Diagnosing breast cancer

Sunday 1 July, 2018

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On this page: Mammogram | Ultrasound | MRI | Biopsy | Further tests | Prognosis | Staging breast cancer | Grading breast cancer | Tests on breast tissue | Key points


If you have symptoms of breast cancer, your GP will take a full medical history, which will include your family history. They will also perform a physical examination,st 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 GP may arrange some tests, such as a mammogram (see below) and biopsy. They may also refer you to a specialist for these and other tests.

Mammogram

A mammogram is a low-dose x-ray of the breast tissue. This x-ray can check any lumps or other changes found by the physical examination. It can also find changes that are too small to be felt during a physical examination.

During the mammogram, one breast at a time is pressed between two x-ray plates, which spread the breast tissue out so that clear pictures can be taken. This can be uncomfortable, but it takes only about 20 seconds. 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 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 is a painless scan that uses soundwaves to create a picture of your breast. It will be done if a mammogram picks up breast changes, or if you or your GP can feel a lump that doesn't show up on the mammogram.

The person performing the ultrasound will spread a gel on your breast, and then move a small device called a transducer 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 not a standard test for breast cancer and can involve extra costs. It is mainly used to screen people who are at high risk of breast cancer or to diagnose breast cancer in women with very dense breast tissue or implants. It may also be used 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 and rest 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 specialist doctor called a pathologist examines the sample and checks it for cancer cells under a microscope.

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.

Core biopsy

A 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 will be numb, although you may feel some pain or discomfort when the anaesthetic is given. During the core biopsy, a mammogram, ultrasound or MRI scan is used to guide the needle into place. You may have some bruising to your breast afterwards.

Vacuum-assisted stereotactic core biopsy

In this type of 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. This biopsy is done under a local anaesthetic, but you may feel some discomfort. A mammogram, ultrasound or MRI may be used to guide the needle into place.

Fine needle aspiration (FNA)

A thin needle is used to take cells from an abnormal lymph node (core biopsy is preferred for breast lumps). Sometimes an ultrasound is used to help guide the needle into place. A local anaesthetic may be used to numb the area where the needle will be inserted.

Surgical biopsy

If the abnormal area is too small to be biopsied using other methods, or the biopsy result is not clear enough to rule out cancer, 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.

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.

Reviewed by: 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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