Diagnosis: Improving Your Survival Chances

Fighting breast Cancer

Breast cancer Awareness

Breast Cancer Diagnosis

Breast Examination

When to examine your breasts

You don’t need to examine your breasts every day or even every week. But it is important to know how your breasts normally feel, and how that changes with your periods.

Some women have lumpier breasts around the time of a period. If this is the same in both breasts, don’t worry. But check your breasts again the following month, a few days after your period is over.

If the lumpiness comes and goes with your menstrual cycle, it is nothing to worry about.

What to look for

You are checking for changes in the size, shape or feel of your breast. This could mean a lump or thickening anywhere in the breast.

Most people naturally have one breast bigger than the other and this is normal. You need to check for any changes in the size, shape or texture of your breasts. Other changes include puckering or dimpling of the skin or changes in the nipple.

Remember to check all parts of your breast, including your armpits and the area above your breasts up to the collarbone.

Tests To Diagnose

Play Video

Diagnostic Mammogram

What Is The Difference Between A Diagnostic Mammogram And A Screening Mammogram?

A mammogram is an x-ray of the breast. While screening mammograms are routinely administered to detect breast cancer in women who have no apparent symptoms, diagnostic mammograms are used after suspicious results on a screening mammogram or after some signs of breast canceralert the physician to check the tissue.

Such signs may include:

  • A lump
  • Breast pain
  • Nipple discharge
  • Thickening of skin on the breast
  • Changes in the size or shape of the breast

A diagnostic mammogram can help determine if these symptoms are indicative of the presence of cancer.

As compared to screening mammograms, diagnostic mammograms provide a more detailed x-ray of the breast using specialized techniques. They are also used in special circumstances, such as for patients with breast implants. 

The Process

 

What’s Involved In A Diagnostic Mammogram?

If your doctor prescribes a diagnostic mammogram, realize that it will take longer than a normal screening mammogram, because more x-rays are taken, providing views of the breast from multiple vantage points. The radiologist administering the test may also zoom in on a specific area of the breast where there is a suspicion of an abnormality. This will give your doctor a better image of the tissue to arrive at an accurate diagnosis.

In addition to finding tumors that are too small to feel, mammograms may also spot ductal carcinoma in situ (DCIS). These are abnormal cells in the lining of a breast duct, which may become invasive cancer in some women.

 

is It reliable?

 
 

How Reliable Are Mammograms For Detecting Cancerous Tumors?

The ability of a mammogram to detect breast cancer may depend on the size of the tumor, the density of the breast tissue, and the skill of the radiologist administering and reading the mammogram. 

Mammography is less likely to reveal breast tumors in women younger than 50 years than in older women. This may be because younger women have denser breast tissue that appears white on a mammogram. Likewise, a tumor appears white on a mammogram, making it hard to detect.

Diagnostic mammogram Vs Screening mammogram
Woman's hospital Baton Rouge

Play Video

Diagnostic Ultrasounds

Breast ultrasound

A breast ultrasound is a scan that uses penetrating sound waves that do not affect or damage the tissue and cannot be heard by humans. You might have a breast ultrasound:

  • as a first test if you have a lump in the breast
  • if you have a lump in your breast that hasn’t shown up on a breast x-ray (mammogram)
  • to see if a breast lump is solid or if contains fluid (a cyst)

You might have this test alongside other tests, such as a breast examination and breast x-ray (mammogram) in a one stop clinic. This is called a triple assessment. You might also have a breast biopsy. 

Preparing for your breast ultrasound

There isn’t usually any special preparation for a breast ultrasound.

Take any medicines as normal.

How you have it

The scan is completely painless. 

The ultrasound scanner has a microphone that gives off sound waves. The sound waves bounce off the organs inside your body, and the microphone picks them up.

The microphone links to a computer that turns the sound waves into a picture on the screen. A sonographer will do your ultrasound. A sonographer is a trained professional who is a specialist in ultrasound scanning.

Diagnose & results

How Does An Ultrasound Help To Diagnose A Breast Lump?

When a suspicious site is detected in your breast through a breast self-examor on a screening mammogram, your doctor may request an ultrasound of the breast tissue. The breast tissue deflects these waves causing echoes, which a computer uses to paint a picture of what’s going on inside the breast tissue. A mass filled with liquid shows up differently than a solid mass.

