Breast Cancer Diagnosis

Oncology is the branch of medicine involved in the study, diagnosis, treatment, and prevention of cancer. Oncology specialists are added to the healthcare team when a person is tested for breast cancer. Additional oncology specialists join the team if breast cancer is diagnosed. When working with the various healthcare team members, it's important to ask questions if anything is unclear and become involved in the decision making process when there is choice of which test or treatment to use.

The breast cancer healthcare team members may include:

Gynecologist, OB/GYN, or primary care physician
Nurse, nurse practitioner, or oncology nurse specialist
Radiologist (performs and interprets various breast cancer tests)
Radiation oncologist (a doctor who specializes in radiation therapy)
Oncologist (a doctor who specializes in chemotherapy, hormonal therapies, targeted therapies, pain management, and nutritional support)
Surgeon (a doctor who performs procedures and surgeries)
Pathologist (a doctor who specializes in medical diagnosis)
Reconstructive/plastic surgeon (a doctor who repairs or reshapes damaged body structures to improve their function and appearance)
Counselor, psychologist, or social worker (helps with any emotional or personal issues)
Dietitian (helps plan a healthy diet)

The tests used to diagnose breast cancer, plan its treatment, and determine if the treatment is working include:

Screening tests
Diagnostic tests
Additional diagnostic tests

Screening tests

Screening tests help find breast cancer in women without symptoms at an earlier, more treatable stage of the disease. The American Cancer Society (ACS) established the following guidelines for breast cancer screening.

Breast self-exam

Starting in their 20s, women are advised to perform a breast self-exam (BSE) monthly. During the exam, women feel for lumps and look for abnormal breast symptoms. Any changes should be reported to a doctor. Healthcare providers can provide BSE instructions.

Clinical breast exam

During a clinical breast exam (CBE), a doctor feels for lumps and looks for abnormal symptoms of the breast and its surrounding tissue. By scheduling the CBE shortly before a screening mammogram, additional pictures can be taken of any suspicious areas during the mammogram. The recommended schedule for clinical breast exams is:

Every 3 years for women in their 20s and 30s
Annually for women starting at age 40

Screening mammogram

A mammogram is an X-ray of the breast that can identify breast lumps when they are too small to be felt. Regular screening mammograms can help find breast cancer early before any symptoms develop. Although a mammogram exposes women to low levels of radiation, it doesn't significantly increase their risk of breast cancer.

Women age 40 and older are advised to get a screening mammogram annually. According to the Centers for Disease Control and Prevention (CDC), screening mammograms can reduce breast cancer death by approximately:

20% to 35% in women aged 50 to 69 years old
20% in women aged 40 to 49 years old

Film mammograms record the pictures on film. Digital mammograms use a newer technology that stores the pictures in a computer. Computer software can enlarge or highlight the stored pictures. At this time, digital mammograms are more expensive and are not available everywhere.

Digital mammograms have been shown to be more accurate in women who:

Are younger than 50
Have dense breasts
Are premenopausal or had their last period within a year of the mammogram

Genetic testing

Some people with a family history of breast cancer may decide to be tested for defective genes associated with breast cancer (such as BRCA1 and BRCA2). The U.S. Preventative Services Task Force (within the U.S. Department of Health & Human Services) recommends that people should only be evaluated if they have a strong family history of breast cancer.

The American Cancer Society recommends that people considering genetic testing should meet with specially trained health counselors, who can help them weigh the benefits and risks of genetic testing, and help them make informed choices about their possible options if they test positive.

Diagnostic tests

Not all breast changes are due to cancer. Diagnostic testing is used to determine if a breast abnormality is cancerous. The testing is preceded by a medical history and physical exam.

Medical history and physical exam

The personal and family medical history identifies a person's:

Breast cancer risk factors
Past and present breast symptoms
Family history of breast or ovarian cancer

The physical examination locates and records information about any:

Breast lumps
Nipple or breast skin irregularities
Lymph node swelling or firmness

Diagnostic mammogram

Diagnostic mammograms take clearer, more detailed pictures of breast tissue than screening mammograms. They also take more pictures of the breasts from different angles.

A diagnostic mammogram is used to evaluate people with new breast cancer symptoms or people who have had breast cancer and require follow-up testing. Diagnostic mammograms are also used instead of screening mammograms for:

Women at high risk of breast cancer
Younger women with dense breasts
Women with breast implants

Breast ultrasound

A breast ultrasound uses high-frequency sound waves to make a picture of the breast tissue. It can determine if a breast lump is solid or fluid filled (a cyst). A breast ultrasound is often used to check the results of a mammogram but does not replace the need for a mammogram. Because a breast ultrasound does not use any type of radiation, there is no risk associated with the test.

