As a GP registrar, you play an important part in the battle against breast cancer, the second most prevalent cancer and cause of death in Australian females. Your role encompasses prevention, treatment and support. That’s why it’s essential you feel comfortable performing breast exams, and know what to look for, as well as how to support those diagnosed.
In this article, Dr Michelle Warman shares her top ten tips for conducting breast examinations, gleaned from her work at St Vincent’s Northside Breast Health Centre, and from her time in general practice.
Michelle’s background working in the breast cancer space
Alongside her medical education duties in GPTQ’s Brisbane North district, Michelle is also a practising GP at Albany Creek with a special interest in breast diseases, including cancer. For the past four years, she has enjoyed a weekly stint at St Vincent’s Northside Breast Health Centre, a clinic that offers a combination of screening, diagnostic imaging, biopsy and surgery.
She says: “I’m one of five breast physicians at the clinic, and we’ve all done additional training to work in the role. It’s an interesting field and one that dovetails nicely with general practice. I still use all of my GP skills, but have gained a significant amount of insight into radiology, particularly in understanding imaging; as well as interacting with a range of specialists involved in the management of breast cancer and other breast diseases. It’s really stimulating work.”
Michelle’s top 10 breast cancer examination tips
- Understand that breast cancer presents differently
“There’s a great image online using lemons in an egg carton to represent the different potential presentations of breast cancer. It’s important to keep in mind that many breast cancers are not clinically evident, and your patient may not have any symptoms. That’s why screening is an essential part of women’s health management, and very effective at picking up those cancers that are not yet evident,” she says.
Michelle recommends encouraging your patients to take advantage of BreastScreen Australia’s free screening service for those aged 45 and over. They may be able to start earlier at 40, especially if there is a family history of breast cancer. The screening should be repeated every two years at minimum.
- Treat a breast exam the same as any intimate examination
“It’s important to first ensure your patient is comfortable. If you feel it necessary, you can ask them if they’d like a chaperone, such as your supervisor or practice nurse. Then approach the examination as you would any other. Washing your hands in warm water, especially during winter, and always explaining to the patient what you’re doing as you go,” she says.
Michelle also believes in the merits of getting your breast examination routine down pat to ensure you’re comfortable.
“You would have already done quite a bit of training in this area, but there are some good resources online detailing breast examination techniques, or you can ask your supervisor if you’re still uncertain. Essentially, breast examinations should cover all of the breast and accessory tissue. They should involve both lying and seated positions, as well as asking the patient to move their arm while upright, so you can examine how the breast tissue moves,” she explains.
Michelle says the best way to get comfortable is by practising your routine as often as possible, even if it’s just in your head, as it then becomes second nature.
- Educate your patients to be ‘breast aware’
Another essential part of your role as a GP is to encourage your patients to be breast aware, especially as Michelle says this is the ‘most effective way of picking up early clinical changes’.
Michelle often uses humour, telling her patients to ‘get to know the girls’ by brushing their teeth topless or jumping up and down in front of a mirror, so they know what their breasts look like when they move and what is normal for them.
“I encourage them to examine their breasts when they’re in the shower, standing up, lying down and at different times of the month. This way they can be aware of any changes. My biggest message to them is, ‘If it changes, get it checked by your GP.’”
- Make sure you cover all these ‘history’ bases during your breast exam
“It’s vital you take a thorough history, particularly if the patient presents with a breast complaint. Is there a cyclical component? Are they overweight, a smoker, on HRT or the combined oral contraceptive pill? Do they have a family history of cancer? Where and when did they last have their imaging done? It’s also important to document their pregnancy history, age of onset of menses and menopause, and whether they breast fed,” Michelle says.
- Write down what you feel as well as what the patient says
Michelle is a big advocate of encouraging registrars to write down findings after performing a breast exam, both in your notes and on imaging forms, as well as the symptoms your patient describes as ‘they can be two different things’.
“The patient might come in saying, ‘I’ve got this lump under my right arm’, but you might not be able to feel it. Still write it down, ‘Patient is concerned about a lump in their right armpit. Not palpable today but I did notice some thickening in the left breast.’ When you then send the patient off for imaging, the radiologist then gets the full story,” she says.
