When is Breast Cancer Day in 2016 ( Cancer Awareness Dates )

March 3, 2016 – Triple Negative Breast Cancer Day

Breast Cancer: Diagnosis

ON THIS PAGE: You will find a list of the common tests, procedures, and scans that doctors can use to find out what’s wrong and identify the cause of the problem. To see other pages, use the menu on the side of your screen.

Doctors use many tests to diagnose cancer and find out if the cancer has spread or metastasized to other parts of the body beyond the breast and the lymph nodes under the arm. Some tests may also help the doctor decide which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. A biopsy is the removal of a small amount of tissue or cells for examination under a microscope. See below for more information about the types of biopsies that can be performed. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out whether the cancer has spread.

This list describes options for diagnosing this type of cancer, and not all tests listed will be used for every person. Your doctor may consider these factors when choosing a diagnostic test:

• Age and medical condition
• Type of cancer suspected
• Signs and symptoms
• Previous test results

The series of tests needed to evaluate a possible breast cancer usually begins when a woman or her doctor discover a mass or abnormal calcifications on a screening mammogram, or a lump or nodule in the woman’s breast during a clinical or self-examination. Less commonly, a woman might notice a red or swollen breast or a mass or nodule under the arm.

The following tests may be used to diagnose breast cancer or for follow-up testing after the cancer has been diagnosed. Not every person will need all of these tests.

Imaging tests

The following imaging tests may be done to learn more about a suspicious area found in the breast during screening.

• Diagnostic mammography. Diagnostic mammography is similar to screening mammography except that more pictures of the breast are taken, and it is often used when a woman is experiencing signs, such as a new lump or nipple discharge. Diagnostic mammography may also be used if something suspicious is found on a screening mammogram.
• Ultrasound. An ultrasound uses high-frequency sound waves to create an image of the breast tissue. An ultrasound can distinguish between a solid mass, which may be cancer, and a fluid-filled cyst, which is usually not cancer.
• MRI. An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. An MRI can also be used to measure the tumor’s size. A special dye called a contrast medium is given into the patient’s vein before the scan to help create a clear picture of the possible cancer. A breast MRI may be used after a woman has been diagnosed with cancer to check the other breast for cancer or to find out how much the disease has grown throughout the breast. It may also be used for screening, along with mammography, for some women with a very high risk of developing breast cancer.

Biopsy

A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. A pathologist then analyzes the sample(s). A pathologist is a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease. There are different types of biopsies, classified by the technique and/or size of needle used to collect the tissue sample.

• A fine needle aspiration biopsy uses a thin needle to remove a small sample of cells.
• A core needle biopsy uses a wider needle to remove a larger sample of tissue. This is usually the preferred biopsy technique for finding out whether an abnormality on a physical examination or an imaging test is cancer. A vacuum-assisted biopsy removes several large cores of tissue. Local anesthesia, which is medication to block pain, is used to lessen a patient’s discomfort during the procedure.
• A surgical biopsy removes the largest amount of tissue. This biopsy may be incisional, which is the removal of part of the lump, or excisional, which is the removal of the entire lump. Because surgery is best done after a cancer diagnosis has been made, a surgical biopsy is usually not the recommended way to diagnose breast cancer. Most often, non-surgical core needle biopsies are recommended to diagnose breast cancer. This means that only one surgical procedure is needed to remove the tumor and to take samples of the lymph nodes.
• Image-guided biopsy is used when a distinct lump cannot be felt, but an abnormality is seen with an imaging test, such as a mammogram. During this procedure, a needle is guided to the location with the help of an imaging technique, such as mammography, ultrasound, or MRI. A stereotactic biopsy is done using mammography to help guide the needle. A small metal clip may be put into the breast to mark where the biopsy sample was taken, in case the tissue is cancerous and more surgery is needed. This clip is usually titanium so it will not cause problems with future imaging tests, but check with your doctor before you have additional imaging tests. An image-guided biopsy can be done using a fine needle, core, or vacuum-assisted biopsy (see above), depending on the amount of tissue being removed. Imaging tests may also be used to help do a biopsy on a lump that can be felt, in order to help find the best location.
• Sentinel lymph node biopsy is a way to find out if there is cancer in the lymph nodes near the breast. Learn more about sentinel lymph node biopsy in the Treatment Options section.

Analyzing the biopsy sample

Analyzing the sample(s) removed during the biopsy can help your doctor learn about specific features of a cancer that help determine treatment options.

