Diagnosing breast cancer

Friday 1 August, 2014

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On this page: Physical examination | Mammogram | Ultrasound | Breast MRI | Biopsy | Testing the tumour cells for hormone receptors and genes | Further tests | Staging breast cancer | Grading breast cancer | Prognosis | Which health professionals will I see? | Key points


Several tests are commonly used to find out if your breast change is due to cancer.

Physical examination

Your doctor will feel your breasts and the lymph nodes under your arms. They will take a full medical history and ask about your family history.

Mammogram

A mammogram is a low-dose x-ray of the breast tissue. This x-ray can find changes that are too small to be felt during a physical examination. Your breast is pressed between two x-ray plates, which spread the breast tissue out so clear pictures can be taken. Both breasts are checked. This procedure can be uncomfortable, but it’s over in about 20 seconds.

If the lump your GP could feel during the physical examination is not shown on a mammogram, other tests will need to be done.

Ultrasound

An ultrasound is a painless scan that uses soundwaves to create a picture of your body. A gel is spread on your breast and a small device called a transducer is moved over the area. This sends out soundwaves that echo when they meet something dense, like an organ or tumour. A computer creates a picture from these echoes. The scan takes about 15–20 minutes.

Breast MRI

This form of breast imaging uses a large magnet in a scanner to image breast tissue. Breast MRI (magnetic resonance imaging) is more sensitive than mammography or breast ultrasound. It is commonly used to screen women at high-risk of breast cancer, but it can also be used in women with very dense breast tissue. Breast MRI is becoming more widely available, however it requires special expertise to interpret the results.

During the scan, you may have an injection of a contrast dye to make any potential cancerous breast tissue easier to see. To have the breast MRI, you will lie facedown on a screening table with cushioned openings for your breasts. The table slides into the machine. This test can take 30–60 minutes.

Biopsy

Your doctor will suggest a biopsy if an abnormal or unusual area is felt in your breast. During a biopsy, a small amount of tissue is removed from your breast. A pathologist examines the removed tissue and checks for cancer cells under a microscope. There are a few ways of taking a biopsy, and you may need more than one.

Fine needle aspiration (FNA)

A thin needle is used to take some cells from the breast lump or abnormal area. Sometimes an ultrasound is used to help guide the needle. The test is a bit uncomfortable – it can feel similar to having blood taken. It is usually done in a specialist’s rooms, by a pathologist in a hospital outpatient department or at a radiology practice.

Core biopsy

A wider needle is used to remove a small piece of tissue, called a core, from the lump or abnormal area. It is usually done under local anaesthetic, so your breast is numb, though you may still feel some pain or discomfort. During this procedure, a mammogram, ultrasound or MRI is used to help guide the needle.

"I had a core biopsy by ultrasound and didn’t find it very painful. Afterwards I had a small amount of bruising. I have heard other women say I was lucky, and they experienced more pain and bruising."
Maria

Vacuum-assisted stereotactic biopsy (VAB)

This is also performed under local anaesthetic. Lots of small tissue samples are removed using a suction-type instrument and computerguided technology.

Surgical biopsy

If the abnormal area is too small to be biopsied using the methods above, a surgical biopsy is done. Before the biopsy, a guide wire may be put into the breast to help the surgeon find the abnormal tissue. You will be given local anaesthetic, and the doctor may use an ultrasound or mammogram to insert the wire. This is done in the radiology department.

The biopsy is then done in a separate operation using a general anaesthetic. The lump and a small area of breast tissue around it are removed, along with the wire. This biopsy is usually done as day surgery, but some women have an overnight stay in hospital.

Testing the tumour cells for hormone receptors and genes

A pathologist will examine the breast tissue. The sample comes from a biopsy or tissue removed during surgery. The findings of these tests will be outlined in a pathology report, which will include the size and location of the tumour, the grade of the cancer, whether there are cancer cells close to the edge of the breast tissue and whether there are cancer cells in your lymph nodes. The pathology report will help your doctor decide what treatments are best for you. Additional tests will be done to show if the cancer has receptors for hormones or growth factors.

Hormone receptors

Hormones affect some types of breast cancer. Hormones are chemical messengers in the body that transfer information. Before menopause, the ovaries produce the hormones oestrogen and progesterone. These hormones can cause cancer to grow.