Ultrasound Results: Breast Sonogram

The detailed picture generated by the ultrasound is called a “sonogram.” Ultrasounds are helpful when a lump is large enough to be easily felt, and the images can be used to further evaluate the abnormality.

A breast ultrasound can provide evidence about whether the lump is a solid mass, a cyst filled with fluid, or a combination of the two. While cysts are typically not cancerous, a solid lump may be a cancerous tumor. Healthcare professionals also use this diagnostic method to help measure the exact size and location of the lump and get a closer look at the surrounding tissue.

Dr Jay K. Harness
Ultrasound Diagnosis

Play Video

Breast biopsis

What Is A Breast Biopsy?

A breast biopsy is a test that removes tissue or sometimes fluid from the suspicious area. The removed cells are examined under a microscope and further tested to check for the presence of breast cancer. A biopsy is the only diagnostic procedure that can definitely determine if the suspicious area is cancerous.

The good news is that 80% of women who have a breast biopsy do not have breast cancer.

There are three types of biopsies:

  • Fine-needle aspiration
  • Core-needle biopsy
  • Surgical biopsy

The latter two are the most commonly used on the breast.

There are several factors that help a doctor decide which type of biopsy to recommend. These include the appearance, size, and location of the suspicious area on the breast. Before discussing biopsy results, let’s first distinguish between the three types of biopsies.

What is fine-needle aspiration?

In most cases, a fine needle aspiration is chosen when the lump is likely to be filled with fluid. If the lump is easily accessible or if the doctor suspects that it may be a fluid-filled cystic lump, the doctor may choose to conduct a fine-needle aspiration (FNA). During this procedure, the lump should collapse once the fluid inside has been drawn and discarded. Sometimes, an ultrasound is used to help your doctor guide the needle to the exact site, whereby sound waves create a picture of the inside of the breast.

If the lump persists, the surgeon or radiologist, a doctor who specializes in medical imaging such as x-rays and mammograms, will perform a fine needle aspiration biopsy (FNABx), a similar procedure using the needle to obtain cells from the lump for examination.

What is a core-needle biopsy?

Core needle biopsy is the procedure to remove a small amount of suspicious tissue from the breast with a larger “core” (meaning “hollow”) needle. It is usually performed while the patient is under local anesthesia, meaning the breast is numbed. During the procedure, the doctor may insert a very small marker inside the breast to mark the location of the biopsy. If surgery is later required, the marker makes it easier for the surgeon to locate the abnormal area.

The radiologist or surgeon performing the core-needle biopsy may use specialized imaging equipment to guide the needle to the desired site. As with fine-needle aspiration, this may involve ultrasound.

During an ultrasound-guided core needle biopsy, the patient lies down while the doctor holds the ultrasound against the breast to direct the needle. On the other hand, during a stereotactic-guided core-needle biopsy, the doctor uses x-ray equipment and a computer to guide the needle. Typically, the patient is positioned lying on the stomach on a special table that has an opening for the breast, and the breast is compressed, similar to a mammogram.

Occasionally, no imaging equipment is used, but this is typically only in cases where the lump can be felt through the skin. This type of procedure is called a freehand core-needle biopsy.

There are fewer side effects associated with a core-needle biopsy than with surgical biopsy.

What should I expect from a surgical biopsy?

(Also known as “wide local excision,” “wide local surgical biopsy,” “open biopsy,” or “lumpectomy”)

As with a core-needle biopsy, a surgical biopsy is done while the patient is under local anesthesia. Typically, this test is performed in a hospital setting where an IV and medications are administered to make the patient drowsy.

The surgeon makes a one- to two-inch cut on the breast and then removes all or part of the abnormal lump and often a small amount of normal-looking tissue, known as the “margin.” If the lump cannot be easily felt but can be seen on a mammogram or ultrasound, a radiologist may insert a thin wire to mark the suspicious spot prior to the surgeon performing the biopsy. Once again, a marker is usually placed internally at the biopsy site at the conclusion of the procedure

What Can Be Learned From The Biopsy Results?

