HISTORY. Assess the patient's and family's previous medical history of breast cancer or other cancers. Obtain a detailed history of hormonal and reproductive sequences and medications (specifically hormonal supplements). Assess lifestyle variables such as diet, exercise, alcohol use, and occupational history. Determine how, when, and by whom the lump was found (breast self-examination [BSE], mammogram, accident) and if any discharge from the breast was noted. Ask how much time elapsed between finding the lump and seeking professional care in order to estimate the length of time the tumor has been present. Proceed with the systemic review with attention to areas where metastasis is common.

PHYSICAL EXAM. Inspect the breast skin for signs of advanced disease: the presence of inflammation, dimpling, orange peel effect, distended vessels, and nipple changes or ulceration. Palpate both breasts to evaluate the tissues and identify the mass. Examine the axillary and supraclavicular areas for enlarged nodes. You may note the tumor is firm and immovable. Assess the patient for pain or tenderness at the tumor site.

PSYCHOSOCIAL. Patients present a wide range of responses: denial, fighting spirit, hopelessness, stoic acceptance, anxious preoccupation. Elicit a careful and ongoing assessment of the patient's feelings (anger, depression, anxiety, fear) and body image concerns. Identify the patient's perceptions of how breast cancer will affect her role relationships, lifestyle, femininity, and sexuality. Be sure to include the husband or significant other and children in the psychological assessment to learn of their emotional needs.

Diagnostic Highlights

General Comments: Because early diagnosis and treatment increases survival, the American Cancer Society recommends the following guidelines for early breast cancer detection:

• Women age 40 and older should have a screening mammogram every year and should continue to do so for as long as they are in good health.

• Women in their 20s and 30s should have a clinical breast examination (CBE) as part of a periodic health examination by a health professional preferably every 3 years. After age 40, women should have a breast examination by a health professional every year.

• BSE is an option for women, starting in their 20s. Women should be told about the benefits and limitations of BSE. Women should report any breast changes to their health professional right away.

• Women at increased risk should talk with their doctors about the benefits and limitations of starting mammograms when they are younger, having additional tests (e.g., ultrasound or magnetic resonance imaging [MRI]), or having more frequent examinations.

Test	Normal Result	Abnormality with Condition	Explanation
Mammogram	No tumor noted	Radiodense or white mass noted	An x-ray of the breast; can only suggest a diagnosis of cancer
Ultrasound of the breast	No evidence of cyst or tumor	Appearance of a white lesion	Can differentiate between cystic and solid lesions; targets specific area
Biopsy: Fine-needle aspiration, stereotactic core needle, Mammotome, excisional	Benign	Malignant	Confirms the diagnosis

Other Tests: Computed tomography (CT) scan; MRI; estrogen receptor (ER) assay and progesterone receptor (PR) assay; flow cytometry; DNA ploidy; full-field digital mammography (recently approved by U.S. Federal Drug Administration but not widely used); computer-aided detection and diagnosis; ductogram.