Diagnosing breast cancer

Friday 1 July, 2016

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On this page: Mammogram | Ultrasound | MRI | Biopsy | Hormone receptor, HER2 and gene tests | Further tests | Staging and grading | Prognosis | Which health professionals will I see? | Key points


If you have symptoms of breast cancer, your general practitioner (GP) will take a full medical history, which will include your family history. They will also perform a physical examination, checking your breasts and the lymph nodes under your arms.

Your GP may refer you to a specialist for further tests to find out if your breast change is due to cancer.

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. Both breasts will be checked during a mammogram.

During the mammogram, your breast is pressed between two x-ray plates, which spread the breast tissue out so clear pictures can be taken. This can be uncomfortable, but it takes only about 20 seconds.

If the lump that you or your GP could feel does not show up 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 breast. 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 a tumour. A computer creates a picture from these echoes. The scan is painless and takes about 15–20 minutes.

MRI

A magnetic resonance imaging (MRI) scan uses a large magnet and radio waves to create pictures of the breast tissue on a computer. Breast MRI is commonly used to screen people who are at high risk of breast cancer, but it can also be used in people with very dense breast tissue.

Before the scan, you will have an injection of a contrast dye to make any cancerous breast tissue easier to see. You will lie face down on a table with cushioned openings for your breasts with your arms above your head. The table slides into the machine, which is large and shaped like a cylinder. The scan is painless and takes 30–60 minutes.

Biopsy

During a biopsy, a small sample of cells or tissue is removed from your breast. A pathologist examines the sample and checks it for cancer cells under a microscope.

The results of the biopsy and further 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 near the edge (margin) of the removed breast tissue, and whether there are cancer cells in your lymph nodes. The report will help your doctor decide what treatment is best for you.

There are a few ways of taking a biopsy, and you may need more than one. The biopsy may be done in a specialist’s rooms, at a radiology practice, in hospital or at a breast clinic.

Fine needle aspiration (FNA)

A thin needle is used to take cells from the breast lump or abnormal area. Sometimes an ultrasound is used to help guide the needle. The test can feel similar to having blood taken and may be a bit uncomfortable. A local anaesthetic may be used to numb the area where the needle will be inserted.

Core biopsy

A wider needle is used to remove a piece of tissue (a core) from the lump or abnormal area. It is usually done under local anaesthetic, so your breast is numb, although you may feel some pain or discomfort when the anaesthetic is given. During a core biopsy, a mammogram, ultrasound or MRI is used to guide the needle. You may have some bruising to your breast afterwards.

Vacuum-assisted stereotactic core biopsy

In this core biopsy, a number of small tissue samples are removed through one small cut (incision) in the skin using a needle and a suction-type instrument. It is done under a local anaesthetic. A mammogram, ultrasound or MRI may be used to guide the needle into place. You may feel some discomfort during the procedure.

Surgical biopsy

If the abnormal area is too small to be biopsied using other methods or the biopsy result isn’t clear, 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 a local anaesthetic, and the doctor may use a mammogram, ultrasound or MRI to guide the wire into place. The biopsy is then done under a general anaesthetic. The lump and a small area of nearby breast tissue are removed, along with the wire. This is usually done as day surgery, but some people stay in hospital overnight.

Hormone receptor, HER2 and gene tests

The breast tissue that is biopsied will be tested to check whether the tumour is sensitive to hormones (hormone receptor status) or has high levels of growth factors (HER2 status). It may also be tested to provide information about the risk of cancer recurrence and whether chemotherapy will be beneficial for you (genomic assays). The results help your doctors recommend the best treatment for you.

Hormone receptor status

Hormones are chemicals in the body that transfer information. The hormones oestrogen and progesterone (present in both men and women) cause some types of breast cancer to grow. These are called hormone receptor positive or hormone sensitive cancers.

A hormone receptor is a protein in a cell. In breast cancer, the hormone receptors receive signals from oestrogen and progesterone to promote cancer cell growth. About three out of four breast cancers contain oestrogen or progesterone receptors (see below).

Status Description
Therapy response
ER+ Cancer cells with oestrogen receptors are called oestrogen receptor positive. A cancer that is ER+ or PR+ is more likely to respond to hormone therapy.
PR+ Cancer cells with progesterone receptors are called progesterone receptor positive.
ER– and/or PR– Cells without hormone receptors are called hormone receptor negative. Hormone receptor negative breast cancer does not respond to hormone therapy.

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 cells to grow and divide in an uncontrolled way.

Tumours that have high levels of these receptors are called HER2 positive (HER2+). Tumours with low levels are called HER2 negative (HER2−).

Treatment with targeted therapy, such as trastuzumab (Herceptin®), is usually recommended to treat HER2+ breast cancer.

Genomic assays

Genomic assays, or molecular assays, are tests that provide information about the risk of the cancer coming back after treatment. They can also predict whether you are likely to benefit from chemotherapy treatment.

The test is for people with hormone receptor positive or HER2 negative breast cancer.

Several types of genomic assays are available. They include the Oncotype DX® Breast Cancer Assay (Oncotype DX test), EndoPredict® and Prosigna®.

None of the tests are currently covered by Medicare or private health funds. They cost between $2900 and $4500, and the results can take up to two weeks.

The available tests all have advantages and disadvantages.

If you and your oncologist decide that it is worth having a genomic assay, the test you choose will depend on a number of factors, including your doctor’s experience. Your doctor can provide you with further information.

Further tests

If the tests described above show that you have breast cancer, one or more tests may be done to see if the cancer has spread to other parts of your body.

Blood tests

Blood samples may be taken to check your general health and 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.

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 the radioactive material is not harmful. You should drink plenty of fluids on the day of the test and the day after.

