June 25th, 2012 by Hasham
How is Breast Cancer Diagnosed?
Breast cancer is sometimes found after symptoms appear, but many women with early breast cancer have no symptoms. This is why getting the recommended screening tests (as described in the section, “Can breast cancer be found early?”) before any symptoms develop is so important.
If something suspicious is found during a screening exam, or if you have any of the symptoms of breast cancer described below, your doctor will use one or more methods to find out if the disease is present. If cancer is found, other tests will be done to determine the stage (extent) of the cancer.
Signs and symptoms
Widespread use of screening mammograms has increased the number of breast cancers found before they cause any symptoms. Still, some breast cancers are not found by mammogram, either because the test was not done or because, even under ideal conditions, mammograms do not find every breast cancer.
The most common symptom of breast cancer is a new lump or mass. A painless, hard mass that has irregular edges is more likely to be cancerous, but breast cancers can be tender, soft, or rounded. They can even be painful. For this reason, it is important that any new breast mass or lump be checked by a health care professional experienced in diagnosing breast diseases.
Other possible signs of breast cancer include:
* Swelling of all or part of a breast (even if no distinct lump is felt)
* Skin irritation or dimpling
* Breast or nipple pain
* Nipple retraction (turning inward)
* Redness, scaliness, or thickening of the nipple or breast skin
* Nipple discharge (other than breast milk)
Sometimes a breast cancer can spread to lymph nodes under the arm or around the collar bone and cause a lump or swelling there, even before the original tumor in the breast tissue is large enough to be felt.
Medical history and physical exam
If you have any signs or symptoms that might be due to breast cancer, be sure to see your doctor as soon as possible. Your doctor will ask you questions about your symptoms, any other health problems, and possible risk factors for benign breast conditions or breast cancer.
Your breasts will be thoroughly examined for any lumps or suspicious areas and to feel their texture, size, and relationship to the skin and chest muscles. Any changes in the nipples or the skin of your breasts will be noted. The lymph nodes in the armpit and above the collarbones may be palpated (felt), because enlargement or firmness of these lymph nodes might indicate spread of breast cancer. Your doctor might also do a complete physical exam to judge your general health and whether there is any evidence of cancer that may have spread.
If breast symptoms and/or the results of your physical exam suggest breast cancer might be present, more tests will probably be done. These might include imaging tests, looking at samples of nipple discharge, or doing biopsies of suspicious areas.
Imaging tests used to evaluate breast disease
Imaging tests use x-rays, magnetic fields, sound waves, or radioactive substances to create pictures of the inside of your body. Imaging tests may be done for a number of reasons, including to help find out whether a suspicious area might be cancerous, to learn how far cancer may have spread, and to help determine if treatment is working.
A mammogram is an x-ray of the breast. Screening mammograms are used to look for breast disease in women who are asymptomatic; that is, they appear to have no breast problems. Screening mammograms usually take 2 views (x-ray pictures taken from different angles) of each breast.
Diagnostic mammograms are used to diagnose breast disease in women who have breast symptoms (like a lump or nipple discharge) or an abnormal result on a screening mammogram. A diagnostic mammogram includes more images of the area of concern. In some cases, special images known as cone or spot views with magnification are used to make a small area of abnormal breast tissue easier to evaluate.
* That the abnormality is not worrisome at all. In these cases the woman can usually return to having routine yearly mammograms.
* That a lesion (area of abnormal tissue) has a high likelihood of being benign (not cancer). In these cases, it is common to ask the woman to come back sooner than usual for her next mammogram, usually in 4 to 6 months.
* That the lesion is more suspicious, and a biopsy is needed to tell if it is cancer.
Even if the mammograms show no tumor, if you or your doctor can feel a lump, a biopsy is usually needed to make sure it isn’t cancer. One exception would be if an ultrasound exam finds that the lump is a simple cyst (a fluid-filled sac), which is very unlikely to be cancerous.
Digital mammograms: A digital mammogram (also known as a full-field digital mammogram, or FFDM) is like a standard mammogram in that x-rays are used to produce an image of your breast. The differences are in the way the image is recorded, viewed by the doctor, and stored. Standard mammograms are recorded on large sheets of photographic film. Digital mammograms are recorded and stored on a computer. After the exam, the doctor can look at them on a computer screen and adjust the image size, brightness, or contrast to see certain areas more clearly. Digital images can also be sent electronically to another site for a remote consultation with breast specialists. Many centers do not offer the digital option, but it is becoming more widely available with time.
