If you notice any breast changes or a mammogram shows something, your GP will ask about your medical history and any family history of breast cancer. They will do a physical examination, checking both breasts and the lymph nodes in your armpit and above your collarbone.
To find out if the changes have been caused by cancer, your GP may arrange some tests, such as a mammogram, ultrasound, breast MRI and possibly a biopsy. They may refer you to a specialist for these and other tests.
The national BreastScreen Australia program gives free access to breast cancer screening tests for all women over 40.
Your guide to best cancer care
A lot can happen in a hurry when you’re diagnosed with cancer. The guide to best cancer care for breast cancer can help you make sense of what should happen. It will help you with what questions to ask your health professionals to make sure you receive the best care at every step.
Read the guide
Mammogram
A mammogram is a low-dose x-ray of the breast tissue. It can check any lump or other breast changes found during a physical examination. It can also show changes that are small or can’t be felt during a physical examination.
If you have breast implants, it’s important to let staff know before you have the mammogram.
Your breast is placed between two x-ray plates. The plates press together firmly for a few moments to spread the breast tissue out so that clear pictures can be taken. You will feel some pressure, which can be uncomfortable. Both breasts will be checked.
Tomosynthesis
Also known as three-dimensional mammography or digital breast tomosynthesis (DBT), tomosynthesis takes x-rays of the breast from many angles and uses a computer to combine them into a three-dimensional (3D) image.
Tomosynthesis may be better for finding small breast cancers, particularly in dense breast tissue.
Ultrasound
An ultrasound uses soundwaves to create a picture of breast tissue. It is often done if a mammogram picks up breast changes, or if you or your GP can feel a lump.
The person doing the ultrasound will spread gel on your breast, and then move a small device called a transducer over the breast area and armpit. 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 15–20 minutes.
Breast 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 mainly used for people who are at high risk of breast cancer or who have very dense breast tissue or breast implants. It may also be used if other imaging test results are not clear or to help plan breast surgery.
The scan can take 30–40 minutes. It is painless but loud, so you'll wear earplugs. Some people feel claustrophobic. If you think you may feel anxious, speak to your doctor before the appointment. You may be offered a mild sedative.
Biopsy
If breast cancer is suspected, a small sample of cells or tissue is taken from the lump or area of concern. A specialist doctor called a pathologist checks the sample under a microscope for any cancer cells.
The biopsy may be done in a specialist’s rooms, at a radiology practice, in hospital or at a breast clinic. Bruising and soreness to your breast is common after any type of biopsy.
Biopsy types
There are different ways of taking a biopsy and you may need more than one type.
- Core biopsy – the piece of tissue (a core) is removed with a needle. Local anaesthetic is used to numb the area, and a mammogram, ultrasound or MRI scan is used to guide the needle into place.
- Vacuum-assisted core biopsy – a needle attached to a suction-type instrument is inserted into a small cut in the breast. A larger amount of tissue is removed with a vacuum biopsy, making it more accurate in some situations. The needle is usually guided into place with a mammogram, ultrasound or MRI. It is done under a local anaesthetic, but you may feel some discomfort.
- Fine needle aspiration (FNA) – a thin needle is inserted into an abnormal lymph node or other tissue, often with an ultrasound to help guide the needle into place. A local anaesthetic may be used to numb the area where the needle is inserted.
- Surgical biopsy – if a needle biopsy is not possible, or if the biopsy result doesn’t provide a clear diagnosis, you may have a surgical biopsy to remove all or part of a lump. A wire or other device is inserted to act as a guide during the surgery, and then the tissue is removed under general anaesthetic. This is usually done as day surgery.
Tests on breast tissue
If tests on the biopsy sample show that it is breast cancer, extra tests will be done to work out the below features and help plan treatment. The results will be included in the pathology report.
Hormone receptor status
The hormones oestrogen and progesterone are produced naturally in the body. A receptor is a protein on the surface of the cell.
Normal breast cells have oestrogen receptors (ER) and progesterone receptors (PR). Breast cancers that have too many of these receptors are known as ER positive (+) or PR positive (+). This lets more oestrogen or progesterone enter the cell, where it stimulates cancer cell growth.
ER+ and PR+ cancers are usually treated with hormone therapy drugs (or endocrine therapy) that block the receptor, or drugs that reduce the amount of hormones that the body makes (aromatase inhibitors). If the cancer has low levels of receptors (ER-), these drugs are generally not used.
ER+ and/or PR+ cancers account for 70–80% of all breast cancers.
HER2 status
HER2 (human epidermal growth factor receptor 2) is a protein that is found on the surface of all cells and controls how cells grow and divide. Tumours that have high levels of these receptors are called HER2 positive (HER+). Tumours with low levels are called HER2 negative (HER2–).
It is often recommended that people with HER2+ breast cancer have chemotherapy and targeted therapy before they have surgery. This is known as neoadjuvant chemotherapy or neoadjuvant therapy. You may also have chemotherapy or other therapy after surgery. This is known as adjuvant therapy.
HER2+ cancers account for 15–20% of all breast cancers.
Triple negative breast cancer
Some breast cancers are hormone receptor negative (ER– and PR–) as well as being HER2 negative (HER2–). These are called triple negative breast cancers.
