Solid, hard, dense, and fixed to underlying tissues or skin as cancer
becomes invasive. Borders are irregular and poorly delineated. Grows constantly. Often painless,
although the person may have pain. Most common in upper outer quadrant.

Differentiating Breast Lumps:

Fibroadenoma Benign Breast Disease Cancer
Lumpier breast tissue
that is normal
Likely age 15-30 years, can occur 30-55 years; decreases 30-80 years, risk
up to 55 years after menopause increases after 50 years
Shape Round, lobular Round, lobular Irregular, star-shaped

Consistency Usually firm, rubbery Firm to soft, rubbery Firm to stony hard

Demarcation Well demarcated, clear Well demarcated Poorly defined

margins
Number Usually single Usually multiple; may be Single
single
Mobility Very mobile, slippery Mobile Fixed

Tenderness Usually none Tender; usually Usually none, can be

increases before menses; tender
may be noncyclic

Skin retraction None None Usually

Pattern of growth Grows quickly and Size may increase or Grows constantly
constantly decrease rapidly; cyclic
with menstrual periods
Risk to health Benign—Diagnose by Benign, although general Serious, needs early
ultrasound and biopsy; lumpiness may mask treatment
may spontaneously other cancerous lump
resolve in women <20
years.
Should be resected in
women >35 years as it
carries a small risk of
associated cancer.

Male Breast Abnormalities:

Gynomastia- Benign enlargement of male breast that occurs when estrogen concentration exceeds
testosterone levels.
Male Breast Cancer- 1% of breast cancer.

Websites of Interest
American Cancer Society, http://www.cancer.com
Breastfeeder task force of Greater LA, http://breastfeedingtaskforla.org

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La Leche Leauge, http://lalecheleague.org

National Breast Cancer Foundation, http://nationalbreastcancer.org
National Cancer Institute Breast Cancer http://www.cancer.gov/cancertopics/types/breast
Oncology Nursing Society, http://www.ons.org
Susan G. Komen for the Cure, http://www.komen.org
Cancer Survivors Network (American Cancer Society), http://www.asccsn.org/

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