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US Public Health Service. Office of Disease Prevention and Health Promotion. Clinician's Handbook of Preventive Services. 2nd edition. Washington (DC): Department of Health and Human Services (US); 1999.

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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Clinician's Handbook of Preventive Services. 2nd edition.

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30Cancer Detection By Physical Examination

Cancer will eventually develop in approximately 30% of Americans; three of every four families will be affected. Many cancers can be cured if they are detected early and treated in the early stages. See Table 30.1 for data on the incidence and mortality of major types of cancer.

Table 30.1. Leading Sites of Cancer Incidence and Death -- 1997 Estimates *.

Table

Table 30.1. Leading Sites of Cancer Incidence and Death -- 1997 Estimates *.

This chapter presents information regarding detection of several cancers through physical examination. Screening tests for early detection of specific cancers are addressed in separate chapters.

Breast Examination

Cancer of the breast can manifest as visual and physical changes of the breast and axilla. Most clinical trials have evaluated the effectiveness of screening for breast cancer in women with either mammography alone or mammography combined with clinical breast examination (CBE). No direct evidence suggests superior effectiveness of CBE alone compared with no screening. When CBE is performed by a clinician, its sensitivity for detection of cancer is approximately 45%. The overall sensitivity of breast self-examination (BSE) is about 26%. The sensitivity of BSE decreases with advancing age: from 41% in women aged 35 to 39 years to only 21% for women aged 60 to 74 years. See chapter 36 for information on the epidemiology of breast cancer and screening mammography.

Recommendations of Major Authorities

Women Under 40 Years of Age

  • American Cancer Society --
  • Women should have clinical breast examinations every 3 years from age 20 to 39 years.
  • American College of Obstetricians and Gynecologists --
  • Women over age 18 years should have clinical breast examination during the periodic evaluation, yearly, or as appropriate.
  • Canadian Task Force on the Periodic Health Examination --
  • Clinical breast examination is not recommended for screening women less than 50 years of age.

Women 40 Years of Age and Over

  • American Academy of Family Physicians --
  • Mammography and clinical breast examination should be offered to women aged 50 to 69 every 1 to 2 years.
  • American Cancer Society, American College of Obstetricians and Gynecologists, and American College of Physicians --
  • Annual clinical breast examination should be performed on women 40 years of age and older.
  • Canadian Task Force on the Periodic Health Examination --
  • Clinical breast examination screening should be performed annually on women 50 to 69 years of age. Clinical breast examination should be used in conjunction with mammography for screening.
  • US Preventive Services Task Force --
  • Breast cancer screening should be performed in women 50 to 69 years of age through mammography every one to two years with or without annual clinical breast examination. There is insufficient evidence to recommend for or against clinical breast examination alone in this age group or in any other age group. Although there is insufficient evidence, recommendations to screen high risk women beginning at age 40 and women over 70 may be made on other grounds.
  • There is no evidence specifically evaluating clinical breast examination in screening high-risk women under 50 years of age; recommendations for screening such women may be made on the basis of their high burden of suffering and the higher positive predictive value of screening. There is limited and conflicting evidence of the value of clinical breast examination screening in women 70 to 74 years of age and no evidence for women over 75; however, recommendations for screening women 70 years of age and older who have a reasonable life expectancy can be made on the basis of the high burden of suffering of this age group. There is insufficient evidence to recommend the use of clinical breast exam alone, without mammography, for screening.

Basics of Breast Examination

1.

General Considerations: Breast examination involves bilateral inspection and palpation of the breasts (and areolae) and the axillary and supraclavicular areas. Perform examination while the patient is in the upright position and again in the supine position.

2.

Inspection: Visually examine the breasts under good lighting with the patient sitting or standing with her hands on her hips. Focus on the symmetry and contour of the breasts; position of the nipples; skin changes such as puckering, dimpling, or scaling of the skin; scars; nipple discharge; nipple retraction; and appearance of a mass. Note any bulging, discoloration, or edema of the lymphatic drainage areas (ie, the supraclavicular and axillary regions).

3.

Screening for Retraction: Observe the breast tissue for signs of retraction while the patient lifts her arms slowly over her head. Both breasts should move symmetrically. With the patient's arms lowered and palms pressed together at waist level, observe the breast tissue again for signs of retraction. Ask patients with large breasts to lean forward, and note the symmetric forward movement of the breasts. No evidence of fixation to the chest wall should be evident.

4.

Breast Palpation: Palpation must be systematic. Two commonly used patterns of palpation are to start with the nipple and move out radially to the periphery -- much like spokes on a wheel -- or to move outward from the nipple and around the breast in a spiral, or corkscrew, pattern. Regardless of the pattern used, be thorough, and do not miss any areas. A careful, thorough examination requires 5 to 10 minutes. Take care to palpate the tail of Spence, which extends from the upper outer quadrant to the axilla. Use the first three fingers to press firmly in a small circular motion. The amount of pressure should vary from firm, to detect deep masses, to light, to detect superficial ones. Palpate all of the breast tissue when the patient is upright and again while she is supine. First, with the woman in an upright position, palpate the breast using a bimanual technique. Support the inferior aspect of the breast with one hand while the other hand palpates the breast. Next, palpate each breast with the patient in a supine position; the arm on the side to be examined should be raised over her head.

