The Breast Examination: Sensitivity and Technique in Equal Measure
The breast examination OSCE tests two things simultaneously: your clinical technique and your ability to conduct an intimate examination with sensitivity, professionalism, and respect. Examiners will deduct marks if you do not explain what you are doing, do not offer a chaperone, or fail to maintain patient dignity throughout.
The most common scenario is a patient with a breast lump or asymmetry. Your job is to examine systematically, characterise any lump fully, assess the lymph nodes, and present your findings with a differential diagnosis.
💡 Tip
Before you begin: "I'd like to examine your breasts — this will involve me looking and then feeling, including your armpits. I'd like to offer you a chaperone — would you like someone else present? I'll explain everything I'm doing as I go. Could you undress to the waist please and sit on the edge of the couch?"
Part 1: Inspection
Inspect with the patient sitting upright, arms by their sides, in good light. Then repeat with arms raised above the head, then hands pressed on hips (tensing the pectorals).
What to Look For
| Sign | Clinical significance |
|---|---|
| Asymmetry | Size difference; distortion of normal contour |
| Skin changes | Peau d'orange (orange-peel skin = lymphoedema from blocked dermal lymphatics → carcinoma) |
| Dimpling / tethering | Skin tethering to underlying mass → malignancy (Cooper's ligaments invaded) |
| Erythema | Inflammatory carcinoma, abscess, mastitis |
| Nipple inversion | If new and unilateral → malignancy; if longstanding bilateral → normal variant |
| Nipple discharge | Note whether it appears spontaneously |
| Prominent veins | Unilateral dilated veins → increased blood flow (rapidly growing tumour) |
| Previous scars | Biopsy, lumpectomy, mastectomy, augmentation |
The importance of arm positions:
- Arms raised: Tethering and skin dimpling become more obvious as the breast lifts
- Hands on hips: Contracting the pectorals accentuates dimpling if the mass is attached to the pectoral fascia
💎 Clinical Pearl
Peau d'orange is caused by lymphatic obstruction of the skin from an underlying cancer. The skin oedema causes the follicular openings to become depressed relative to the oedematous skin, creating an orange-peel appearance. It is a sign of locally advanced breast cancer.
Part 2: Palpation
Ask the patient to lie supine with their ipsilateral hand behind their head (this flattens the breast tissue over the chest wall, making palpation easier). Use the flat of your fingers (pads, not tips) with a gentle rotary motion. Never pinch the breast tissue.
Systematic Palpation Technique
Cover the entire breast using one of these two systematic methods:
Concentric circles: Start at the nipple and work outwards in enlarging circles until you reach the periphery.
Radial sectors: Divide the breast into quadrants and palpate each — upper outer (most common site for cancer), upper inner, lower outer, lower inner, and the axillary tail of Spence (breast tissue extending into the axilla).
💡 Tip
Always palpate the normal side first. This gives you a baseline for that patient's normal breast texture (which varies enormously between individuals) and is more comfortable psychologically for the patient.
Characterising a Lump
If you find a lump, describe it systematically using SWIFT:
| Letter | What to assess |
|---|---|
| Site | Which quadrant? Distance from the nipple? |
| What it feels like | Consistency: soft, firm, hard, rubbery |
| Irregularity | Smooth (fibroadenoma, cyst) vs irregular (carcinoma) |
| Fixity | Mobile (fibroadenoma — "breast mouse") vs tethered to skin or fixed to chest wall (malignant) |
| Tenderness | Tender = cyclical change, cyst, abscess; non-tender = more suspicious |
🧠 Mnemonic
Malignant vs benign lump features: "MISFITS vs SMILES"
MISFITS (suspicious for cancer):
- Malignant (hard)
- Irregular surface
- Skin tethering
- Fixed / not mobile
- Infiltrating edge (ill-defined)
- Tenderness absent
- Single
SMILES (reassuring benign features):
- Smooth
- Mobile ("breast mouse")
- Isolated from skin
- Lobed / lobulated (fibroadenoma)
- Elastic / soft
- Sometimes tender (cyst, fibroadenosis)
Nipple Examination
Gently palpate behind the nipple/areola. Then, if clinically indicated:
- Gently squeeze the nipple — note any discharge: colour, consistency, unilateral or bilateral, from one duct or multiple
- Bloody discharge from a single duct → intraductal papilloma or carcinoma — urgent referral
- Green/brown bilateral discharge → fibrocystic change — benign
- Milky discharge → galactorrhoea — check prolactin, medications (antipsychotics, metoclopramide)
Part 3: Axillary Lymph Node Assessment
The axilla has five groups of nodes. Stand facing the patient, support their arm with your hand (this relaxes the pectorals and opens the axilla), and use your free hand to palpate:
| Node group | Location | Significance |
|---|---|---|
| Central | Apex of axilla — most commonly palpable | Breast cancer metastasis — most commonly involved first |
| Anterior (pectoral) | Along the lateral border of the pectoralis minor | Breast and chest wall drainage |
| Posterior (subscapular) | Along the posterior axillary fold | Breast and posterior thoracic wall |
| Lateral (brachial) | Along the medial aspect of the humerus | Arm and hand drainage |
| Infraclavicular | Below the clavicle | Advanced nodal disease |
If nodes are palpable: note size, number, consistency (hard = metastasis; soft, tender = reactive infection), and whether they are matted (stuck together — suggests extranodal tumour spread).
