Your doctor will ask about your medical history, including any family history of breast cancer. Your breasts will be examined for characteristic symptoms, including lumps or thickening, nipple discharge or inversion, redness or changes in the skin or contour of the breast. The underarm area will also be examined. Your doctor may recommend different tests in order to identify tumors and confirm diagnosis.
Assessing Breast Changes
If your doctor finds abnormal results from physical exam the following tests may be done to better identify the changes. Not all breast changes are cancer. Tests to help distinguish noncancerous and potential cancerous changes include:
Blood tests may identify markers or genetic mutations in the blood. For example, tumor markers or specific blood proteins may be elevated in the presence of cancer. Tumor markers are also used to stage the cancer and evaluate if the treatments are working .
Imaging tests may be used to look for the presence of tumors. They can also help assess their size and location. Some tests use contrast material to highlight structures so images are more clear and detailed. Imaging tests may include:
A mammogram is an x-ray of the breast. It can often find tumors that are too small for you or your doctor to feel. The accuracy of a mammogram to detect cancer will depend on several factors. It may be affected by the size of the tumor, your age, breast density, and the skill of the radiologist. Although mammograms are the most sensitive test currently used to evaluate the breast, they will miss 10%-15% of breast cancers.
During an ultrasound, sound waves are bounced off tissues. The echoes are converted into a picture. Ultrasound is used to evaluate lumps that have been identified through breast self-exam, clinical breast exam, or mammography. They help to see if a mass is solid or liquid-filled. Solid masses are generally more concerning than cystic or liquid-filled masses
Ultrasound may also be used to:
- Determine where the cancer has spread
- Detect any cancer cells that are in the ducts
- Determine if cancer has spread to the lymph nodes in the underarm area
An MRI scan of the breast may have better accuracy in detecting some types of tumors. It may be more accurate in cases where the breast tissue is more dense than usual or when breast cancer of both breasts is suspected. MRI scans can also be used if there are conflicting results from other tests, such as a mammogram and/or ultrasound.
Diagnosis of Breast Cancer
The clinical breast exam and imaging (like a mammogram) can suggest cancer, but a biopsy will confirm the presence of cancer cells. During a biopsy, a sample of suspicious tissue is removed so it can be examined under a microscope.
Biopsy types include:
- Fine needle aspiration —A thin needle is used to remove fluid and/or cells from a breast lump.
- Core needle—A larger, hollow needle is used to remove a wider area of tissue.
- Vacuum-assisted—A small incision is made in the skin before a hollow device is placed into the breast tissue. The suspicious tissue is pulled into the device. A small knife inside the device can also cut the biopsy sample from the remaining breast tissue.
- Surgical —During a surgical biopsy, all or part of a breast lump is removed for microscopic examination. An incisional biopsy removes a small portion of a large lump, while an excisional biopsy removes the entire lump (usually a small one).
Biopsies needles may be guided by imaging, such as an MRI scan or ultrasound, to improve accuracy.
If breast cancer is confirmed, results from completed tests and new tests will help determine the stage of cancer. Staging is used to identify characteristics of the tumor that will help determine the prognosis and treatment plan. Factors that play a role in staging include how far the original tumor has spread, whether lymph nodes are involved, if cancer has spread to other tissue, and microscopic cellular details.
Tests that may help determine breast cancer stage:
- Imaging tests—To help determine how deep the tumor has moved into the layers of the breast or nearby structures. They may also help to determine if there are any metastatic growths in other areas of the body. Imaging tests may include:
Lymph node biopsy—Cancer cells can drain from the tumor site into nearby lymph nodes. From here, cancer cells can travel through the lymph to blood flow and other areas of the body. Lymph nodes under the arm are normally checked if suspicious tissue is removed, or if they are swollen or felt during the physical exam. Lymph biopsies can be done with a fine needle aspiration during the breast biopsy. Specific types of lymph node biopsies include:
- Sentinel lymph node biopsy—Sentinel lymph nodes are the first nodes that a tumor will drain into. These nodes are located by injecting a traceable material near the tumor and watching which nodes take up the material first. If these nodes are free of cancer cells, it is unlikely that the cancer has spread. If cancer cells are present, then more lymph nodes may need to be removed to determine how far the cancer has spread.
- Axillary node dissection—Removal of a lymph node from the underarm. Will be done if the sentinel lymph nodes have cancer cells. This is also done as part of a modified radical mastectomy for breast cancer treatment.
- Tissue evaluation—Cancer tissue from the biopsy will be closely examined to look for characteristics that can help with prognosis and treatment selection. Important characteristics include presence of :
- Estrogen and progesterone receptors
- HER2/neu and Oncotype DX
Breast cancer is staged from 0-IV:
- Stage 0—Carcinoma in situ—A very localized group of abnormal cells are still contained in the primary site. The cancer remains in the breast and has not spread.
- Stage IA—The tumor is no larger than 2 centimeters (cm) in size and has not spread beyond the primary tumor site in the breast.
- Stage IB—The tumor is not present OR up to 2 cm in size WITH small clusters of cancer cells in the lymph nodes.
- The tumor is not present OR is up to 2 cm in size WITH cancer found in 1-3 lymph nodes in the underarm or in the lymph nodes near the breastbone (in the center of the chest) OR
- The tumor is 2-5 cm in size, but has NOT spread to any lymph nodes
- The tumor is 2-5 cm in size WITH small clusters of cancer cells found in the lymph nodes OR
- The tumor is 2-5 cm in size WITH cancer found in 1-3 lymph nodes in the underarm or in lymph nodes near the breastbone OR
- The tumor is more than 5 cm in size, but has NOT spread to any lymph nodes
- The tumor is not present OR is any size WITH cancer in 4-9 lymph nodes in the underarm or in lymph nodes near the breastbone OR
- The tumor is more than 5 cm in size WITH small clusters of cancer cells found in the lymph nodes OR
- The tumor is more than 5 cm in size WITH cancer found in 1-3 lymph nodes in the underarm or in lymph nodes near the breastbone
- The tumor is any size and WITH cancer in the the chest wall WITH/WITHOUT swollen or ulcerated skin on the breast AND
- Up to 9 lymph nodes in the underarm OR in lymph nodes near the breastbone
- Note: If cancer has spread to the skin causing swelling or ulcers, it may be inflammatory breast cancer. This type of cancer can be stage IIIB or higher.
- The tumor is not present OR is any size WITH/WITHOUT cancer in the chest wall AND/OR swollen or ulcerated skin on the breast WITH spreading to 10 or more lymph nodes in the underarm OR
- To lymph nodes above and below the collarbone OR
- To the lymph nodes in the underarm and lymph nodes in the breastbone
- Stage IV—Cancer has spread beyond the breast and lymph nodes to other parts of the body. The most common sites for metastatic breast cancer are in the bones, lungs, brain, and liver
Treatment and outcomes depend on several factors, such as location, tumor size, stage, overall health, and age. In a large study, for example, younger women (less than age 40 years), who were initially diagnosed with Stage I or II breast cancer, had lower survival rates compared to older women. Researchers are investigating what may account for this unexpected result.
- Reviewer: Mohei Abouzied, MD
- Review Date: 12/2014 -
- Update Date: 10/26/2015 -