Because digital mammograms cost more than standard mammograms, studies are now looking at which form of mammogram will benefit more women in the long run. Some studies have found that women who have a FFDM have to return less often for additional imaging tests because of inconclusive areas on the original mammogram. One large study found that a FFDM was more accurate in finding cancers in women younger than 50 and in women with dense breast tissue, although the rates of inconclusive results were similar between FFDM and film mammograms. It is important to remember that a standard film mammogram also is effective for these groups of women, and that they should not miss their regular mammogram if a digital mammogram is not available.
Magnetic resonance imaging (MRI) of the breast
MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of body tissue and by certain diseases. A computer translates the pattern into a very detailed image of parts of the body. For breast MRI to look for cancer, a contrast liquid called gadolinium is injected into a vein before or during the scan to show details better.
MRI scans can take a long time — often up to an hour. You have to lie inside a narrow tube, face down on a platform specially designed for the procedure. The platform has openings for each breast that allow them to be imaged without compression. The platform contains the sensors needed to capture the MRI image. It is important to remain very still throughout the exam.
Lying in the tube can feel confining and might upset people with claustrophobia (a fear of enclosed spaces). The machine also makes loud buzzing and clicking noises that you may find disturbing. Some places will give you headphones with music to block this noise out. MRIs are also expensive, although insurance plans generally pay for them in some situations, such as once cancer is diagnosed.
MRI machines are quite common, but they need to be specially adapted to look at the breast. It’s important that MRI scans of the breast be done on one of these specially adapted machines and that the MRI facility can also do a MRI guided biopsy if it is needed.
MRI can be used along with mammograms for screening women who have a high risk of developing breast cancer, or it can be used to better examine suspicious areas found by a mammogram. MRI is also used for women who have been diagnosed with breast cancer to better determine the actual size of the cancer and to look for any other cancers in the breast. It is not yet clear how helpful this is in planning surgery in someone known to have breast cancer. In someone known to have breast cancer, it is sometimes used to look at the opposite breast, to be sure that it does not contain any tumors.
If an abnormal area in the breast is found, it can often be biopsied using an MRI for guidance. This is discussed in more detail in the “Biopsy” section.
Ultrasound, also known as sonography, uses sound waves to outline a part of the body. For this test, a small, microphone-like instrument called a transducer is placed on the skin (which is often first lubricated with ultrasound gel). It emits sound waves and picks up the echoes as they bounce off body tissues. The echoes are converted by a computer into a black and white image that is displayed on a computer screen. This test is painless and does not expose you to radiation.
Ultrasound has become a valuable tool to use along with mammography because it is widely available and less expensive than other options, such as MRI. The use of ultrasound instead of mammograms for breast cancer screening is not recommended. Usually, breast ultrasound is used to target a specific area of concern found on the mammogram. Ultrasound helps distinguish between cysts (fluid-filled sacs) and solid masses and sometimes can help tell the difference between benign and cancerous tumors.
Ultrasound may be most helpful in women with very dense breasts. Clinical trials are now looking at the benefits and risks of adding breast ultrasound to screening mammograms in women with dense breasts and a higher risk of breast cancer.
This test, also called a galactogram, sometimes helps determine the cause of nipple discharge. In this test a very thin plastic tube is placed into the opening of the duct in the nipple that the discharge is coming from. A small amount of contrast medium is injected, which outlines the shape of the duct on an x-ray image and shows if there is a mass inside the duct.
Newer imaging tests
Newer tests like scintimammography and tomosynthesis are not used commonly and are still being studied to determine their usefulness. They are described in the section, “What’s new in breast cancer research and treatment?”
If you are having nipple discharge, some of the fluid may be collected and looked at under a microscope to see if any cancer cells are in it. Most nipple discharges or secretions are not cancer. In general, if the secretion appears milky or clear green, cancer is very unlikely. If the discharge is red or red-brown, suggesting that it contains blood, it might possibly be caused by cancer, although an injury, infection, or benign tumors are more likely causes.
Even when no cancer cells are found in a nipple discharge, it is not possible to say for certain that a breast cancer is not there. If a patient has a suspicious mass, it will be necessary to biopsy the mass, even if the nipple discharge does not contain cancer cells.
Ductal lavage and nipple aspiration
Ductal lavage is an experimental test developed for women who have no symptoms of breast cancer but are at very high risk for the disease. It is not a test to screen for or diagnose breast cancer, but it may help give a more accurate picture of a woman’s risk of developing it.
Ductal lavage can be done in a doctor’s office or an outpatient facility. An anesthetic cream is applied to numb the nipple area. Gentle suction is then used to help draw tiny amounts of fluid from the milk ducts up to the nipple surface, which helps locate the ducts’ natural openings. A tiny tube (called a catheter) is then inserted into a duct opening. Saline (salt water) is slowly infused into the catheter to gently rinse the duct and collect cells. The ductal fluid is withdrawn through the catheter and sent to a lab, where the cells are looked at under a microscope.