A hormone receptor is a protein in a cell. In breast cancer, hormone receptors receive signals from oestrogen and progesterone to promote cancer cell growth. There are two types of hormone receptors: oestrogen receptors and progesterone receptors. About two out of every three breast cancers contain hormone receptors.

  • Cancer cells that have oestrogen receptors are called oestrogen receptor positive (ER+).
  • Cancer cells that have progesterone receptors are called progesterone receptor positive (PR+).
  • Cells without receptors are hormone receptor negative.

A cancer that is ER+ or PR+ is more likely to respond to hormone treatments.

HER2 status

The HER2 (human epidermal growth factor receptor 2) test looks for a protein that is found on the surface of cells. This protein causes the cell to grow and divide in an uncontrolled way. Tumours that have high levels of these receptors are referred to as HER2-positive (HER2+).

About one in five women have HER2+ cancer cells. Treatment with targeted therapies, such as Herceptin® is usually recommended.

Genomic assays

The use of the Oncotype DX Breast Cancer Assay or Oncotype DX test is still new in Australia, but it is widely used in the United States.

In Australia, this test costs $5000, and is not currently covered by either Medicare or private health funds.

The Oncotype DX test uses a sample of breast tissue to analyse a group of 21 genes. These genes help predict the risk of breast cancer coming back after treatment and if you are likely to benefit from chemotherapy after surgery (adjuvant chemotherapy).

Women who are suitable for this test include:

  • those with ER+ or PR+ tumours
  • those who have 0–3 positive lymph nodes.

Talk to your doctor if you would like to know more about this test. A pathologist will take a portion of the tumour tissue, which will be sent to America, where all Oncotype DX testing is currently done. Your doctor will usually receive the results within 2–3 weeks.

Further tests

If the tests described above show you have breast cancer, one or more tests may be done to see if the cancer has spread to other parts of your body. The test and scan results will be written in a pathology report.

Blood tests

Blood samples may be taken to check your general health, and also to look at your bone and liver function for signs of cancer.

Chest x-ray

Your doctor may take an x-ray of your chest to check your lungs for signs of cancer.

CT scan

A CT (computerised tomography) scan is a type of x-ray procedure that takes pictures of the inside of the body. Unlike a standard x-ray, which takes a single picture, a CT scan uses a computer to compile many pictures of the body. It can show if the cancer has spread to the lymph nodes or other organs.

To make the scan pictures clearer and easier to read, you may have to fast (not eat or drink). You will also be asked to drink a liquid and have an injection of a dye into a vein in your arm. This can make you feel hot all over for a few minutes.

You will lie flat on a table while the CT scanner, which is large and round like a doughnut, takes pictures. This painless test takes about 30–40 minutes.

Bone scan

A bone scan may be done to see if the breast cancer has spread to your bones. A small amount of radioactive material is injected into a vein, usually in your arm. This material is attracted to areas of bone where there is cancer.

After a few hours, the bones are viewed with a scanning machine, which sends pictures to a computer. This scan is painless and will not make you radioactive. You should drink plenty of fluids on the day of and the day after the test.

PET scan

A PET (positron emission tomography) scan is a specialised test, which is rarely done for breast cancer. It uses low-dose radioactive glucose to measure cell activity in different parts of the body.

A small amount of glucose is injected into a vein, usually in your arm. You will need to wait for about an hour for the fluid to flow through your body.

You will then lie on a treatment table that moves through a scanning machine. This body scan will show ‘hot spots’ where the fluid has accumulated – this happens where there are active cells, like cancer cells

While a PET scan is not a routine test, it may be used if other types of scans don’t give doctors the information they need.

Tip

There are extra costs associated with some tests and scans, depending on whether you are treated in a public or private hospital. Talk to your medical team for information about how much you will be charged.

Staging breast cancer

The tests described on above show if the cancer has spread to other parts of the body. Working out how far the cancer has spread is called staging. Stages are numbered from I to IV.

Stages of early breast cancer
Stage I
The tumour is less than 2 cm in diameter and has not spread to the lymph nodes in the armpit.
Stage IIA
The tumour is less than 2 cm in diameter and has spread to the lymph nodes in the armpit.
The tumour is between 2 cm and 5 cm in diameter and has not spread to the lymph nodes in the armpit.
Stage IIB (early)
The tumour is 2-5 cm in diameter and has spread to the lymph nodes.
Stages IIB (advanced), III and IV refer to advanced breast cancer. For information about these stages, call Cancer Council 13 11 20 or visit Cancer Australia.