Breast MRI

A breast MRI (magnetic resonance imaging) uses a magnet connected to a computer to create detailed pictures of breast tissue without the use of radiation. Breast MRI is not used for routine breast cancer screening. Instead, it is used to examine abnormal areas seen on a mammogram, or identified after breast surgery or radiation therapy. Breast MRI also can be used to determine the extent of an existing breast tumor.

The American Cancer Society (ACS) recommends that women who have cancer in one breast should get an MRI scan of the other breast. The ACS also recommends that women who have an especially high risk of developing breast cancer should get MRI scans in addition to their yearly mammogram.

Breast PET Scan

A positron emission tomography (PET) scan creates a computerized picture of breast tissue. Sugar combined with a very small amount of a short-lived radioactive material is injected into the bloodstream. The radioactive sugar is absorbed faster by cancer cells than other tissues in the body. The PET scanner detects the radiation and a computer creates pictures of the tumor. PET scans are more accurate in locating larger, more aggressive tumors, and the technique is being evaluated for recurring and metastatic breast cancer testing.

Breast biopsy

A breast biopsy is the most accurate way to tell if a breast lump is cancerous. Several kinds of breast biopsies are available, some more invasive than others. Each type of biopsy removes a small sample of breast tissue for microscopic examination by a pathologist (a doctor who specializes in medical diagnosis). If cancer is found, the pathologist can determine which kind of breast cancer it is.

Breast biopsies include:

Fine-needle aspiration biopsy
A fine-needle aspiration biopsy is a minor surgical procedure, during which a thin needle is inserted into a breast lump and fluid is removed. If the fluid is clear, the lump is most likely a benign (noncancerous) cyst and a more invasive type of biopsy is unnecessary.
Core-needle biopsy
A core-needle biopsy is used for breast lumps that can be seen on a mammogram or felt. The procedure is less invasive than a surgical biopsy. A needle with a special tip is inserted into the breast lump. Ultrasound, MRI, or X-ray imaging are often used to guide the needle placement for tissue removal.
Stereotactic biopsy
A stereotactic biopsy is used when a suspicious area is seen on a mammogram but cannot be felt. The procedure uses a three-dimensional scanning device to locate a tumor and guide the core-needle placement for tissue removal.
Surgical biopsy
A surgical biopsy is often performed in a hospital under anesthesia. When the tumor is too large to be removed, an incisional biopsy only removes part of the lump. When the tumor is small, an excisional biopsy removes the entire lump plus some of the surrounding tissue.
Sentinel node biopsy
A sentinel node biopsy can determine if a person's breast cancer has spread to the sentinel lymph nodes, which are the first lymph nodes affected when breast cancer spreads (metastasizes). The first lymph nodes reached by an injected radioactive substance or dye are removed and tested for cancer. The remaining lymph nodes in the armpit are only removed if the sentinel nodes test positive for cancer.

Additional diagnostic tests

The following diagnostic tests provide additional information about a person's breast cancer, help doctors create a treatment plan, and determine the effectiveness of the treatment:

Tumor marker tests

Tumor markers are substances produced in higher concentrations than normal by cancer cells or by the body in response to cancer cells. Breast cancer tumor marker tests identify the presence or absence of tumor markers, such as:

CEA (carcinoembryonic antigen)
CA 125 (cancer antigen)
CA 15-3
ER (estrogen receptor)
PR (progesterone receptor)
HER2 protein (human epidermal growth factor receptor)
HER2 gene

Additional testing is needed for a final diagnosis of breast cancer, because tumor markers are also present in noncancerous conditions.

Hormone receptor testing

Many breast cancers are sensitive to hormones. Hormone receptors on cancer cells bind to estrogen or progesterone. If a high number of estrogen receptors are found, a drug that prevents estrogen from binding to the tumor may be prescribed, such as tamoxifen. African American women are more likely to have HER2-positive cancer, which is not helped by estrogen-based drugs.

HER2 test

The HER2 test examines breast tissue for the human epidermal growth factor receptor-2 (HER2) protein and the HER gene. (HER2 is sometimes called HER2/neu.)