Ductal lavage is not done for women who aren’t at high risk for breast cancer. It is not clear if it will ever be useful. The test has not been shown to detect cancer early. It is more likely to be helpful as a test of cancer risk rather than as a screening test for cancer. More studies are needed to better define the usefulness of this test.
Nipple aspiration also looks for abnormal cells developing in the ducts, but is much simpler, because nothing is inserted into the breast. The device for nipple aspiration uses small cups that are placed on the woman’s breasts. The device warms the breasts, gently compresses them, and applies light suction to bring nipple fluid to the surface of the breast. The nipple fluid is then collected and sent to a lab for analysis. As with ductal lavage, the procedure may be useful as a test of cancer risk but is not appropriate as a screening test for cancer. The test has not been shown to detect cancer early.
During a biopsy, the doctor removes a sample of the suspicious area to be looked at under a microscope. A biopsy is done when mammograms, other imaging tests, or the physical exam finds a breast change (or abnormality) that is possibly cancer. A biopsy is the only way to tell if cancer is really present.
There are several types of biopsies, such as fine needle aspiration biopsy, core (large needle) biopsy, and surgical biopsy. Each has its pros and cons. The choice of which to use depends on your specific situation. Some of the factors your doctor will consider include how suspicious the lesion appears, how large it is, where in the breast it is located, how many lesions are present, other medical problems you may have, and your personal preferences. You might want to discuss the pros and cons of different biopsy types with your doctor.
Fine needle aspiration biopsy
In a fine needle aspiration (FNA) biopsy, the doctor uses a very thin, hollow needle attached to a syringe to withdraw (aspirate) a small amount of tissue from a suspicious area, which is then looked at under a microscope. The needle used for an FNA biopsy is thinner than the ones used for blood tests.
If the area to be biopsied can be felt, the needle can be guided into the area of the breast change while the doctor is feeling (palpating) it.
If the lump can’t be felt easily, the doctor might use ultrasound to watch the needle on a screen as it moves toward and into the mass.
A local anesthetic (numbing medicine) may or may not be used. Because such a thin needle is used for the biopsy, the process of getting the anesthetic may actually be more uncomfortable than the biopsy itself.
Once the needle is in place, fluid is drawn out. If the fluid is clear, the lump is probably a benign cyst. Bloody or cloudy fluid can mean either a benign cyst or, very rarely, a cancer. If the lump is solid, small tissue fragments are drawn out. A pathologist will look at the biopsy tissue or fluid under a microscope to determine if it is cancerous.
An FNA biopsy is the easiest type of biopsy to have, but it has some disadvantages. It can sometimes miss a cancer if the needle is not placed among the cancer cells. And even if cancer cells are found, it is usually not possible to determine if the cancer is invasive. In some cases there may not be enough cells to perform some of the other lab tests that are routinely done on breast cancer specimens. If the FNA biopsy does not provide a clear diagnosis, or your doctor is still suspicious, a second biopsy or a different type of biopsy should be done.
Core needle biopsy
A core biopsy uses a larger needle to sample breast changes felt by the doctor or pinpointed by ultrasound or mammogram. (When mammograms taken from different angles are used to pinpoint the biopsy site, this is known as a stereotactic core needle biopsy.) In some centers, the biopsy can be guided by an MRI scan.
The needle used in core biopsies is larger than that used in FNA. It removes a small cylinder (core) of tissue (about 1/16- to 1/8-inch in diameter and ½-inch long) from a breast abnormality. Several cores are often removed. The biopsy is done using local anesthesia (where you are awake but the area is numbed) in an outpatient setting.
Because it removes larger pieces of tissue, a core needle biopsy is more likely than an FNA to provide a clear diagnosis, although it may still miss some cancers.
Vacuum-assisted biopsies can be done with systems such as the Mammotome® or ATEC® (Automated Tissue Excision and Collection). For these procedures the skin is numbed and a small incision (about ¼ inch) is made. A hollow probe is inserted through the incision into the abnormal area of breast tissue. The probe can be guided into place using x-rays or ultrasound (or MRI in the case of the ATEC system). A cylinder of tissue is then suctioned in through a hole in the side the probe, and a rotating knife within the probe cuts the tissue sample from the rest of the breast. Several samples can be taken from the same incision. Vacuum-assisted biopsies are done as an outpatient procedure. No stitches are needed, and there is minimal scarring. This method usually removes more tissue than core biopsies.
Surgical (open) biopsy
Sometimes, surgery is needed to remove all or part of the lump for microscopic examination. This is referred to as a surgical biopsy or an open biopsy. Most often, the surgeon removes the entire mass or abnormal area as well as a surrounding margin of normal-appearing breast tissue. This is called an excisional biopsy. If the mass is too large to be removed easily, only part of it may be removed. This is called an incisional biopsy.