Grading breast cancer

The cancer will also be given a grade. The grade describes how fast the cancer is growing.

Grading
Grade 1
(low grade)
Cancer cells look a little different from normal cells. They are usually slow growing.
Grade 2
(intermediate grade)
Cancer cells do not look like normal cells. They are growing faster than grade 1 but not as fast as grade 3.
Grade 3
(high grade)
Cancer cells look very different from normal cells. They are fast growing.

Prognosis

Prognosis means the expected outcome of a disease.

Most people with early breast cancer can be treated successfully. Survival rates have increased significantly over time due to better diagnostic tests and scans, earlier detection and improvements in treatment methods. According to recent statistics, the five-year survival rate for women with IDC, the most common type of breast cancer, is 90%.

A cure may still be possible for people with other types of breast cancer. For many, treatment can improve quality of life.

Which health professionals will I see?

You will be cared for by health professionals who specialise in different aspects of your treatment. You may also see other allied health professionals who work alongside the doctors and nurses.

Allied health professionals provide important care and support services. The following health professionals may be in your multidisciplinary team (MDT).

Specialist health professionals
breast surgeon
specialises in surgery and performs biopsies; some breast surgeons also perform breast reconstruction and specialised oncoplastic procedures as part of the breast cancer surgery
oncoplastic breast surgeon
specialises in the use of plastic surgery techniques to achieve good appearance after surgery
pathologist
examines cells and tissue that is removed from the breast to determine the type and extent of the cancer
breast care nurses
specialist nurses who are trained in breast cancer care and provide information and support through all stages of treatment and ongoing care
radiologist
specialises in reading x-rays, such as mammograms
radiation oncologist
prescribes and coordinates radiotherapy
radiation therapist
plans and delivers radiation treatment
medical oncologist
prescribes and coordinates chemotherapy, hormone therapy and targeted drug therapies
GP (general practitioner)
explains information provided by specialists, helps you with treatment decisions, assists you in obtaining practical and emotional support, and works in partnership with your specialist in providing your ongoing care
reconstructive (plastic) surgeon
performs breast reconstruction for women who have had a mastectomy
lymphoedema therapist
educates patients about lymphoedema management and provides treatment if lymphoedema occurs
physiotherapist, occupational therapist
assist in restoring range of movement after surgery
nurses
support and help you through all stages of your treatment
genetic counsellor
provides advice for people with a strong family history of breast cancer
counsellor, psychologist, psychiatrist
provide emotional support and help manage anxiety and depression

Key points

  • Several tests are used to diagnose breast cancer.
  • Your doctor will feel your breasts and upper body, and you will probably have an x-ray of the breast (mammogram) to check for any changes.
  • You may have an ultrasound, which is a painless scan that uses soundwaves to create a picture of your body.
  • You may have a breast MRI, which is used to assess dense breast tissue and involves an injection of dye.
  • A biopsy is when a small sample of tissue is removed from your breast. There are a few ways of doing a biopsy.
  • Some types of breast cancer are sensitive to hormones that can cause the cancer to grow. Knowing if the cancer cells have hormone receptors helps your doctors recommend treatment.
  • You may have other tests, such as blood tests, x-rays, and CT and PET scans to see if the cancer has spread to other parts of your body.
  • Knowing how far the cancer has spread (stage) helps your doctors plan treatment. The cancer will also be given a grade, which describes how fast the cancer cells are growing.
  • Prognosis is the expected outcome of the disease. Most women with early breast cancer can be treated successfully.
  • A range of health professionals will work together to care for you. This multidisciplinary team may include a surgeon, nurses, a medical oncologist and a radiation oncologist.

Information reviewed by: Dr Carolyn Cho, Breast and General Surgeon, Surgical Oncology, Deakin, ACT; Lynn Buglar, Breast Physician, BreastScreen, NSW; Mena Crew, Consumer; Elizabeth Jacobson, Consumer; Jane Marsh, Clinical Manager, Breast Centre, Brian Fricker Oncology Centre and Burnside War Memorial Hospital, SA; Marie Murdoch, Breast Care Nurse, Cancer Council Queensland, QLD; and Marion Strong, Clinical Nurse Consultant Breast Care Nurse and Cancer Care Coordinator, Toowoomba Hospital, QLD.

Updated: 01 Aug, 2014