5.

Axillary and Supraclavicular Node Palpation: Palpate the axillary and supraclavicular areas for adenopathy while the patient is sitting. While lifting and supporting the woman's arm, place the fingers high into the axilla and move them down firmly to palpate in four directions: along the chest wall, along the anterior border of the axilla, along the posterior border of the axilla, and along the inner aspect of the upper arm. It may be helpful to move the patient's arm through the full range of motion to increase the surface area that can be reached. Palpate the supraclavicular nodes while the patient is sitting and relaxed, with neck flexed slightly forward. It mayhelp to have the patient's head turned slightly toward the side being examined. The supraclavicular nodes may be felt in the angle formed by the clavicle and the sternocleidomastoid muscle.

6.

Areolae: Check the nipple for discharge by gently squeezing the nipple. Discharge is easier to elicit when the patient is in an upright position. Nipple inversion may be normal. However, changes in nipple inversion should not occur after puberty, and inverted nipples should not be fixed (ie, it should be possible to pull the nipple out).

7.

Breast Self-Examination: The American Cancer Society and the American College of Obstetricians and Gynecologists recommend encouraging women to examine their breasts every month. Instructing female patients in breast self-examination may be desirable. See "Patient Resources" for information about ordering pamphlets on breast self-examination.

Oral Cavity Examination

An estimated 30,750 new cases of oral cavity and pharyngeal cancer will be diagnosed in 1997, and approximately 8440 deaths are expected to occur during that period. Most deaths occur within 3 or 4 years of diagnosis. The incidence of oral cancer among men is more than twice that among women; the highest rates are seen among men over age 40 years. In the United States, 90% of oral cancer cases are attributable to the use of tobacco and to a lesser extent, alcohol.

Recommendations of Major Authorities

  • American Cancer Society --
  • Individuals 20 to 39 years of age should have a cancer checkup, including examination of the oral region, every 3 years; those 40 years of age and older should have one yearly.
  • American College of Obstetricians and Gynecologists --
  • Examinations of the oral cavity in women 40 years of age and older should be part of periodic health examinations performed annually, as appropriate.
  • Canadian Task Force on the Periodic Health Examination --
  • There is insufficient evidence for inclusion or exclusion of oral cancer screening in the periodic health examination. Annual examination by physicians and/or dentists should be considered for men and women over 60 years of age who have a known risk factor for oral premalignancy and invasive oral cancers, such as tobacco use in any form and regular alcohol consumption.
  • US Preventive Services Task Force --
  • There is insufficient evidence to recommend for or against routine screening of asymptomatic persons for oral cancer by primary care clinicians. Although direct evidence of a benefit is lacking, clinicians may wish to include an examination for cancerous and precancerous lesions of the oral cavity in the periodic health examination of persons who chew or smoke tobacco (or did so previously), older persons who drink regularly, and anyone with suspicious symptoms or lesions detected through self-examination. All patients, especially those over 65 years of age, should be advised to receive a complete dental examination on a regular basis.

Basics of Oral Cavity Examination

1.

General Considerations: Examination of the oral cavity is intended to identify the presence of lesions that are precancerous or may predispose to cancer. Lesions that have the potential for malignant transformation tend to be flat and white (leukoplakia), white-red (erythroleukoplakia), or red (erythroplakia). The examination should include inspection and palpation of the lips, gingivae, buccal mucosa, palate, floor of the mouth, tongue, and pharynx. If the patient is wearing dentures, these should be removed before examination. Work systematically from anterior to posterior, omitting no areas. Use a bright light for optimal visualization.

2.

Lips: Inspect the lips closely, noting symmetry, color, moisture, and the presence of cracking and lesions.

3.

Gingivae: Inspect the gums for bleeding, sponginess, and discoloration. Normal gums appear pink or coral with a stippled surface.

4.

Buccal Mucosa: Ask the patient to hold his or her mouth open widely. Holding the cheek open with a wooden tongue blade, inspect the buccal mucosa, noting color and the presence of nodules and lesions. The normal buccal surface appears pink, smooth, and moist. Leukoplakia appears as white plaque on the mucous membranes of the cheeks, gums, and tongue. Squamous cell carcinoma in its earliest stages may present as an erythematous, indurated lesion.

5.

Palate: Inspect the palate for plaques, ulceration, and masses. A normal variation is a torus palatinus, a nodular bony ridge down the middle of the hard palate.

6.

Floor of the Mouth: Closely examine the entire U-shaped area under the patient's tongue; this is the most common location for oral malignancies. Inspect the mouth for white patches, nodules, and ulcerations. Palpate the floor of the mouth bimanually with one finger under the tongue and the other hand under the jaw to stabilize the tissue, feeling for induration, thickening, and masses.

7.

Tongue: Note color, surface characteristics, and moisture. Ask the patient to touch the tongue to the roof of the mouth to permit examination of its undersurface. While the patient's tongue is protruded, gently grasp it with a piece of gauze, using the other hand to palpate the tongue. More than 85% of all lingual cancers arise in the lateral margins of the tongue. Neoplasms may limit a patient's ability to protrude the tongue. Induration and ulceration are suggestive of carcinoma.

8.

