Methods and Positions in Performing BSE:

1. Inspection before a Mirror

Look for any change in size or shape; lumps or thickenings; any rashes or other skin
irritations; dimpled or puckered skin; any discharge or change in the nipples (e.g.
position or asymmetry). Inspect the breasts in all of the following positions:

1.1 Stand and face the mirror with your hands resting on the hips; then turn to the right
and the left for a side view.
This will allow you to observe for any flattening or dimpling on the peripheral areas
of the breasts; repeatedly alternating the left and the right side aids in checking for
lateral symmetry.



1.2 Bend forward from the waist and raise your arms over your head.
With the breasts not resting or flattened on your chest wall, it will accentuate
any changes in shape or size.

1.3 Still facing the mirror, raise both arms over your head to inspect for skin or nipple
retraction.
Such movements can cause the contraction of anterior chest muscles and
stretch the breast ligament

1.3 Press your hands firmly down on your hips and again, look at your breasts for any
changes of size, shape, contour, or dimpling.
The pressing down on the hips position contracts the chest wall muscles and
enhances any breast changes.

1.4 Check your nipples for discharge (fluid). Place your thumb and forefinger on the
tissue surrounding the nipple and pull outward toward the end of the nipple. Look for
any discharge. If discharge is present, milk the breast along its radii. Assess discharge for
amount, color, consistency, and odor. Repeat on your other breast.
The pressing motion pushes any fluid, if any, from the opening. Pulling on the
nipple enables you to assess its elasticity and consistency. Milking the breast
along its radii enables you to identify the lobe producing discharge.









2. Palpation: Lying Position

2.1 Place a pillow under your right shoulder and place the right hand behind your head.
This position allows the breast tissue to spread evenly over the chest wall as
thinly as possible, making it much easier to feel all the breast tissue.
The shoulders can be elevated by a small pillow placed under them to allow
the breasts to rest more symmetrically on the chest wall for more detailed and
convenient examination.

2.2 Mark imaginary lines around the breast. Take the nipple as the central point, a
horizontal line and a vertical line through the central point departs the breast into four
quadrants.
This makes it convenient to locate the lesion or masses if any.

2.3 Use the finger pads of the 3 middle fingers (held together) on your left hand to feel
for lumps.
The pads of the fingers are used because their concentration of nerve endings
makes them highly sensitive to tactile discrimination.

2.4 Press the breast tissue against the chest wall firmly enough to know how your breast
feels. A ridge of firm tissue in the lower curve of each breast is normal.

2.5 Use small, circular motions systematically all the way around the breast as many
times as necessary until the entire breast is covered.
Start and end at a fixed point to ensure that all breast surfaces are assessed.

2.6 The left breast should be palpated from the upper lateral quadrant, with a
procedure of clockwise direction for thorough examination, The same procedure is
adopted for palpation of the right breast with anti-clockwise direction.
Pay particular attention to the upper outer quadrant area and the tail of Spence.
About 50% of breast cancers develop in the upper outer quadrant area
and in the tail of Spence.


2.7 Each quadrant is palpated superficially and then deeply, and the nipple is palpated
finally.


Note: Vary the levels of the pressure as you palpate:
Light superficial
Medium mid-level tissue

Light palpation should always precede deeper palpation because heavy
pressure on the fingertips can dull the sense of touch.

2.8 Repeat the steps on your left breast.



3. Palpation: Standing or Sitting

3.1 the steps are similar with that of palpating supine. Perform the examination while
upright (sitting or standing) with one arm raised behind your head.
This position makes it easier to check the area where a large percentage of
breast cancers are found, the upper outer part of the breast and toward the armpit.

3.2 Palpate the axillary, subclavicular and supraclavicular lymph nodes. Examine each
underarm while sitting up or standing and with your arm only slightly raised so you can
easily feel in this area.
The axilla, supraclavicular region and neck should be palpated carefully, to
detect any enlargement of lymph nodes or other abnormalities; these areas are
usually involved in inflammatory lesion.
Raising your arm straight up tightens the tissue in this area and makes it very
difficult to examine.













NORMAL AND ABNORMAL FINDINGS WHEN PERFORMING SELF-BREAST EXAMINATION
ASSESSMENT NORMAL ABNORMAL SIGNIFICANCE



Size and
Symmetry
Breasts can be a
variety of sizes and
are somewhat
round and
pendulous. One
breast may be larger
than the other.
A recent increase in size of
one breast
Inflammation or
abnormal growth

Peau d orange appearance
Results from edema
which is seen in
metastatic breast
cancer
Clients breasts
should rise
symmetrically with
no sign of dimpling
or retraction.
Dimpling or retraction
usually caused by malignant
tumor that has fibrous
strands attached to the
breast tissue and fascia of
the muscles.
Usually caused by
malignant tumor that
has fibrous strands
attatched to the
breast tissue and
fascia of the muscles



Color and
Texture
Color varies
depending on the
clients skin tone.
Texture is smooth
with no edema.
Redness Associated with
breast inflammation.
Linear stretch marks
may be seen during
or after pregnancy
or when there is
significant weight
loss.




Superficial
Venous Pattern
Veins radiate either
horizontally and
towards the axilla
(transverse) or
vertically with a
lateral flare
(longitudinal). Veins
are more prominent
during pregnancy.
A prominent venous pattern

May occur as a result
of increased
circulation due to a
malignancy.
An asymmetric venous
pattern
May be due to
malignancy.



ASSESSMENT NORMAL ABNORMAL SIGNIFICANCE


Areolas
Areolas vary from
dark pink to dark
brown, depending
on the clients skin
tone. They are
round and may vary
in size. Small
Montgomery
tubercles are
present.
Peau d orange skin may be
first seen in the areola.
Results from edema
which is usually seen
in metastatic breast
malignancy.

Red, scaly, crusty areas

Indicative of Pagets
disease



Nipples
Nipples are equally
bilateral in size and
are in the same
location of each
breast. Nipples are
usually everted but
they may be
inverted or flat.
Supernumerary
Nipples may appear
along the embryonic
milk line.

A recently retracted nipple
that was previously everted

May suggest
malignancy
Any type of
spontaneous
discharge should be
referred for cytologic
study and further
evaluation.

Texture and
Elasticity
Smooth, firm, elastic
tissue
Older clients
breasts may feel
more granular

Thickening of tissues

May suggest
underlying malignant
tumor



Tenderness and
Temperature
A generalized
increase in
nodularity and
tenderness may be
a normal finding
associated with the
menstrual cycle or
hormonal
medication. Breasts
should be a normal
body temperature.

Painful breasts


Indicative of benign
breast disease but
can also be
malignant.

Heat in the breast of
women who have not just
given birth or who are not
lactating


Inflammation
ASSESSMENT NORMAL ABNORMAL SIGNIFANCE


Presence of
Masses
No masses should
be palpated.
However, a firm
ridge may normally
be palpated at the
lower base of the
breasts.
Malignant tumors are most
often found in the upper
outer quadrant of the
breast. They are usually
unilateral, irregular, poorly
delineated borders. They
are hard and nontender and
fixed to underlying tissues.

Should be referred to
cytologic study and
further evaluation for
management.
Axillae


Inspection and
Palpation
No rash or infection
noted.

No palpable nodes
or one or two small
(less than 1cm)
discrete, nontender
moveable nodes in
the central area.
Enlarged (greater than 1cm)
lymph nodes may indicate
infection of the hand or
arm.
May indicate
infection of the hand
or arm.


Large nodes that are hard or
fixed to the skin may
indicate an underlying
malignancy.

May indicate an
underlying
malignancy.