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Complete clinical examination is the first and most often the best way to obtain a precise diagnosis and cancer staging.

(See below the main revealing symptoms for major cancers)

The physician should give himself/herself enough time and should have all the practical facilities available in order to perform a complete and calm examination of his/her patient.

The first step, should involve letting the patient explain with his/her own words his/her disease; the physician listening to and taking into account silences and doubts. Usually, a patient only speaks for about 30 to 60 seconds: calmly listening to the patient will offer the physician a great deal of information on the patient’s psychological state of mind (which will be very important when the subject of cancer diagnosis needs to be broached) and it is also a clear sign of politeness and respect.

Clinical questioning should be precise, well-mannered, discreet and empathetic. When investigating personal and family history, an open dialogue is the first way to establish a mutually confident relationship with the patient. It allows the evaluation of the patient’s thoughts and fears about his/her disease. It also allows (if the patient is willing) improved understanding on his/her personal, family, professional and social situation. All of these aspects are important when the time comes to announce bad news and to propose, always feared and potentially mutilating, treatment.

This initial period should also allow a relaxed, attentive clinical examination, respecting the patient's modesty and avoiding unnecessary painful procedures.

In many cases, the patient will be asked to undress and show a part of his/her body often qualified as disgraceful or shameful by many people. Patient modesty should always be respected, however a precise and careful examination is most necessary: most cultural inhibitions can be relieved by tactful consideration and patience. We also have to overcome our own modesty and our own inhibitions. It is of course easier not to perform a complete clinical examination than to convince the patient of its usefulness. Such ill-placed modesty may inhibit early diagnosis and result in monstrous tumours (breast tumours, gynaecological tumours, urological tumours) because the physician has, at no time, dared to perform a correct clinical examination.

Some cancers are truly monstrous and we may wonder how the patient managed to live with such a tumour. For instance, the following pictures demonstrate how a communication gap can result in abysmal tumours of the lip, the face, the cervical nodes, the breast, the anus, the testis or the penis. The psychological reactions to the discovery of cancer, denial, shame and fear of being examined, the fear of surgery and of the medical world are among the factors which may explain the relative frequency of such monstrous discoveries.

The clinical examination should be performed in the greatest calm: the physician should concentrate on his/her work and ask the patient (and the family) for silence, if necessary. A precise, detailed clinical examination, during which the physician looks for the smallest clinical evidence, even if it somewhat disturbs the patient's intimacy, is most often understood by the patient as a total interest in the disease and, consequently, the patient himself/herself.

Some cancer classifications are carried out by the clinical examination alone: thus learning how to correctly perform an exhaustive examination is a major part of medical student teaching. For a few difficult or unpleasant examinations, a general anaesthesia is recommended (in particular for gynaecological tumours where pelvic examination may be painful due to inflammation: for instance, the required relaxation for a quality clinical evaluation of the invasion of uterine parameters is rarely obtained during the first examination).

In the same manner, discovering metastastic nodes or skin lesions, by a precise clinical examination, renders complex and costly paramedical examinations unnecessary and prevents futile surgery. A poor clinical examination may induce a waste of time and money and unpleasant and unnecessary procedures.

Among the major clinical procedures:

• Inspection and palpation of breasts for the characterization of a mammary tumour, which can be visible, distort the shape of the breast or infiltrate the skin with the classical 'peau d'orange' aspect, (see illustration),
  
• pulmonary region percussion and auscultation to detect a pleural effusion,
  
• Mouth cavity examination (comprising palpation) for diagnosis and staging of mouth cancers (see pictures),
  
• Examination with Clarke's mirror of laryngeal cancers,
  
• Systematic palpation of every node area, in particular cervical, axillary and inguinal nodes
  
• Palpation of the hepatic area to detect secondary hepatomegaly,
  
• Percussion (and palpation) of the splenic area to detect splenomegaly
  
• Abdomen palpation to detect abdominal or ovarian tumours,
  
• Vaginal examination with speculum to discover a cervix uteri tumour,
  
• Vaginal examination with bimanual examination looking for an enlarged uterus or a pelvic mass,
  
• Rectal examination to study the status of parameters (during cervix carcinoma staging) or looking for a pelvic mass, like ovarian carcinoma,
  
• For male patients, a rectal examination is necessary for diagnosis and evaluation of a prostate tumour,
  
• Rectal examination is an important step for diagnosis and evaluation of a rectal tumour,
  
• Complete skin examination looking for skin metastases,
  
• Careful and quiet palpation of an enlarged scrotum in order to differentiate a testis tumour (large indolent testis) from an epididymitis (testicular painful adnexa).
  
• Neurological examination to detect a neurological metastasis

Thus, very often, the clinical examination can enable the precise diagnosis and staging of the cancer.

The examination enables a genuine physical contact between the carer and the patient, communication which is essential for quality patient/carer dialogue.

Many psychological mistakes arise from the absence of this contact communication. The intimate dialogue with the other carers (such as nurses and auxiliaries) is the consequence of this type of communication, and how the patient suffers from a distant impersonal dialogue when the physician uses radiographies and scanner as a protective screen.

A quality clinical examination avoids unnecessary paraclinical examinations. Although these paraclinical examinations are useful for other purposes (such as measuring tumour size), they will be accepted all the better if the physician has performed a complete examination and explained why he/she needs such paraclinical exams.

Explaining the necessity of paraclinical examination is lawful. The physician should explain the reasons, the advantages and the risks of any paraclinical examination and obtain the patient's tacit agreement. If the patient knows why such an examination is necessary, he/she will understand the diagnostic protocol and will also be more confident in the therapeutic protocol.

Only necessary complementary examinations should be requested for diagnosis and classification of cancer. Any complementary examination is more or less toilsome for the patient. Certain patients demand many complementary examinations, sometimes because the first clinical examination appeared to them too superficial to convince them of their disease. An examination should offer genuinely useful information: the physician may explain to the patient why an examination is futile, painful or even dangerous, through constructive and direct dialogue.

In the same manner, the physician or the nurse should explain how the complementary examination will be performed in order to avoid unnecessary patient fears. The general practitioner, the oncologist or the internist must know enough of the procedure to be able to explain to the patient precisely what is going to happen (advantages and disadvantages).

Giving detailed and specific documentation (which offers a second explanation) is generally recommended. Drafting of such written information should be coordinated with the specialist (performing the examination), the prescribing physician, the paramedical personnel involved in the examination (nurse, technician) because they are generally the people most likely to be solicited for further simple explanations, and possibly a patient's committee. Giving such a written explanation does not dispense from answering the patient with a reply such as, "It’s all written down in the leaflet!”.