Pharynx: Depress the middle third of the patient's tongue with a tongue blade to increase visualization of the posterior pharynx. Note any asymmetry, discharge, mass, or ulceration of the pharynx.

Pelvic Examination And Ovarian Cancer

Pelvic examination is used to detect and identify cancers of the female genital tract. Use of the Pap smear testing during pelvic examination to identify cervical neoplasms and premalignant lesions (chapter 37) has been an unqualified success. Some authors have advocated performing bimanual examination during the pelvic examination to detect some pelvic neoplasms, including ovarian cancer, which has the highest mortality of all the gynecologic cancers. Approximately 26,800 new cases of ovarian cancer will occur in the United States in 1997, with an estimated 14,600 deaths occurring in that period. Ovarian cancer will develop in one of every 70 women. A woman's risk of ovarian cancer is increased by nulliparity; older age at the time of first pregnancy or live birth; fewer pregnancies; and a personal history of breast, endometrial, or colorectal cancer. Often, no signs or symptoms of ovarian cancer occur until late in the course of disease, and the cancer is often of considerable size by the time it is detectable by pelvic examination.

Recommendations of Major Authorities

  • American Cancer Society --
  • Pelvic examination should be performed every 1 to 3 years for women aged 18 to 39 and annually for women over age 40.
  • American College of Obstetricians and Gynecologists --
  • Women who have become sexually active or are 18 years of age and older should have annual pelvic examinations as part of a periodic health examination.
  • Canadian Task Force on the Periodic Health Examination (CTFPHE) and US Preventive Services Task Force --
  • Routine pelvic examination is not recommended for the detection of ovarian cancer. There is insufficient evidence to recommend for or against screening of asymptomatic women at increased risk for ovarian cancer. The CTFPHE states that it would be reasonable to examine the adnexa if a pelvic examination were being done for another reason, such as cervical inspection or Pap smear.

Basics of Pelvic Examination

1.

General Considerations: Use good lighting and proper examination procedure. Instruct the patient to empty her bladder and rectum before examination.

2.

Inspection: Perform a general inspection of the external genitalia with the patient in the lithotomy position. Inspect the skin of the vulva for redness, excoriation, masses, leukoplakia, and pigmentation.

3.

Femoral Nodes: Palpate the horizontal chain of nodes inferior to the inguinal ligament and the vertical chain along the upper inner thigh. Nodes in this area that are smaller than 1 cm in diameter may be normal if they are soft, discrete, and movable.

4.

Vagina and Cervix: Use a speculum to inspect the vagina and cervix. Warm the speculum, and lubricate it with water, not a lubricating jelly, because the jelly may interfere with interpretation of cervical cytology. Separate the labia with two fingers, and apply pressure posteriorly in the introitus. Introduce the speculum at an oblique angle, avoiding pain-sensitive anterior structures, then rotate the speculum to the transverse position. Open the blades slowly, and lock the speculum open. Use a cotton-tipped applicator or swab to remove any discharge that obscures the vaginal walls or cervix. Visually inspect the vagina and cervix for erosion, ulceration, leukoplakia, and masses. At this point, obtain a specimen for Pap smear testing (chapter 37). As the speculum is removed, examine the vaginal sidewalls again for leukoplakia, masses, and other abnormalities.

5.

Bimanual Palpation: Place the lubricated index and middle fingers of one hand into the vaginal vault; place the other hand on top of the abdomen. Use the fingers within the vaginal vault to palpate the cervix and sidewalls of the vagina for induration, masses, and tenderness. Next, use the fingers within the vagina to lift the reproductive organs out of the pelvis so they can be palpated with the hand on the abdomen. Note the size, location, contour, and mobility of the uterus, ovaries, and adnexa.

6.

Rectovaginal Septum: Partially withdraw the hand from the vagina, moving the middle finger to insert it into the rectum. This maneuver allows for palpation of the rectovaginal septum to detect tumors, inflammatory or granulomatous masses, and for better evaluation of the uterus in obese individuals or in those in whom the uterus is retroverted.

Digital Rectal Examination For Colorectal And Prostate Cancer

Digital rectal examination (DRE) can be used to identify colorectal and prostate cancers. The DRE is of limited value as a screening test for colorectal cancer, because fewer than 10% of colorectal cancers can be palpated. See chapter 34 for information on the epidemiology of colorectal cancer and screening with fecal occult blood testing.

Rectal examination does afford an opportunity for limited palpation of the prostate gland in men. See chapter 39 for information on the epidemiology of prostate cancer and screening with prostate-specific antigen (PSA). The sensitivity and specificity of digital rectal examination for detecting prostate cancer are 33% to 69% and 49% to 97%, respectively. Scant evidence exists suggesting that screening by digital rectal examination decreases mortality from prostate cancer. Some authorities believe that the limited effectiveness of DRE may be attributable to either its inability to detect tumors at an early, treatable stage or the fact that some tumors grow so rapidly that yearly screening cannot detect most of them at an early, treatable stage, or both.