In rare cases, a surgical biopsy can be done in the doctor’s office, but it is most often done in the hospital’s outpatient department under a local anesthesia (where you are awake, but your breast is numbed), often with intravenous sedation (medicine given to make you drowsy). This type of biopsy can also be done under general anesthesia (you are asleep).
If the breast change cannot be felt, a mammogram may be used to place a wire into the correct area to guide the surgeon. This technique is called wire localization or stereotactic wire localization. After the area is numbed with local anesthetic, a thin hollow needle is placed in the breast, and x-ray views are used to guide the needle to the suspicious area. Once the tip of the needle is in the right spot, a thin wire is inserted through the center of the needle. A small hook at the end of the wire keeps it in place. The hollow needle is then removed. The surgeon can then use the wire as a guide to the abnormal area to be removed. The surgical specimen is sent to the lab to be looked at under a microscope (see below).
A surgical biopsy is more involved than an FNA biopsy or a core needle biopsy. It typically requires several stitches and may leave a scar. The larger the amount of tissue removed, the more likely it is that you will notice a change in the shape of your breast afterward.
Core needle biopsy is usually enough to make a diagnosis, but sometimes an open biopsy may be needed depending on where the lesion is, or if a core biopsy is not conclusive.
All biopsies can cause bleeding and can lead to swelling. This can make it seem like the breast lump is larger after the biopsy. This is generally nothing to worry about and the bleeding and bruising resolve quickly in most cases.
Breast Cancer Tests: Screening, Diagnosis, and Monitoring
Whether you’ve never had breast cancer and want to increase your odds of early detection, you’ve recently been diagnosed, or you are in the midst of treatment and follow-up, you know that breast cancer and medical tests go hand in hand.
Most breast-cancer-related tests fall into one or more of the following categories:
* Screening tests: Screening tests (such as yearly mammograms) are given routinely to people who appear to be healthy and are not suspected of having breast cancer. Their purpose is to find breast cancer early, before any symptoms can develop and the cancer usually is easier to treat.
* Diagnostic tests: Diagnostic tests (such as biopsy) are given to people who are suspected of having breast cancer, either because of symptoms they may be experiencing or a screening test result. These tests are used to determine whether or not breast cancer is present and, if so, whether or not it has traveled outside the breast. Diagnostic tests also are used to gather more information about the cancer to guide decisions about treatment.
* Monitoring tests: Once breast cancer is diagnosed, many tests are used during and after treatment to monitor how well therapies are working. Monitoring tests also may be used to check for any signs of recurrence.
On the following pages, you can read more about the many tests you may have at different points in the process of screening, diagnosis, and treatment. The tests are covered in alphabetical order.
Breast Cancer Detection
The earlier breast cancer is detected, the better it may be for the patient’s long-term health. Get a brief overview of the tests that can help detect breast cancer.
Breast Cancer Screening: What Kind and When?
For women at normal risk of breast cancer, self-exams, clinical exams, and mammography starting at 40 may screen for breast cancer. Abnormal results or high-risk women may need earlier screening or additional tests. Read more.
Do you do regular breast self-exams? While some cancers are too tiny to feel, and most lumps aren’t cancer, self-exams are a proactive way to help take care of yourself. Learn how.
Clinical Breast Exam
A clinical breast exam is a breast exam performed by a health care professional. It’s a basic part of women’s check-ups, starting at age 20. Find out what to expect from a clinical breast exam.
A mammogram is a special type of X-ray taken to look for abnormal growths or changes in breast tissue. It’s a key tool in breast cancer detection, though no test is perfect. Learn more here.
Understanding the Mammogram Results
Most abnormal mammogram results aren’t breast cancer. But more testing is needed to make sure. The bottom line: Don’t panic, but do get the follow-up tests.
Do you find mammograms uncomfortable? Don’t skip the test; just learn how to handle it better. This video explains how to deal with mammogram discomfort.
Doctors sometimes use ultrasound images to check whether a breast lump is a cyst (a fluid-filled sac that is not cancer) or a solid mass. Read more here.
MRI stands for magnetic resonance imaging. Learn how breast MRI is used to help detect breast cancer.
When doctors perform a biopsy, they remove cells from a suspicious mass to see if it’s cancer. This article provides an overview of breast biopsies.
Minimally Invasive Breast Biopsy
This type of breast biopsy generally uses a needle, not surgery. Learn what’s involved in minimally invasive breast biopsy.
Sentinel Node Biopsy
In a sentinal node biopsy, doctors check a few lymph nodes under the arm to see if cancer has spread into the lymph system. Learn what’s involved in a sentinel node biopsy.
Ductal lavage checks cells from the milk ducts for precancerous cells. Read about it here.