CT scan

A CT (computerised tomography) scan uses x-rays and a computer to create detailed, cross-sectional pictures of the inside of the body. You may have to fast (not eat or drink) for a period of time beforehand to make the scan pictures clearer and easier to read.

Before the scan, you will either drink a liquid dye or be given an injection of dye into a vein in your arm. This dye is known as the contrast and it makes the pictures clearer. If you have the injection, you may 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 30–40 minutes.

The dye used in a CT scan usually contains iodine. If you have had an allergic reaction to iodine or dyes during previous scans, let the person performing the scan know in advance. You should also tell the doctor if you’re diabetic, have kidney disease or are pregnant.

PET scan

A PET (positron emission tomography) scan is a specialised test, which is rarely done for breast cancer. It is currently not funded by Medicare as a routine test for breast cancer. A PET scan uses low-dose radioactive glucose to measure cell activity in different parts of the body.

If you do have a PET scan, a small amount of the glucose will be injected into a vein, usually in your arm. You will need to wait for about an hour for the fluid to move around your body, and then you will lie on a table that moves through a scanning machine. The scan will show ‘hot spots’ where the fluid has accumulated – this happens where there are active cells, like cancer cells.

Staging and grading breast cancer

The tests described above show whether 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.

The grade describes how active the cancer cells are and how fast the cancer is likely to be growing.

Staging
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 2–5 cm in diameter and has not spread to the lymph nodes in the armpit.
Stage IIB
  • The tumour is 2–5 cm in diameter and has spread to the lymph nodes in the armpit.

Stage III is referred to as locally advanced breast cancer, and stage IV refers to advanced breast cancer. For information about these stages, call Cancer Council 13 11 20 or visit canceraustralia.gov.au.

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 breast cancer, 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. You may wish to discuss your prognosis with your doctor, but it is not possible for any doctor to predict the exact course of the disease.

Survival rates for people with breast cancer have increased significantly over time due to better diagnostic tests and scans, earlier detection, and improvements in treatment methods. Most people with early breast cancer can be treated successfully.

Which health professionals will I see?

You will be cared for by a range of health professionals who specialise in different aspects of your treatment. Specialists and other health professionals will take a team-based approach to your care as part of a multidisciplinary team (MDT). The health professionals listed below may be in your MDT.

Health professional Role
GP works in partnership with your specialist in providing your ongoing care
breast surgeon* specialises in surgery and performs biopsies; some breast surgeons also perform breast reconstruction and specialised oncoplastic procedures
oncoplastic breast surgeon* specialises in using plastic surgery techniques to achieve a good cosmetic outcome after surgery
reconstructive (plastic) surgeon* performs breast reconstruction for women who have had a mastectomy
anaesthetist* administers anaesthetic before surgery and monitors you during the operation
pathologist* examines cells and tissue samples that are 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
nurses administer drugs and provide care, information and support throughout your treatment
radiologist* specialises in reading x-rays, such as mammograms
radiation oncologist* prescribes and coordinates the course of radiotherapy
radiation therapist plans and delivers radiotherapy
medical oncologist* prescribes and coordinates the course of chemotherapy, hormone therapy and targeted therapy
lymphoedema practitioner/therapist educates people about lymphoedema prevention and management, and provides treatment if lymphoedema occurs
dietitian recommends an eating plan to follow during treatment and recovery
physiotherapist, occupational therapist assist in restoring range of movement after surgery, and help with practical issues
social worker links you to support services and helps with emotional, physical or practical issues
genetic counsellor provides advice for people with a strong family history of breast cancer
psychiatrist*, counsellor, psychologist provide emotional support and help manage feelings of anxiety and depression
*Specialist doctor

Key points

  • Several tests are used to diagnose breast cancer.
  • Your doctor will examine your breasts, 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 breast.
  • An MRI is used to assess dense breast tissue and involves an injection of dye to show up cancerous tissue.
  • A biopsy is when a sample of tissue is removed from your breast. Types of biopsy include fine needle aspiration, core biopsy, vacuum-assisted stereotactic core biopsy and surgical 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 the best treatment.
  • You may have other tests, such as blood tests, a chest x-ray, a bone scan or a CT scan, to see if the cancer has spread to other parts of your body. In rare cases, a PET scan is done.
  • Staging the cancer helps your doctors plan treatment. The grade describes how fast the cancer cells are growing.
  • Prognosis is the expected outcome of the disease. Most people with early breast cancer can be treated successfully.
  • A range of health professionals will work together to care for you. This multidisciplinary team (MDT) may include a surgeon, breast care nurses, a radiation oncologist and a medical oncologist.

Please note: This information is about early breast cancer. For information about secondary breast cancer (also called metastatic or advanced breast cancer), visit Breast Cancer Network Australia or Cancer Australia.

Related topics: Genetics and breast cancer | Breast reconstruction and prosthesis | Breast cancer trials | Breast health

Reviewed by: A/Prof Meagan Brennan, Breast Physician, Westmead Breast Cancer Institute, NSW; Carole Andary, Cancer Council Nurse, Cancer Council SA; Tracey Bretag, Consumer; Terri-lee Cooper, McGrath Breast Care Nurse, Cancer Screening and Control Services, Tasmanian Health Service, TAS; Dr Richard de Boer, Medical Oncologist, Royal Melbourne and Epworth Hospitals, VIC; Miss Jane O’Brien, Specialist Breast and Oncoplastic Surgeon, Epworth Breast Service, VIC; Susan Schwabe, Breast Cancer Care: Clinical Nurse Consultant, W.P. Holman Clinic, Launceston General Hospital, TAS; Dr Anita Taylor, Deputy Director, The Wesley Breast Clinic, QLD.

 

Updated: 01 Jul, 2016