Recommendations of Major Authorities

  • American Academy of Family Physicians --
  • Clinicians should counsel men age 50 to 65 about the known risks and uncertain benefits of screening for prostate cancer.
  • American Cancer Society --
  • Annual digital rectal examination should be performed for men aged 50 and over as part of prostate cancer screening (chapter 39). In men and women age 50 and over, a rectal examination should be done as part of colorectal cancer screening every 5 to 10 years, depending on the type of screening test used.
  • American College of Obstetricians and Gynecologists --
  • Digital rectal examination should be included in the periodic health examination of women 50 years of age and older as part of the pelvic exam.
  • American Society of Colon and Rectal Surgeons --
  • Annual digital rectal examination should be performed for asymptomatic, low-risk individuals 40 years of age and older and for asymptomatic individuals over 35 years of age with either a family history of colorectal adenomatous polyps or cancer in one or more first-degree relatives.
  • American Urological Association --
  • Annual digital rectal examination is recommended as part of prostate cancer screening for all men age 50 and over and for those at high risk starting at age 40 (chapter 39).
  • Canadian Task Force on the Periodic Health Examination(CTFPHE) --
  • There is insufficient evidence to recommend for or against the use of digital rectal examination to screen for prostate cancer. The CTFPHE has stated that evidence is insufficient to advise physicians who currently include digital rectal exam in examination on men 50 to 70 years of age to discontinue the practice.
  • US Preventive Services Task Force --
  • There is insufficient evidence to recommend for or against routine digital rectal examination as an effective screening test for prostate cancer in asymptomatic men. No recommendation has been made regarding the use of the examination for colorectal cancer screening.

Basics of Rectum and Prostate Examination

1.

General Considerations: Examine male and female patients while they are in the left lateral decubitus position or are standing, bent over the examination table. Female patients may also be examined while they are in the lithotomy position during a pelvic examination.

2.

Inspection: Inspect the anal opening visually, noting any skin breakdown, fissures, and protrusions from the anal opening.

3.

Palpation: To perform the examination, insert the lubricated, gloved index finger into the anal opening. Insert the gloved finger just past the rectal sphincter; do not advance it until the sphincter relaxes. The procedure can be uncomfortable for the patient but usually is not painful. Be sure to palpate all sides of the rectum for polyps, which may be sessile (attached by a base) or pedunculated (attached by a stalk). Intraperitoneal metastases may be felt anterior to the rectum as hard, shelf-like projections into the rectum. In men, thoroughly palpate the posterior and lateral lobes of the prostate gland. The normal prostate gland is approximately 2.5 cm by 4 cm and does not protrude into the rectum by more than 1 cm. It should feel smooth and rubbery throughout and have a palpable central groove. Asymmetry of the prostate gland or the presence of a hard, irregular nodule, or both, is typical of prostate cancer.

Skin Examination

Skin cancer is the most common type of cancer in the United States. Approximately 900,000 new cases of basal and squamous cell carcinoma, as well as
40,300 cases of malignant melanoma, will be diagnosed in 1997. An estimated 7300 deaths from malignant melanoma and approximately 2190 deaths from other types of skin cancer will occur in 1997. The incidence of malignant melanoma is increasing at the rate of 4% per year. Virtually 100% of skin cancers are curable if they are diagnosed and excised early. Skin cancers occur more commonly in fair-skinned individuals who have been exposed to the sun, radiation, or ultraviolet light for prolonged periods of time. Chronic overexposure to sunlight is the cause of 95% of all basal cell carcinomas. Other risk factors for basal cell and squamous cell carcinomas include exposure to radiation, complications of burning or scarring, and contact with arsenic. Basal cell cancer is more common in older adults and affects men more frequently than women. Both basal cell and squamous cell cancers can occur in anyone with a history of prolonged sun exposure, and both are most likely to occur in sun-exposed areas. Factors placing individuals at increased risk for malignant melanoma include the presence of atypical moles and a personal or family history of skin cancer, especially malignant melanoma.

Recommendations of Major Authorities

  • American Academy of Dermatology and Skin Cancer Foundation --
  • Annual skin examinations are recommended for all patients.
  • Canadian Task Force on the Periodic Health Examination (CTFPHE), and US Preventive Services Task Force (USPSTF) --
  • There is insufficient evidence to recommend for or against routine screening for skin cancer by primary care clinicians with total skin examination. Clinicians should remain alert for skin lesions with malignant features when examining patients for other reasons, particularly in those with established risk factors. Risk factors include: melanocytic precursor or marker lesions (eg, atypical moles), large numbers of common moles, immunosuppression, a family or personal history of skin cancer, substantial cumulative lifetime sun exposure, intermittent intense sun exposure or severe sunburns in childhood, freckles, poor tanning ability, and light skin, hair, and eye color. The USPSTF states that clinicians should consider referring patients with melanocytic precursor or marker lesions to skin care specialists. The CTFPHE states that patients with family melanoma syndrome should receive total body skin examinations and be considered for referral to a specialist. Both the CTFPHE and the USPSTF state that there is insufficient evidence to recommend for or against routine counseling of patients to perform skin self-examination or to use sunscreens to prevent skin cancer. The CTFPHE states that use of sunscreen is recommended for patients with prior history of solar keratosis. The USPSTF states that use of sunscreen may be appropriate for such patients.
  • American Cancer Society --
  • Patients should undergo a cancer checkup that includes examination of the skin every 3 years for those 20 to 39 years of age, and yearly after age 40.
  • American College of Obstetricians and Gynecologists --
  • Skin examination should be performed for individuals with a family or personal history of skin cancer, increased occupational or recreational exposure to sunlight, or clinical evidence of precursor lesions (eg, dysplastic nevi and certain congenital nevi).

