How is Breast Cancer Diagnosed?

If you have signs and symptoms or screening test results that indicate breast cancer, your physician will need to determine whether or not your symptoms are cancer-related or caused by another health issue. Your physician may take one of the following actions:

• Conduct an interview regarding your personal and family medical history to gather more information about your symptoms and risks associated with breast cancer.
• Conduct a physical examination, including clinical breast examination, to check for any abnormalities, such as lumps.

Your physician may recommend further testing in case your symptoms and/or your medical history indicate the likelihood of having breast cancer. These tests and procedures are performed for diagnosing breast cancer. In case your test results reveal that you have breast cancer, these will be used to develop a treatment plan.

How do doctors diagnose breast cancer using imaging tests?

• The diagnostic mammogram is an X-ray image of the breast that is done to look for signs of breast cancer. This test is done when a lump or any other sign of the disease is detected. Also, the test is performed as a follow-up on changes found through screening mammograms. The diagnostic mammogram usually takes more images than a screening one and examines abnormal areas more closely.
• An examination known as a breast ultrasound uses high-frequency sound waves (HFSW) to create images of the breast's inside.
• A breast MRI is an examination that creates comprehensive images of the breast using radio waves, a powerful magnetic field, and a computer.

What is Biopsy for Breast Cancer?

You will require a biopsy if an imaging test finds an abnormal spot in your breast. A sample of cells or tissues is taken by a surgeon to be examined under a microscope by a pathologist. Only a biopsy can determine whether there is cancer in the breast.

The following are some types of biopsies that help diagnose breast cancer:

• A fine-needle aspiration biopsy is performed by taking fluid or tissue samples through a thin needle.
• The core-needle biopsy involves removing a tissue sample using a thick needle. A small metal clip goes easily into the biopsy area for future reference.
• Image-guided biopsy is usually performed with fine-needle aspiration, but more commonly with core-needle biopsies. Image-guided biopsies are done using ultrasound, mammography, or magnetic resonance imaging (MRI). It is performed when the abnormality is deeply seated in the breast or when the doctor cannot feel a lump or mass. A stereotactic biopsy is a kind of biopsy in which mammography guides the needle.
• The surgical biopsy is done through the process of surgically removing all or a portion of an abnormal area.

What are the types of surgical biopsy?

In most cases, a biopsy is performed as an outpatient procedure, which means you will probably return home on the day of the biopsy. Whether or not you will be under anesthesia and the time it will take for you to recover from a breast biopsy will vary depending on whether the biopsy is surgical or not.

Non-surgical biopsies (fine-needle or core biopsies) are performed without anesthesia, whereas surgical biopsies require either local or general anesthesia. It takes longer to recover from a surgical biopsy than a non-surgical one.

The pathologist examines the tissue sample taken during the biopsy and writes their findings in a pathology report. In case the pathologist finds out that you have cancer, a pathology report will give both you and your physician some information concerning your cancer and treatment options.

The pathology report will tell you:

• The location of cancer in your breast, whether it's the ducts or lobules
• The tumor grade
• If the cancer has spread beyond your breast into nearby healthy tissue (invasive breast cancer)

What are the Tests for Staging Breast Cancer?

In case you are diagnosed with breast cancer, additional tests will be carried out to check whether the cancer has spread and, if yes, up to what extent. In some cases, the cancer is confined only to the breasts. In other cases, it might already have spread or extended from the breast to the lymph nodes or other parts of the body. The process by which the extent of cancer spread is determined is called staging.

In the case of breast cancer, the stages depend upon several things, such as the spread of the cancer, results of biomarkers, grading of tumors, and multi-gene tests in some cases. It is essential to determine the stage of breast cancer to develop an appropriate treatment plan.

The following tests and procedures are effective ways to determine your breast cancer stage:

What happens during a sentinel lymph node biopsy?

In case of breast cancer, cancer may spread to nearby lymph nodes, such as the lymph nodes in the underarm region. Sentinel lymph node biopsy helps determine whether cancer cells have spread outside the breast. Sentinel lymph node is the term for the first lymph node to which cancer cells have metastasized from the main tumor. There may be many sentinel lymph nodes in some cases.

To find the sentinel lymph node, a radioactive material, a blue dye, or both will be injected around the tumor. Then the doctor looks for lymph nodes containing the radioactive material using special equipment, or locates lymph nodes that have turned blue from the blue dye. After identifying the sentinel lymph node, a small incision is made in the skin, and the lymph node is removed.

A pathologist examines the sentinel node for cancerous cells. If cancer is detected, the other lymph nodes are removed either at the same time as taking out the sentinel lymph node or in the next operation. Sentinel lymph node biopsy is conducted under general anesthesia on an outpatient basis.

Which imaging scans check if breast cancer has spread to other organs?

These imaging procedures help determine whether breast cancer has spread:

• A CT scan (CAT scan) is a procedure that uses a computer attached to an X-ray machine to produce detailed images of structures inside the body. Images are taken at various angles and combined to produce a three-dimensional view of the tissues and organs being examined. Dye can be administered either intravenously or orally to make organs and tissues more visible. CT scans can also be referred to as computerized tomography or computerized axial tomography—more information on Computed Tomography (CT) Scans and Cancer.
• A bone scan is a test that determines whether there are any fast-dividing cells, like those of cancer, within the bone. A minute quantity of radioactive material is injected into a vein. The radioactive material will accumulate in the areas of the bone where there is cancer.
• A PET scan (positron emission tomography) involves the use of a small amount of radioactive sugar (radioactive glucose) injected into a vein.