A normal breast cell has two copies of the HER2 gene, which sends signals to a person's cells to grow and divide. HER2-positive breast cancer cells have more than two copies of the HER2 gene, which start overproducing the HER2 protein, and signaling the cells to grow and divide too quickly.

HER2-positive breast cancers grow faster and are more likely to spread than HER2-negative breast cancers. They also are less responsive to hormone therapy and are typically treated with Herceptin or chemotherapy, or a combination of the two.

Staging

The information gathered from breast cancer diagnostic tests is used to determine the stage of a person's breast cancer. The stage may not be known until tissue is tested after surgery to remove a breast tumor and lymph nodes under the arm.

Doctors use cancer staging to create a person's treatment plan, follow-up care, and expectation for recovery. Although staging provides useful information about a person's breast cancer, it can't predict what actually will happen.

Cancer stages are numbered from 0 to IV, depending on:

The size and location of the tumor
Whether or not the cancer has spread to the lymph nodes
Whether or not the cancer has spread to distant organs (metastasized)

In general:

The lower the staging number, the smaller and more localized the cancer.
The higher the staging number, the more advanced and metastasized the cancer.

Stage 0

Stage 0 breast cancers are small and noninvasive.

The tumor is less than 2 centimeters (three-quarters of an inch).
The cancer is either in the lining of a duct (ductal carcinoma in situ) or lining of a lobule (lobular carcinoma in situ) and has not invaded the local breast tissue.

Stage I

Stage I is an early stage of invasive breast cancers in which:

The tumor is 2 centimeters (three-quarters of an inch) or less.
The cancer has not spread beyond the breast.

Stage II

Stage II is one of the following types of invasive breast cancers:

The tumor is smaller than 2 centimeters (three-quarters of an inch) and the cancer has spread to the lymph nodes under the arm.
The tumor is between 2 centimeters (three-quarters of an inch) and 5 centimeters (2 inches) and the cancer may have spread to the lymph nodes under the arm.
The tumor is larger than 5 centimeters (2 inches) and the cancer has not spread to the lymph nodes under the arm.

Stage III

Stage III is a locally advanced breast cancer. It is divided into the following subcategories:

Stage IIIA

Stage IIIA is one of the following types:

The tumor is smaller than 5 centimeters (2 inches) and the cancer has spread to underarm lymph nodes that are attached to each other or to other structures.
The tumor is larger than 5 centimeters (2 inches) and the cancer has spread to the underarm lymph nodes.

Stage IIIB

Stage IIIB is breast cancer that has spread to one of the following:

The breast skin
The chest wall
The internal mammary lymph nodes (behind the breastbone)

Stage IIIB includes inflammatory breast cancer.

Stage IIIC

Stage IIIC is breast cancer that has spread to one of the following lymph nodes:

Behind the breastbone and under the arm.
Under or above the collarbone.

Stage IV

Stage IV is an invasive, advanced breast cancer. The cancer has spread to other parts of the body (metastatic breast cancer), such as the:

Lymph nodes near the breast
Lungs
Liver
Bone
Brain

Testing for metastatic breast cancer

The following tests are used to determine if breast cancer has metastasized (spread) to distant organs:

Sentinel node biopsy

A sentinel node biopsy helps determine if a person's breast cancer has spread to the sentinel lymph nodes.

Bone scan

A bone scan is used to determine if a person's breast cancer has spread to their bones. During the test, people are injected with a very small amount of radioactive material (tracers), which distribute evenly throughout healthy bone but accumulate in diseased areas. As the tracers decay, they emit gamma waves, which can be detected by a special camera. Other imaging techniques are needed to distinguish tumors from fractures, infections, or inflammation. All radioactivity in the body disappears after a few days.

CAT scan

A CAT scan (computerized axial tomography or CT scan) uses X-rays to produce a series of cross-sectional computerized images of the body. The images are created using a computer connected to an X-ray machine. CAT scans can determine if breast cancer has spread to the lymph nodes, lungs, liver, brain, spine, or other parts of the body.

X-rays

An X-ray uses a small amount of radiation to create an image of structures within the body. A chest X-ray helps determine if a person's breast cancer has spread to the lungs. A bone X-ray helps determine if cancer has spread to the bones.

MRI scan

An MRI (magnetic resonance imaging) uses strong magnetic fields, radio waves, and a computer to create images of a person's internal structures without radiation or surgery. MRI scans help identify breast cancer in women with dense breasts whose cancer was not found on mammograms. MRI scans are also used to determine if cancer has spread to the bones or brain.

Back | Top | Next