Basics of Skin Examination

1.

General Considerations: Perform the examination in a room that is comfortably warm; adjust lighting to produce optimal illumination. Basal cell or squamous cell carcinomas are likely to present in one of the following ways: as an open sore that bleeds, oozes, or crusts and is present for more than 3 weeks; as an irritated red patch that may itch or hurt; as a growth with a rolled border and central indentation; as a shiny bump or nodule; or as a scar-like area. Characteristics that may make a lesion suspicious for malignant melanoma may be remembered by following the ABCDs: A -- Asymmetry; B -- irregular Borders; C -- variation in Color from one area to another within the same lesion; and D -- a Diameter greater than 6 mm, about the size of a pencil eraser. Additional warning signs for malignant melanoma include sudden or continuous enlargement of a lesion; elevation of a previously macular pigmented lesion; surface changes, such as bleeding, crusting, erosion, oozing, scaliness, or ulceration; changes in the surrounding skin, such as redness, swelling, or satellite pigmentation; changes in sensation, such as itching, tenderness, or pain; changes in consistency, such as softening or friability; and the development of a new pigmented lesion, particularly in patients older than 40 years of age. Carefully evaluate all pigmented lesions.

2.

With the Patient Seated: Examine the skin of the head, upper torso, and upper extremities while the patient is seated. Part the hair and inspect the scalp thoroughly and carefully. While examining the skin of the face and neck, take special note of the eyelids, forehead, ears, nose, and lips. Examine the upper extremities, shoulders, and back completely.

3.

With the Patient Supine: Inspect the skin of the chest and abdomen with particular attention to the inguinal and genital areas. Elevate the scrotum to allow inspection of the perineal area. Carefully examine the feet, including the soles and the area between the toes.

4.

With the Patient Lying on the Left Side: Examine the remaining skin of the back, legs, gluteal and perianal areas.

Testicular Examination

Testicular cancer accounts for only about 1% of all cancers in men. However, it is the most common cancer in white men aged 20 to 34 years; 7200 new cases and 350 deaths are expected to occur in 1997. The prognosis for testicular cancer is very good, especially if it is treated early. The major risk factor is a history of cryptorchidism. Other risk factors include a previous history of testicular cancer, gonadal dysgenesis, Klinefelter's syndrome, and in utero exposure to diethylstilbestrol (DES). Testicular cancer is more common in white men than in African Americans; incidence rates are intermediate in Hispanics, American Indians, and Asians.

The two screening tests proposed for testicular cancer are health provider palpation of the testes and patient self-examination of the testes. No information is available on the sensitivity, specificity, or positive predictive value of testicular examination in asymptomatic men by either modality. Published evidence that self-examination can detect testicular cancer in asymptomatic men is limited to a small number of case reports.

Recommendations of Major Authorities

  • American Cancer Society --
  • Testicular examination should be a part of the cancer checkup received by men every 3 years from 20 to 39 years of age and annually beginning at age 40.
  • American Urological Association --
  • Yearly clinical examinations should begin at age 15.
  • Canadian Task Force on the Periodic Health Examination and US Preventive Services Task Force (USPSTF) --
  • There is insufficient evidence to recommend for or against routine screening of asymptomatic men for testicular cancer by physician examination or patient self-examination. The USPSTF has stated that recommendations against such screening can be made on other grounds, such as the current excellent prognosis of testicular cancer patients and the likelihood that a large number of false-positive results would result from screening. Patients with an increased risk of testicular cancer (those with a history of cryptorchidism or testicular atrophy) should be informed of their increased risk of testicular cancer and counseled about the options for screening (physician or self-examination). Adolescent and young adult males should be advised to seek prompt medical attention if they notice a testicular or intrascrotal abnormality.

Basics of Testicular Examination

1.

Inspection: With the patient standing, inspect the genital area for swelling, edema, and other visible abnormalities. Elevate the scrotum to permit inspection of the perineum.

2.

Femoral Nodes: Palpate the horizontal chain of nodes inferior to the inguinal ligament and the vertical chain along the upper inner thigh. Nodes smaller than 1 cm in diameter may be normal if they are soft, discrete, and movable.

3.

Palpation: With the patient standing, use both hands to examine each testicle individually. One hand holds the superior and inferior poles of the testicle while the other hand palpates the anterior, posterior, medial, and lateral surfaces. If any masses are noted, attempt to place a finger between the mass and the testicle. This will help differentiate between masses that originate from the testicle and those that arise from other structures within the scrotum. Next, attempt to transilluminate the mass. A tumor should not transilluminate. When a neoplasm is present, the testicle is usually enlarged, firm, and heavier than normal. If any abnormalities are noted, examine the patient while he is in the supine position to try to distinguish between solid masses (which will remain) and varicoceles (which may resolve).

4.

Testicular Self-Examination: Authorities disagree about whether to encourage patients to examine their testes regularly. Clinicians wishing to do so may refer to pamphlets on self-examination listed in " Patient Resources " below.

