Breast cancer


Diagnosing breast cancer

Wednesday 16 September, 2020

If you have any breast changes or a mammogram shows something suspicious, your doctor will ask about your medical history, including your family history of breast cancer. They will also perform a physical examination, checking both your breasts as well as the lymph nodes under your arms and above your collarbone.

To find out if your breast change has been caused by cancer, your doctor 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.

Cancer care pathways

For an overview of what to expect during all stages of your cancer care, read or download the What To Expect guide for breast cancer (also available in Arabic, Chinese, Greek, Hindi, Italian, Tagalog and Vietnamese – see details on the site). The What To Expect guide is a short guide to what is recommended for the best cancer care across Australia, from diagnosis to treatment and beyond.

Mammogram

A mammogram is a low-dose x-ray of the breast tissue. The mammogram can check a lump or other change found by the physical examination. It can also show changes that can’t be felt during a physical examination.

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. If you have breast implants, let staff know before you have the mammogram.

Tomosynthesis

Also known as three-dimensional mammography or digital breast tomosynthesis (DBT), tomosynthesis takes x-rays of the breast from different angles and uses a computer to combine them into a three-dimensional image. This form of breast imaging is sometimes used to find small breast cancers, particularly in women with dense breast tissue.

Ultrasound

An ultrasound uses soundwaves to create a picture of breast tissue. It will often be done if a mammogram picks up breast changes, or if you or your doctor can feel a lump.

The person performing the ultrasound will spread a gel on your breast, and then move a small device called a transducer over the area and the lymph nodes in your armpit. The transducer 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 to 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 implants. It may also be used if imaging tests results are not clear and to help plan breast surgery.

Before an MRI, 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. The table slides into the machine, which is large and shaped like a cylinder. The scan may take 30 to 40 minutes. It is painless but can be noisy. You will usually be offered earplugs or headphones to listen to music. Some people feel anxious or claustrophobic in the cylinder. If you think you may become distressed, mention it beforehand to your medical team. You may be given a mild sedative to help you relax.

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 examines the sample and checks it for cancer cells under a microscope.

There are different ways of taking a biopsy and you may need more than one type. The biopsy may be done in a specialist’s rooms, at a radiology practice, in hospital or at a breast clinic. Bruising to your breast is common after any type of biopsy.

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 stereotactic 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. This biopsy 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 found on a screening mammogram or other imaging technique. 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.

Further tests

If the tests described above show that you have breast cancer, one or more tests may be done to check whether the cancer has spread to other parts of your body. Bone scans and CT scans are not routine tests for breast cancer and are only done if the cancer has a high risk of spreading.

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. 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, known as the contrast, makes the pictures clearer. 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.

Before having scans, tell the doctor if you have any allergies or have had a reaction to contrast during previous scans. You should also let them know if you are diabetic, have kidney disease or are pregnant.

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. In working out a prognosis, your doctor will consider the stage and grade of the cancer (see below), as well as its hormone receptor and HER2 status.

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

Staging breast cancer

The tests described above show whether the cancer has spread to other parts of the body. This is called staging.

Stage I Tumour less than 2 cm and no spread to lymph nodes.
Stage IIA Tumour less than 2 cm and spread to 1–3 lymph nodes in armpit; or tumour 2–5 cm and no spread to lymph nodes.
Stage IIB Tumour 2–5 cm and spread to 1–3 lymph nodes in armpit; or tumour more than 5 cm and no spread to lymph nodes.
Stage IIIA Tumour less than 5 cm but spread to 4–9 lymph nodes in armpit or any lymph nodes under breastbone; or tumour more than 5 cm and spread to 1–9 lymph nodes.
Stage IIIB Tumour any size but spread to nearby muscles and skin.
Stage IIIC Tumour any size but spread to at least 10 lymph nodes in armpit; or to at least 1 node under breastbone and at least 1 in armpit; or to at least 1 node near collarbone.

Stages I and II are called early breast cancer, while stage III is referred to as locally advanced. Stage IV breast cancer has spread to other parts of the body and is called advanced or metastatic.