Once the biopsy is complete, a specially trained doctor called a pathologist examines the tissue or fluid samples under a microscope, looking for abnormal or cancerous cells. The pathology report, which can take one or two weeks to complete, is sent to the patient’s doctor. It indicates whether the suspicious area is cancerous and provides a full picture of your situation. For the patient, waiting for results can be a real challenge, but being able to make an informed decision regarding your treatment is well worth it. Your doctor will go over the report with you and, if necessary, discuss the treatment options.

If no cancer cells are found, the report will indicate that the cells in the lump are benign, meaning non-cancerous. However, some type of follow-up or treatment may still be needed, as recommended by the healthcare professional.

If cancer cells are found, the report will provide more information to help determine the next steps.

The report for a core-needle biopsy sample will include tumor type and the tumor’s growth rate or grade. If cancer is found, the pathologist will also perform lab tests to look at cells for estrogen or progesterone receptors.

In the case of a surgical biopsy, the results reveal data about the type, grade, and receptor status of the tumor, as well as the distance between the surrounding normal tissue and the excised tumor. The margin, as we mentioned earlier, shows whether the site is clear of cancer cells.

A positive margin means cancer cells are present at the margin of the tumor. In cases of positive margins, the cancer has spread beyond the immediate area.

A negative margin or clear margin indicates there are no tumor cells at the margin. That means the cancer is contained in the area nearest to the tumor.

A close margin means that the space between the cancerous tissue and surrounding normal tissue is less than about 3 millimeters (0.118 inch).

If you have a biopsy resulting in a cancer diagnosis, the pathology report will help you and your doctor talk about the next steps. You will likely be referred to a breast cancer specialist, and you may need more scans, lab tests, or surgery. Your medical team uses the pathology report and the results of the other tests to determine the stage of cancer and to design the best treatment plan for you

Play Video

Types Of Biopsies

These are some examples of Needles and instruments used for breast biopsies.

The larger Core needle biopsy or the smaller for Fine Needle biopsises.

 

Image Source: US National Institutes of Health - National Cancer Institute

Needle Biopsies

Play Video

lab Tests

Testing The Tumor Cells For Hormone Receptors

A hormone receptor is a specialized protein located on the surface of or within a cell. The receptor binds to the female hormones estrogen and progesterone, which flow through the blood. Once bound, the hormone signals the cell to start growing and multiplying. 

Many breast cancer tumors contain hormone receptors, often in large numbers. 

When hormone receptors are present, estrogen and/or progesterone can fuel the growth of the cancer. Such hormone-dependent cancers often respond well to hormone therapy, which differs from hormone replacement therapy (HRT). If neither estrogen receptors (ER) nor progesterone receptors (PR) are present, the cancer is said to be “hormone-receptor-negative,” and hormone therapy would likely be ineffective. 

Knowing whether the cancer cells have hormone receptors can be valuable to your medical team and your treatment plan.

Who Needs Hormone Receptor Testing?

Hormone receptor testing is generally recommended for patients who are diagnosed with invasive breast cancer. If your doctor orders this test, you may be asked to discontinue taking any prescribed hormones for a period of time before the breast tissue sample is obtained.

Usually, the sample comes from a biopsy, but the test may also be performed on tissue removed during a mastectomy.

The Procedure & Results

How Does The Test Work?

The testing lab typically uses a specialized staining process on the breast tissue sample to see if hormone receptors are present. The technical name for this procedure is an “immunohistochemical staining assay” or an “ImmunoHistoChemistry (IHC).” Findings will be included in a pathology report given to your doctor.  If the cancer is deemed “estrogen-receptor-positive” (ER+), its cells have receptors for the estrogen hormone. That means that the cancer cells likely receive signals from estrogen to promote growth. About two out of every three breast cancers contain hormone receptors.

If the cancer is progesterone-receptor-positive (PR+), its cells have receptors for the progesterone. This hormone could then promote the growth of the cancer. 

What do the results of hormone testing mean?