Thyroid Examination

Approximately 16,100 cases of thyroid cancer will be diagnosed in 1997 in the United States; approximately 1239 deaths will be attributable to the disease. Persons at increased risk include those who have undergone irradiation of the head and neck as children and persons with a family history of multiple endocrine neoplasia, type II. Thyroid malignancy occurs twice as frequently in women as in men.

Recommendations of Major Authorities

  • American Academy of Family Physicians --
  • Use of ultrasound screening in asymptomatic persons for detection of thyroid cancer is not recommended.
  • American Cancer Society --
  • A cancer checkup, including palpation of the thyroid, should be performed every 3 years on individuals 20 to 39 years of age and yearly for individuals aged 40 years and over.
  • American College of Obstetricians and Gynecologists --
  • Thyroid palpation should be part of the periodic health examination for all women over the age of 18 years.
  • Canadian Task Force on the Periodic Health Examination and US Preventive Services Task Force (USPSTF) --
  • There is insufficient evidence for or against the performance of thyroid palpation for screening for thyroid cancer. The USPSTF has stated that a recommendation for screening patients with a history of external upper-body (primarily head and neck) irradiation in infancy and childhood can be made on other grounds, such as patient preference or anxiety.

Basics of Thyroid Examination

1.

Inspection: The patient should be seated with the neck flexed slightly in order to relax the sternocleidomastoid muscles. To highlight any swelling, position a standing lamp so that it shines tangentially across the neck. Observe the neck as the patient takes a sip of water. Thyroid masses will move up and down with swallowing because of the thyroid's location within the fascial sheath of the trachea. A midline mass may also be a thyroglossal duct cyst.

2.

Palpation: The patient should be sitting straight, with the neck flexed slightly forward and to the right. While standing behind the patient, use the fingertips of the left hand to push the trachea slightly to the right and the fingers of the right hand to retract the sternocleidomastoid muscle. While the patient takes a sip of water, palpate the medial and lateral margins of the thyroid with the fingertips of the right hand. Reverse the procedure on the left side. A malignancy may present as a discrete area of firmness or hardness. Thyroid gland tenderness may also be suggestive of malignancy.

3.

Lymph Nodes: Examine the thyroid for the presence of lymphadenopathy. The uppermost pretracheal node that lies above or over the thyroid isthmus is called the Delphian node. An enlarged Delphian node may be the earliest sign of metastatic papillary cancer. Also examine the pre- and postauricular nodes, as well as the anterior and posterior cervical nodes. The anterior cervical nodes are clustered in a 7-shaped configuration, with the horizontal axis just below the body of the mandible and the vertical axis along the anterior border of the sternocleidomastoid muscle. The posterior cervical nodes are clustered in an L-shaped configuration, with the horizontal axis along the clavicle and the vertical axis along the anterior margin of the trapezius. Palpate the lymph nodes using a gentle circular motion of the finger pads. It is usually most efficient to palpate with both hands to permit comparison of the two. Normal nodes should feel movable, discrete, soft, and nontender.

Patient Resources - Breast Cancer

  • Breast Cancer: Steps to Finding Breast Lumps Early. American Academy of Family Physicians, 8880 Ward Pkwy, Kansas City, MO 64114-2797; (800)944-0000. Internet address: http://www.aafp.org
  • How To Do Breast Self Examination; Breast Cancer - Questions and Answers; Cancer Facts for Women. American Cancer Society, 1599 Clifton Rd, NE, Atlanta, GA 30329-4251; 1-800-ACS-2345. Internet address: http://www.cancer.org
  • Mammography. American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC 20024; (800)762-2264. Internet address: http://acog.com
  • Questions and Answers About Evaluating Breast Changes; Benign Breast Lumps and other Benign Breast Changes; What You Need To Know About Ovarian Cancer; The Pap Test: It Could Save Your Life (Spanish). Office of Cancer Communications, National Cancer Institute, Bldg 31, Room 10A16, Bethesda, MD 20892; 1-800-4-CANCER.
  • Chances are You Need a Mammogram; Are You Age 50 or Older? A Mammogram Could Save Your Life (English and Spanish). Office of Cancer Communications, National Cancer Institute, Bldg 31, Room 10A16, Bethesda, MD 20892; (800)4-CANCER. Internet address: http://cancernet.nci.nih.gov

Provider Resources - Breast Cancer

  • Detecting and Treating Breast Problems. American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC 20024-2188; (202)638-5577. Internet address: http://www.acog.com
  • Nonmalignant Conditions of the Breast (ACOG Technical Bulletin 156; 1991). American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC 20024; 1-800-762-2264. Internet address: http://www.acog.com
  • Mammography Awareness Kit. Office of Cancer Communications, National Cancer Institute, Bldg 31, Room 10A16, Bethesda, MD 20892; (800)4-CANCER. Internet address: http://cancernet.nci.nih.gov