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 slow-growing.
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 fast-growing.

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 factors shown here and help plan treatment. Your surgeon may suggest leaving some of these tests until the whole lump is removed and examined after surgery. The results will be included in the pathology report.

Hormone receptor status

Hormones are chemicals in the body that transfer information. Both women and men produce the female sex hormones oestrogen (ER) and progesterone (PR), although the levels are lower in postmenopausal women and in men.

A hormone receptor is a protein in a cell. Most breast cancers have cells with hormone receptors that receive signals from oestrogen or progesterone, so these hormones may be helping the cancers grow. These cancers are called hormone receptor positive (ER+ and/or PR+) or hormone sensitive cancers. They are likely to respond to hormone therapy that blocks oestrogen.

ER and or PR positive

HER2 status

HER2 (human epidermal growth factor receptor 2) is 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 (brand name Herceptin, as well as chemotherapy, is usually recommended for HER2+ breast cancer.

HER2 positive

Triple negative breast cancer

Some breast cancers are hormone receptor negative (ER- and PR-) and HER2 negative (HER2-). These are called triple negative cancers.

Triple negative cancers do not respond to hormone therapy nor to targeted therapy aimed at HER2. However, triple negative cancers often respond well to chemotherapy.

As triple negative is a less common form of breast cancer, you may find it helpful to talk to other women with a similar diagnosis. See information on peer support services.

Genomic assays

Genomic assays, also called molecular assays, are tests that look at the patterns of certain genes within the cancer cells. These patterns help predict the risk of the cancer coming back, and this information helps guide treatment. For example, if there is a low risk of the cancer coming back, you may not need chemotherapy.

The genomic assays that are currently available are only for breast cancer that is ER+ and HER2-. They include the Oncotype DX Breast Cancer Assay, EndoPredict and Prosigna. These tests can cost up to several thousand dollars and are not currently covered by Medicare or private health funds.

It is important to remember that the standard pathology tests that are done on all breast cancers often provide enough information to guide treatment plans. 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.

Key points about diagnosing breast cancer

Main tests

Tests to diagnose breast cancer include:

  • physical examination
  • mammogram (breast x-ray)
  • ultrasound
  • MRI (for those with strong family history)
  • biopsy (taking a tissue sample).

Other tests

Other tests can give more information about the cancer to help guide treatment. These tests may include:

  • blood tests
  • chest x-ray
  • bone scan
  • CT scan.

Key information about the cancer

  • The stage shows how far the cancer has spread. Early breast cancer is stage I or II. Locally advanced breast cancer is stage III.
  • The grade indicates how fast the cancer is likely to grow.
  • Hormone receptor status (ER+/- and/or PR+/-) shows whether the cancer may respond to hormone therapy.
  • HER2 status (HER2+/-) shows whether the cancer may respond to targeted therapy.
  • Genomic assays look at gene patterns within cancer cells. These can help work out if chemotherapy is needed.

Expert content reviewers:

Prof Christobel Saunders, Professor of Surgical Oncology and Head, Division of Surgery, The University of Western Australia, and Consultant Surgeon, Royal Perth, Fiona Stanley and St John of God Subiaco Hospitals, WA; Dr Marie-Frances Burke, Radiation Oncologist, Medical Director, Genesis CancerCare Queensland, QLD; Kylie Campbell, Breast Care Nurse and Clinical Lead, Murraylands, McGrath Foundation, SA; Carmen Heathcote, 13 11 20 Consultant, Cancer Council Queensland, QLD; Annmaree Mitchell, Consumer; Sarah Pratt, Nurse Coordinator, Breast Service, Peter MacCallum Cancer Centre, VIC; Dr Wendy Vincent, Breast Physician, Chris O'Brien Lifehouse and Royal Hospital for Women, Randwick, NSW, and Clinical Director BreastScreen NSW, Royal Prince Alfred Hospital, NSW; A/Prof Nicholas Wilcken, Director of Medical Oncology, Westmead Hospital, and Co-ordinating Editor, Cochrane Breast Cancer Group, NSW.

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