What are Breast Cancer Biomarker Tests?

All types of breast cancer are tested to detect specific markers in the cells, such as hormone receptors (estrogen and progesterone) and HER2. This helps to determine the stage of the breast cancer and also the appropriate treatment. Find more on this topic at Tests for Breast Cancer Biomarkers.

What does tumor grade mean in breast cancer diagnosis?

Tumor Grade is the extent to which cancer cells and tissues resemble normal cells and tissues when viewed under a microscope and how fast the cancer cells are expected to grow and spread. Tumor grade is measured by assigning a score of 1 to 3 to the cell or tissue. A grade of 1 indicates cells and tumor tissue that are closest to normal and are less likely to spread. A grade of 3 indicates cells and tissue that are furthest from normal and tend to grow faster and spread more rapidly.

How do multigene tests predict the risk of cancer recurrence?

These are laboratory tests performed on cells from your breast cancer to assess how active the cells' genes are. The results of these tests could be used to estimate the chances that the cancer may spread to other parts of your body or recur.

The tests listed below can usually be performed using a tumor sample obtained through biopsy or surgery. Most people will not need to undergo any further procedures for these tests.

Multigene tests come in many different forms. Some of the tests you could have include:

• Oncotype DX: This test measures the expression levels of 21 genes in women with early-stage breast cancer that is ER-positive, HER2-negative, and has not spread beyond the lymph nodes or has spread to no more than 3 lymph nodes. The test allows doctors to predict how likely it is that breast cancer will spread. In cases where the risk of spread is high, chemotherapy is used to reduce it.
• Mamma Print: The test measures the levels of 70 genes expressed in the tumor tissues of patients diagnosed with early-stage breast cancer that has not metastasized to any other part of the body except for the lymph nodes. It allows doctors to predict how likely it is that the breast cancer will spread or return. Where there is a high risk of either happening, chemotherapy is used to reduce this risk.
• Breast Cancer Index is a multi-gene test that examines the activity of 11 genes found in breast cancer tissue in individuals diagnosed with early-stage breast cancer that is HR-positive, where there is either no spread to the lymph nodes or fewer than three lymph node metastases. This test can predict the chances of the recurrence of your breast cancer between five and ten years from the time of the diagnosis. In case this test reveals that your risk of having a recurrent breast cancer is high, you are likely to receive five more years of hormone therapy.

There are other multi-gene tests available. Discuss with your oncologist whether these multigene tests would suit you.

Who should get genetic counseling and testing for breast cancer?

Your doctor may ask for genetic testing as part of the diagnosis of your breast cancer. Genetic tests are also done on blood samples, saliva samples, or mouth swabs. The report from the genetic tests will indicate whether you have a genetic change you have had since birth in the BRCA1, BRCA2, or other breast cancer genes. Knowing the specific genetic change you carry could help your doctor suggest the most appropriate treatment options for your cancer. These gene changes are also referred to as mutations or pathogenic variants.

The benefit of genetic counseling before getting genetic tests is that it helps you understand your probability of having a genetic change causing your breast cancer and whether you need genetic testing. For instance, genetic testing may be recommended in the following cases:

• There is a family history of a genetic change in BRCA1, BRCA2, or another breast cancer gene.
• You were diagnosed with breast cancer at less than 50 years old.
• You have been diagnosed with two or more separate primary breast cancers in one or both breasts.
• You have triple negative breast cancer.
• Have lobular breast cancer and a family history of diffuse gastric cancer
• Have a family history of breast cancer or specific other cancers, like pancreatic, prostate, and ovarian cancer.
• Have male breast cancer.
• Are an Ashkenazi Jew

Genetic counseling can also assist in dealing with your genetic testing results, including the way to talk about them with your relatives. Genetic counseling can help in determining who else in your family should undergo genetic testing to see if they carry the risks of breast cancer and other cancers. Learn more about genetic changes in BRCA genes and cancer risks and genetic testing for inherited cancer risks.

How can patients cope with stress while waiting for cancer lab results?

In some instances, the results are sent to your patient portal before you meet with your doctor. Waiting until you can talk to your doctor about the results may be difficult, but doing so helps avoid confusion.

Should you experience any trouble coping with stress caused by waiting for the results, feel free to contact your health care team. You can receive help and guidance from a social worker in this situation. Regardless of the test results, you can count on your doctor to guide you regarding the next steps.

How do I get a second opinion on my breast cancer diagnosis?

In some cases, obtaining a second opinion to ensure the accuracy of your diagnostic outcomes and treatment procedures is recommended. In case you decide to have a second opinion on your breast cancer, you will have to inquire about your test results and reports from the first doctor to present to the second doctor. The second doctor will review your pathology report, slides, and scans before providing an opinion. The second doctor may concur with the first one, advise on changes, or give more information about your cancer.

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