A woman must be disrobed from the waist up for a complete breast examination. Although attention to modesty is appropriate, and a gown or drape should be provided, inspection is an important part of the examination, and subtle abnormalities are best appreciated by comparing the appearance of both breasts. Breast examination should be done with the patient in both the sitting and supine positions, and care should be taken at all times to be gentle. The steps of a breast examination are illustrated in Figure 3-1.

The breasts should initially be inspected while the patient is in the sitting position with the arms relaxed (Fig. 3-1A). A comparison of breast size and shape should be made. If a size discrepancy is noted, its chronicity should be determined. Many women’s breasts are not identical in size, and the finding of small size discrepancies is rarely a sign of malignancy. Differences in breast size that are of recent onset or progressive in nature, however, may be owing to both benign and malignant tumors, and require further evaluation (Fig. 3-2). Alterations in breast shape, in the absence of previous surgery, are of more concern. Superficially located tumors can cause bulges in the breast contour or retraction of the overlying skin. The skin retraction seen with superficial tumors may be caused by direct extension of tumor or fibrosis. Tumors deep within the substance of the breast that involve the fibrous septa (Cooper’s ligaments) can also cause retraction. Retraction is not itself a prognostic factor except when caused by the direct extension of tumor into the skin and, for this reason, it is not a part of the clinical staging of breast cancer (2). Although retraction is often a sign of malignancy, benign lesions of the breast, such as granular cell tumors (3) and fat necrosis (4), also cause retraction. Other benign causes of retraction include surgical biopsy and thrombophlebitis of the thoracoepigastric vein (Mondor’s disease) (5) (Fig. 3-3).