Triple negative cancers do not respond to hormone therapy or to the targeted therapy drugs used for HER2+ cancers. The current treatment options for people with triple negative breast cancer include chemotherapy before and/or after surgery and some other types of targeted therapy drugs. Triple negative breast cancers usually respond well to chemotherapy. Radiation therapy may also be given after some types of surgery.
Women who have not been through menopause and people with a BRCA1 mutation are at higher risk of having triple negative breast cancer.
ER-, PR- and HER2- cancers account for 10–20% of all breast cancers.
Further tests
If tests show that you have breast cancer, you may have further tests to check whether the cancer has spread. Not everyone will need all these tests.
- Blood tests – a blood sample may be taken to check your general health, bone marrow and liver function, and to test for specific tumour markers.
- Bone scan – may be done to see if the breast cancer has spread to your bones.
- CT scan – uses x-ray beams to take pictures of the inside of the body and looks for signs that the cancer has spread.
- PET scan – uses a small amount of low-level radioactive solution to help cancerous areas show up brighter in the scan.
Before a scan, tell the doctor if you have any allergies or had a reaction to dyes during previous scans. Also tell them if you have diabetes or kidney disease or are pregnant or breastfeeding.
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Staging breast cancer
Tests show the size of the breast cancer and if it has spread to other parts of the body. This is called staging. It helps you and your health care team decide what treatment is best for you.
- Early breast cancer (stage 1 or 2) – the cancer is contained in the breast and may or may not have spread to lymph nodes in the armpit.
- Locally advanced breast cancer (stage 3) – the cancer is larger than 5 cm, has spread to tissues around the breast such as the skin, muscle or ribs, or has spread to a large number of lymph nodes.
- Metastatic breast cancer (stage 4) – breast cancer has spread to other parts of the body. It is also called secondary or advanced breast cancer. It is different to locally advanced breast cancer.
The most common staging system for breast cancer is the TNM (Tumour-Nodes-Metastasis) system. It can be complicated so ask your doctor to explain how it applies to you.
The staging system also shows other details about the breast tumour such as oestrogen and progesterone receptor status, HER2 status and the grade of the cancer. Sometimes your doctor will also do further tests to examine the changes in the cancer cells and how likely it is the cancer may come back. These are called gene activity tests.
What are gene activity tests?
Known as molecular assays, genomic assays, or a gene expression profile, these tests look at which genes are active in the cancer cells. The patterns they show help to predict the risk of cancer returning. This can help guide treatment plans.
These tests may be suggested for some early breast cancers (ER+ and HER–) to see whether chemotherapy is needed. For example, if the risk of cancer returning is high, chemotherapy may be needed. If the risk is low, hormone therapy, or no extra therapy, may be suggested.
The current molecular assays used include Oncotype DX, EndoPredict, Prosigna and MammaPrint. They are not usually covered by Medicare or private health funds and can cost several thousand dollars.
Ask your medical oncologist if a gene activity test is of use for you. The standard pathology tests done on all breast cancers may be all that’s needed for your treatment plan.
Grading breast cancer
The grade describes how active the cancer cells are and how fast the cancer is likely to be growing.
- Grade 1 (low grade) – cancer cells look a little different from normal cells. They are usually growing slowly.
- Grade 2 (intermediate grade) – cancer cells do not look like normal cells. They are growing faster than grade 1 cancer cells.
- Grade 3 (high grade) – cancer cells look very different from normal cells. They are usually growing fast.
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 anyone to predict the exact course of the disease. To work out your prognosis, your doctor will consider the stage and grade of the cancer, as well as features such as the cancer’s hormone receptor and HER2 status.
The survival rates for people with breast cancer have increased significantly over time due to more people taking part in screening, better tests and scans, and improved medicines and treatments.
Doctors often use five-year survival rates as a way to discuss prognosis. This is because research studies often follow people for five years – it does not mean you will survive for only five years. Compared with other cancers, breast cancer has one of the highest five-year survival rates when diagnosed early.
Expert content reviewers:
A/Prof Elisabeth Elder, Specialist Breast Surgeon, Westmead Breast Cancer Institute and The University of Sydney, NSW; Collette Butler, Clinical Nurse Consultant and McGrath Breast Care Nurse, Cancer Support Centre, Launceston, TAS; Tania Cercone, Consumer; Kate Cox, 13 11 20 Consultant, Cancer Council SA; Dr Marcus Dreosti, Radiation Oncologist and Medical Director, GenesisCare, SA; Dr Susan Fraser, Breast Physician, Cairns Hospital and Marlin Coast Surgery Cairns, QLD; Dr Hilda High, Genetic Oncologist, Sydney Cancer Genetics, NSW; Prof David W Kissane AC, Chair of Palliative Medicine Research, The University of Notre Dame Australia, and St Vincent’s Hospital Sydney, NSW; Prof Sherene Loi, Medical Oncologist, Peter MacCallum Cancer Centre, VIC; Dr W Kevin Patterson, Medical Oncologist, Adelaide Oncology and Haematology, SA; Angela Thomas, Consumer; Iwa Yeung, Physiotherapist, Princess Alexandra Hospital, QLD.
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The information on this webpage has been adapted from Understanding Breast Cancer - A guide for people with cancer, their families and friends (2022 edition). This webpage was last updated in July 2022.