Patient Resources - Cancers of the Oral Cavity

  • Head & Neck Cancer: Know What the Warning Signs Are. American Academy of Otolaryngology-Head and Neck Surgery, Order Department, 1 Prince St, Alexandria, VA 22314; (703)836-4444.
  • Facts on Oral Cancer; Self Oral Screen in Six Orderly Steps. American Cancer Society, 1599Clifton Rd, NE, Atlanta, GA 30329-4251; (800)ACS-2345. Internet address: http://www.cancer.org
  • What You Need to Know about Oral Cancer. Office of Cancer Communications, National Cancer Institute, Bldg 31, Room 10A16, Bethesda, MD 20892; (800)4-CANCER. Internet address: http://cancernet.nci.nih.gov

Patient Resources - Cancer of Pelvic Organs

  • Preventing Cancer; Cancer of the Ovary. American College of Obstetricians and Gynecologists, 409 12th St SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com
  • What You Need To Know About Ovarian Cancer; The Pap Test: It Could Save Your Life (Spanish). Office of Cancer Communications, National Cancer Institute, Bldg 31, Room 10A16, Bethesda, MD 20892; 1-800-4-CANCER.
  • Preventing Cancer; Cancer of the Ovary. American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com

Provider Resources - Cancer of Pelvic Organs

  • Cervical Cytology: Evaluation and Management of Abnormalities. Technical Bulletin 183. American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC 20024; 1-800-762-2264. Internet address: http://www.acog.com
  • The Pap Test. American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington DC 20024; (800)762-2264. Internet address: http://www.acog.com

Patient Resources - Prostate Cancer

  • For Men Only: Prostate Cancer; Cancer Facts for Men. American Cancer Society, 1599 Clifton Rd, NE, Atlanta, GA 30329-4251; 1-800-ACS-2345. Internet address: http://www.cancer.org
  • Prostate Disease: What Every Man Over 40 Should Know. Prostate Health Council, c/o American Foundation for Urologic Disease, Inc, 1128 N Charles St, Baltimore, MD 21201. Written requests only.
  • The prostate puzzle. Consumer Reports. 1993;58(7):459-465.

Patient Resources - Colorectal Cancer

  • Colorectal Cancer, Questions & Answers. American Society of Colon and Rectal Surgeons, 800 E Northwest Hwy, Suite 1080, Palatine, IL 60067; (708)359-9184.
  • Colonoscopy: Questions and Answers; Polyps of the Colon and Rectum: Questions and Answers. American Society of Colon and Rectal Surgeons, 800 E Northwest Hwy, Suite1080, Palatine, IL 60067; (708)359-9184.
  • What You Need to Know about Cancer of the Colon and Rectum. Office of Cancer Communications, National Cancer Institute, Bethesda, MD 20892; (800)4-CANCER. Internet address: http://cancernet.nci.nih.gov

Patient Resources - Skin Cancer

  • Skin Cancer: Saving Your Skin From Sun Damage. American Academy of Family Physicians, 8880 Ward Pkwy, Kansas City, MO 64114-2797; (800)944-0000. Internet address: http://www.aafp.org
  • The ABCDs of Moles & Melanomas; Dysplastic Nevi and Malignant Melanoma: A Patient's Guide; Skin Cancer: If You Can Spot It, You Can Stop It. The Skin Cancer Foundation, POBox 561, New York, NY 10156; (212)725-5176.
  • Facts on Skin Cancer. American Cancer Society, 1599 Clifton Rd, NE, Atlanta, GA 30329-4251. (800)ACS-2345. Internet address: http://www.cancer.org

Provider Resource - Skin Cancer

  • Prevention and Early Detection of Malignant Melanoma. American Cancer Society, 1599 Clifton Rd, NE, Atlanta, GA 30329-4251. (800)ACS-2345. Internet address: http://www.cancer.org

Patient Resource - Testicular Cancer

  • Testicular Cancer & Testicular Self-Examination. American Urological Association, Inc, 1120 N Charles St, Baltimore, MD 21201-5559; (410)727-1100.

Provider Resource - General

  • PDQ: The Physician Data Query System for Cancer Information. PDQ is the National Cancer Institute's computerized database providing the most up-to-date cancer information available. Access to the system can be gained 24 hours a day, 7 days a week, using a personal computer and standard telephone line or through medical libraries. Ask a medical librarian for assistance or call (800)4-CANCER (line 3). In Hawaii, on Oahu, call 524-1234.
  • OncoLink - The University of Pennsylvania Cancer Center Resource. Internet address: http://cancer.med.upenn.edu