Also palpate the supraclavicular fossa — supraclavicular lymphadenopathy (Virchow's node on the left) indicates advanced disease (N3 staging).
Common Breast Lump Differentials
| Diagnosis | Typical patient | Key features |
|---|---|---|
| Fibroadenoma | Young woman 15–35 | Smooth, mobile, firm, non-tender — "breast mouse" |
| Cyst | 35–55 (perimenopausal) | Smooth, well-defined, fluctuant, may be tender |
| Breast cancer | Older woman (any age) | Hard, irregular, tethered, non-tender, possible lymphadenopathy |
| Abscess | Lactating woman, or periareolar in smokers | Red, hot, tender, fluctuant |
| Fat necrosis | Post-trauma or post-surgery | Irregular, hard — can mimic cancer |
| Lipoma | Any age | Soft, lobulated, non-tender, mobile |
How to Present Findings
"On inspection with the patient seated, there was a visible asymmetry in the upper outer quadrant of the left breast, with skin dimpling on raising the arms. On palpation, there was a 2 cm hard, irregular, non-tender lump in the upper outer quadrant of the left breast, approximately 5 cm from the nipple. It appeared fixed to the overlying skin with tethering on movement, but I could not demonstrate fixation to the chest wall. The right breast was normal. Axillary assessment revealed two firm, non-tender, matted lymph nodes palpable in the left axilla. There was no supraclavicular lymphadenopathy. The nipple was not inverted and there was no discharge. These findings are highly suspicious for left breast carcinoma with possible axillary lymph node involvement. I would refer urgently under the 2-week-wait pathway for triple assessment — clinical examination, imaging (mammogram ± ultrasound), and needle biopsy."
Common Examiner Follow-Up Questions
"What is triple assessment and why is it used?"
"Triple assessment is the gold standard investigation of any breast lump. It combines three modalities because each has limitations alone, but together they have a sensitivity and specificity approaching 100% for breast cancer. The three components are: clinical assessment (history and examination — scored on a 1–5 scale: 1 = normal, 5 = highly suspicious); imaging (mammography in women over 35, ultrasound in younger women where dense breast tissue makes mammography less sensitive — ultrasound also helps differentiate cystic from solid lesions); and tissue sampling (fine needle aspiration cytology for cysts and quick results, or core needle biopsy which provides histology and receptor status — oestrogen, progesterone, HER2). All three are reported on a 1–5 scale and the overall management decision is based on the combined triple assessment result."
"A 26-year-old woman presents with a smooth, mobile, non-tender lump in the right breast. What is the most likely diagnosis and how do you manage it?"
"In a young woman, the most likely diagnosis is a fibroadenoma — a benign, hormonally responsive tumour of breast stroma and lobular epithelium, colloquially known as a breast mouse due to its characteristic mobility. It is the most common benign breast tumour in women under 30. Triple assessment should still be performed — the clinical score would likely be P2 (benign), imaging would show a well-defined homogeneous mass, and core biopsy would confirm fibroadenoma histology. If triple assessment is reassuring and the lump is under 4 cm, conservative management with 6-monthly review is appropriate — around 30% of fibroadenomas regress spontaneously over 2 years. Surgical excision is offered if the lump is enlarging, over 4 cm, causing significant distress, or if triple assessment is equivocal."
"What are the risk factors for breast cancer?"
"The main risk factors are: female sex (99% of cases), increasing age (most common in women over 50 in the UK), family history of first-degree relatives with breast or ovarian cancer, BRCA1/BRCA2 gene mutations (lifetime risk up to 85%), previous breast cancer or DCIS, prolonged oestrogen exposure (early menarche, late menopause, nulliparity, late first pregnancy, combined OCP, hormone replacement therapy), dense breast tissue, previous chest wall irradiation (e.g. for lymphoma in young women), and obesity in post-menopausal women (peripheral oestrogen synthesis in adipose tissue). Lifestyle factors include alcohol consumption and lack of physical activity. Protective factors include breastfeeding and parity."
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