Breast cancer patients who test positive for both estrogen receptors and progesterone receptors usually have a better-than-average prognosis for survival and a complete recovery than those who have no receptors present. Also, the more receptors and the more intense their reaction, the better they respond to hormone therapy. Patients with one type of receptor but not the other may still reap benefits from this form of treatment, but likely not to the same degree. As mentioned earlier, if the cancer is both ER- and PR-negative, it probably won’t respond to hormone therapy. Typical response rates to hormone therapy are as follows:

  • ER and PR positive: 75-80%
  • ER positive and PR negative: 40-50%
  • ER negative and PR positive: 25-30%
  • ER negative and PR negative: 10% or less

 

HER2/neu Test

Similar to the hormone receptor test, the HER2/neu test looks for a specific kind of protein that is found with certain types of cancer cells and the gene that produces it. The formal name of that gene is the human epidermal growth factor receptor 2, and it makes HER2 proteins. These proteins are receptors on breast cells.

In a sense, genes contain the formula for the number and combination of proteins a cell needs to remain healthy and function properly. Certain genes and the proteins they create can determine how breast cancer progresses, as well as how it responds to various types of treatment. 

What is a HER2 receptor and how does it relate to breast cancer?

Healthy HER2 receptors are the proteins that help manage how a breast cell grows, divides, and repairs itself.  However, in about a quarter of all breast cancer patients, the HER2 gene isn’t functioning properly. It makes an excess number of copies of itself in a process known as “HER2 gene amplification.” Then these extra genes instruct the cells to make too many HER2 receptors, which is called “HER2 protein overexpression.” The ultimate result is that breast cells grow and divide in an uncontrolled fashion. 

The HER2/neu test can discover whether the sample is normal or whether it has too much of the HER2/neu protein or an excessive number of copies of its gene. If you have been diagnosed with invasive breast cancer or have had recurrent breast cancer, your doctor may recommend this test. It will help your medical team determine your prognosis, characteristics of the tumor including how aggressive the tumor is likely to be, and the best treatment options. 

This test is often ordered in conjunction with the hormone receptor test. Typically, the breast cancer tissue sample from a biopsy or the tumor removed during a mastectomy is used. 

Play Video

QUALITY OF SCREENING TESTS

Sensitivity and specificity

The quality of a screening test is described in terms of:

  • How well the screening test tells who truly has a disease (sensitivity)
  • How well the screening test tells who truly does not have a disease (specificity)

The goals of any screening test are:

  • To correctly identify everyone who has a certain disease (100 percent sensitivity)
  • To correctly identify everyone who does not have the disease (100 percent specificity)

A perfect test would correctly identify everyone with no mistakes. There would be no:

  • False negatives (when people who have the disease are missed by the test) 
  • False positives (when healthy people are incorrectly shown to have the disease)

The trade-off between sensitivity and specificity

No screening test has perfect (100 percent) sensitivity and perfect (100 percent) specificity. There’s always a trade-off between the two.

A test that’s very sensitive will pick up even the slightest abnormal finding. This means it will miss few cases of the disease, but it will also mistake some people as having the disease when they don’t.

These false positive findings can lead to further testing and some anxious moments for people who don’t have the disease. 

A test that’s very specific, on the other hand, will have few false positive results, but will miss more cases of the disease.

This balance between sensitivity and specificity is important for all screening tests, including mammography.

Screening Recommendations
FOR women & Men

Women

Breast cancer screening is important for all women.

If you’re at higher than average risk of breast cancer, you may need to be screened earlier and more often than women at average risk

.

SCREENING FOR WOMEN AT AVERAGE RISK

Men

Breast cancer screening is not recommended for most men. It’s only recommended for some men at higher than average risk due to an inherited gene mutation or a strong family history of breast cancer.

Learn about breast cancer screening recommendations for men at higher than average risk

Screening Questions to ask your doctor

QUESTIONS FOR YOUR PROVIDER – BREAST CANCER SCREENING

Articles Sources

Cancer Care Ontario-  Screening Breast Cancer

National Health Services UK – Breast Cancer Screening

Radiologyinfo.org – Breast Cancer Screening

Maurer Foundation for Breast Health Education – The Stages Of Breast Cancer & the importance of Early Detection

American Cancer Society – Breast Cancer Early Detection and Diagnosis

cancer research Uk – Breast Cancer Screening

Center For Disease Control and Prevention – What is Breast Cancer Screening

NCBI – Screening For breast Cancer in 2018

American Cancer Society – Cancer Screening Guideline

Close Menu