“The more information you can give them in your referral, the better they can interpret the results and give valuable feedback. You can then clearly explain to the patient the cause of their symptoms, even if normal findings are made, and allay their concerns.”
- If a patient notices a change in their breasts, do a ‘triple investigation’
“If your patient presents with symptoms such as breast lumps, a discharging nipple, a painful breast, thickening or a tethering, or they just say ‘my breast or nipple feels a bit odd’, then you need to do a triple investigation, which is an examination followed by imaging and a biopsy if indicated,” she says.
“Imaging can be done at either a radiology provider, breast health centre or hospital offering diagnostic services. Breastscreen Queensland just do screenings. While they will work up anything they find on a screening, they are not a diagnostic service, so you can’t send patients to them if they present with a symptom,” she says.
- Ensure you’re connected with the right allied professionals in your area
“Investigate if there are any radiologists in your area that do a lot of breast work. This is a really great way to ensure your patients are getting the best service available,” Michelle says.
With some patients, affordability comes into play so you need to keep this in mind too.
“There are a number of suburban radiology groups that provide bulk billing imaging and sometimes diagnostics, even if they aren’t breast specialists. Certainly anyone who has a breast symptom can be referred to diagnostic imaging at the Royal Brisbane Women’s Hospital to get a full workup done too.”
- Always image both breasts
If a patient presents with a breast symptom, Michelle says it’s important to get a mammogram or ultrasound done in both breasts, not just the symptomatic one.
“It’s vital to be able to compare both sides. Another good tip is to write down ‘plus or minus biopsy’ on the imaging form. That can expedite the biopsy that may need to follow.”
- Consider doing baseline imaging
Michelle encourages GPs and registrars to ‘watch this space’ in relation to emerging evidence about breast density being a risk factor for breast cancer.
“At our clinic, we screen women aged between 40 and 50 every year as that’s when their breast tissue is changing, but still dense. I would recommend registrars encourage their patients to get a baseline mammogram or ultrasound done at this time, particularly if they have risk factors. As their GP, you then have a clearer idea of how dense and complex their breasts are. It can be an extremely useful comparative tool in years to come, and also allows for an individual screening plan to be developed,” Michelle explains.
- Make sure you have adequate time when supporting a patient with a breast cancer diagnosis
There are a number of ways patients are diagnosed with cancer, Michelle says. They may have already been told and are coming to you for follow-up and support, or are returning to you for investigation results.
“One of the most important things when breaking bad news is that you have enough time. Ideally you would ask your patient to book a longer appointment to discuss results when they return. If this hasn’t happened, let reception or your supervisor know you might be delayed. They might be able to juggle later patients to allow you the time you need,” she suggests.
“Listen to your patient’s concerns and address what you can. It’s okay to say ‘I don’t know what chemotherapy you’re going to have, or what it will do to your hair or your nails, but I can find out for you.’ Be their advocate and get that information from their specialist so you can relay it back in layman’s terms.”
Michelle says it’s also imperative to only answer the question they ask, rather than give them information they may not want.
“Some women don’t want to know anything. They just want to get their treatment over with so they can get on with their lives. Others want to know all the ins and outs of what’s going to happen to them. There’s plenty of online resources that will help you, such as Breast Cancer Network Australia or Westmead Breast Cancer Institute. But realistically, when it comes to counselling, it’s all about giving patients time and empathy.”
Extra tip: screening your male and transgender patients for breast cancer
Men have a much lower risk of breast cancer, so are not routinely screened. However, those with a family history should still understand the need for self-examination.
“When men come in for a midlife health check around 45 – 50 years, take this opportunity to raise awareness that men can get breast cancer too, particularly if they have risk factors. This can be a good time to encourage them to check their chest and breasts, and to come and see you if they notice a change.”
As for transgender women, Michelle says it’s no different to the current guidelines for non-transgender women.
“I’d be encouraging those anywhere upwards of 40 to 45 to undergo breast imaging screening, and then follow guidelines accordingly, which are regular self-examinations and seeing their GP if changes occur,” she says.