Selected References

  1. American Academy of Family Physicians. Summary of Policy Recommendations for Periodic Health Examination. Kansas City, Mo: American Academy of Family Physicians; 1997.
  2. American Cancer Society. Cancer Facts & Figures-1997. Atlanta, Ga: American Cancer Society; 1997.
  3. American Cancer Society. Summary of American Cancer Society recommendations for the early detection of cancer in asymptomatic people. CA. 1993; 43:–.
  4. American Cancer Society. Cancer Information Database. Atlanta, Ga: American Cancer Society; June 1997.
  5. American College of Obstetricians and Gynecologists. Routine Cancer Screening. ACOG Committee Opinion #128. Washington, DC: American College of Obstetricians and Gynecologists; 1993.
  6. American College of Obstetricians and Gynecologists. Guidelines for Women's Health Care. Washington, DC: American College of Obstetricians and Gynecologists; 1996.
  7. American College of Physicians. Guidelines. In Eddy DM, ed. Common Screening Tests. Philadelphia, Pa: American College of Physicians; 1991:411-416.
  8. American Society of Colon and Rectal Surgeons. Practice Parameters for the Detection of Colorectal Neoplasms. Palatine, Ill: American Society of Colon and Rectal Surgeons; 1992.
  9. American Urological Association. Early Detection of Prostate Cancer. Baltimore, Md: American Urological Association; 1995.
  10. Canadian Task Force on the Periodic Health Examination. Prevention of skin cancer. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 70.
  11. Canadian Task Force on the Periodic Health Examination. Screening for breast cancer. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 65.
  12. Canadian Task Force on the Periodic Health Examination. Screening for colorectal cancer. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 66.
  13. Canadian Task Force on the Periodic Health Examination. Screening for oral cancer. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 69.
  14. Canadian Task Force on the Periodic Health Examination. Screening for ovarian cancer. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 72.
  15. Canadian Task Force on the Periodic Health Examination. Screening for prostate cancer. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 67.
  16. Canadian Task Force on the Periodic Health Examination. Screening for testicular cancer. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 74.
  17. Canadian Task Force on the Periodic Health Examination. Screening for thyroid disorders and thyroid cancer in asymptomatic adults. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 51.
  18. Canadian Task Force on the Periodic Health Examination. The periodic health examination: 2. 1987 update: endometrial cancer. Can Med Assoc J. 1988;138:620-621.
  19. DeGowin EL, DeGowin RL. Bedside Diagnostic Examination.5th ed. New York, NY: Macmillan Publishing Co; 1987.
  20. Eddy DM, Gordon MA, Bredt A. Screening for breast cancer. Ann Intern Med. In press.
  21. Fink DJ, Mettlin CJ. Cancer detection: the cancer-related checkup guidelines.In: Murphy GP, Lawrence W, Jr., Lenhard RE, Jr., eds. American Cancer Society Textbook of Clinical Oncology. 2nd ed. Atlanta, Ga: American Cancer Society; 1995: chap 10.
  22. Friedman RJ, Rigel DS, Silverman MK, Kopf AW, Vossaert KA. Malignant melanoma in the 1990s: the continued importance of early detection and the role of physician examination and self-examination of the skin. CA. 1991;41:201-227.
  23. Gerber GS, Thompson IM, Thisted R, Chodak GW. Disease-specific survival following routine prostate cancer screening by digital rectal examination. JAMA. 1993;269:61-64.
  24. Jarvis C. Physical Examination and Health Assessment. Philadelphia, Pa: WB Saunders Co; 1992.
  25. MacLeod J, Munro J, eds. Clinical Examination.7th ed. New York, NY: Churchill Livingstone; 1986.
  26. Mettlin C, Jones G, Averette H, et al. Defining and updating the American Cancer Society guidelines for the cancer-related checkup: prostate and endometrial cancers. CA. . 1993; 43:42–46. [PubMed: 8422604]
  27. Moloy PJ. How to (and how not to) manage the patient with a lump in the neck. In: Common Problems of the Head and Neck Region. Philadelphia, Pa: WB Saunders Co; 1992:129-150.
  28. Parker SL, Tong T, Bolden S, Wingo PA. Cancer statistics, 1997. CA . 1997; 47:5–27. [PMC free article: PMC1312878] [PubMed: 8996076]
  29. Rhodes AR, Weinstock MA, Fitzpatrick TB, Mihm MC, Sober AJ. Risk factors for cutaneous melanoma: a practical method of recognizing predisposed individuals. JAMA. 1987;258:3146-3153.
  30. Garnick MB, Mayer RJ, Richie JP. Testicular self-examination. N Engl J Med. . 1980; 302:–. [PubMed: 7350489]
  31. Smart CR, Chu K, Conley V, Henson DE, Pommerenke F, Srivastova S. Cancer screening and early detection.In: Holland JF, Frei EF III, Bast RC Sr. , Kufe DW, Morton DL, Weichselbaum RR, eds. Cancer Med. 3rd ed. Vol 1. Philadelphia, Pa: Lea and Febiger, 1993;408-431.
  32. Swartz MH. Textbook of Physical Diagnosis. Philadelphia, Pa: WB Saunders Co; 1989.
  33. US Preventive Services Task Force. Screening for breast cancer.In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 7.
  34. US Preventive Services Task Force. Screening for colorectal cancer.In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 8.
  35. US Preventive Services Task Force. Screening for oral cancer.In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 17.
  36. US Preventive Services Task Force. Screening for ovarian cancer.In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 14.
  37. US Preventive Services Task Force. Screening for prostate cancer.In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 10.
  38. US Preventive Services Task Force. Screening for skin cancer.In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 12.
  39. US Preventive Services Task Force. Screening for testicular cancer.In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 13.
  40. US Preventive Services Task Force. Screening for thyroid cancer.In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 18.
  41. Wartofsky L. Examination of the thyroid. In: Becker KL, ed. Principles and Practice of Endocrinology & Metabolism. New York, NY: JB Lippincott; 1990.
  42. Wingo PA, Landis S, Ries LAG. An adjustment to the 1997 estimate for new prostate cancer cases. CA. . 1997; 47(4):239–242. [PubMed: 9242172]