• Tumor features. Examination of the tumor under the microscope is used to determine if it is invasive or in situ, ductal or lobular, and whether the cancer has spread to the lymph nodes. The margins or edges of the tumor are also examined and their distance from the tumor is measured, which is called margin width.
• ER and PR. Testing for ER and PR  helps determine both the patient’s risk of recurrence and the type of treatment that is most likely to lower the risk of recurrence. ER and PR are often measured for DCIS as well. Generally, hormonal therapy (see Treatment Options) works well for ER-positive and/or PR-positive cancers. Learn about ER and PR testing recommendations from ASCO and the College of American Pathologists (CAP).
• HER2. The HER2 status (see Overview) helps determine whether drugs that target the HER2 receptor, for example the antibody treatment trastuzumab (Herceptin), might help treat the cancer. In addition, about 50% of HER2-positive tumors also have hormone receptors and can benefit from both hormone and HER2 directed therapy. Read ASCO’s and CAP's recommendations for HER2 testing for breast cancer
• Grade. The tumor grade is also determined from a biopsy. Grade refers to how different the cancer cells look from healthy cells, and whether they appear slower growing or faster growing. There are three grades: grade 1 (well differentiated), grade 2 (moderately differentiated), and grade 3 (poorly differentiated).

Your doctor may recommend additional laboratory tests on your tumor sample to identify specific genes, proteins, and other factors unique to the tumor. This helps your doctor find out the subtype of cancer.

Genomic tests to predict recurrence risk

Tests that take an even closer look at the biology of the tumor are commonly used to understand more about a woman’s breast cancer, particularly for a cancer that has not spread to other organs. These tests can help estimate the risk of cancer recurrence in the years after diagnosis. They can also predict whether a treatment will be helpful to reduce the risk of cancer recurrence. This helps some patients avoid the possible side effects of a treatment that is not likely to work well.

The tests described below are typically done on tissue removed during surgery. Most patients will not need an extra biopsy or more surgery. For more information about genomic tests, what they mean, and how the results might affect your treatment plan, talk with your doctor.

• Oncotype Dx™. This test evaluates 16 cancer-related genes and 5 reference genes to estimate the risk of the cancer coming back in a place other than the breast and nearby lymph nodes within 10 years after diagnosis for women with stage I or stage II (see Stages) ER-positive breast cancer treated with hormonal therapy alone. Results are mainly used to help make decisions about whether chemotherapy should be added to a person’s treatment with hormonal therapy. Although this test is typically used for patients with breast cancer that has not spread to the lymph nodes, recent research suggests that this test may be useful for some patients with cancer that has spread to the lymph nodes.
• Mammaprint™. This test uses information from 70 genes to predict the risk of the cancer coming back for early-stage, low-risk breast cancer. It is approved by the FDA for estimating the risk of recurrence in early-stage breast cancer, but it is not yet known if this test can predict whether chemotherapy will work. This test is more common in Europe than in the United States.
• Additional tests. Other tests are being researched and may become additional tools to guide treatment options in the future. These tests include the following, among others:
  • Breast cancer index (BCI)
  • Prosigna™ (PAM50)

Blood tests

The doctor may also need to do several types of blood tests to learn more about the cancer:

• Complete blood count. A complete blood count (CBC) is used to measure the number of different types of cells, such as red blood cells and white blood cells, in a sample of a person’s blood. It is done to make sure that your bone marrow is functioning well.
• Serum chemistry. These tests are often done to look at minerals in your blood, such as potassium and calcium, called electrolytes and specialized proteins called enzymes that can be abnormal if cancer has spread. However, many noncancerous conditions can cause changes in these tests, and they are not specific to cancer.
  • Alkaline phosphatase is an enzyme that can be associated with disease that has spread to the liver, bone, or bile ducts.
  • Blood calcium levels can be high if cancer has spread to the bone.
  • Total bilirubin count and the enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST) evaluate liver function. High levels of any of these substances can indicate liver damage, a sign that the cancer may have spread to that organ.
• Hepatitis tests. These may be used to check for evidence of prior exposure to hepatitis B and/or hepatitis C. If you have evidence of an active hepatitis B infection, you may need to take a special medication to suppress the virus before you receive chemotherapy. Without this medication, the chemotherapy can help the virus to grow and cause damage to the liver.
• Blood tumor marker tests. Serum tumor markers are tumor proteins in a person's blood. Higher levels of a serum tumor marker may be due to cancer or a noncancerous condition. Tumor marker testing is not recommended for early-stage breast cancer because the markers are not usually high, but they may be useful to monitor the growth of recurrent or metastatic disease along with symptoms and imaging tests. Tumor markers should not be used to monitor for a recurrence, as such testing does not appear to improve a patient’s chance of recovery. Learn more about tumor markers for breast cancer

Additional tests

The tests your doctor recommends to evaluate whether the cancer has spread and its stage depends on your medical history, symptoms, how much the disease has grown in the breast and lymph nodes, and the results of your physical examination. Read Stages for more information. Many of these tests may not be done until after surgery. These tests are generally only recommended for patients with later-stage disease. Most patients with early-stage breast cancer do not need additional imaging tests.

• X-ray. An x-ray is a way to create a picture of the structures inside of the body, using a small amount of radiation. A chest x-ray may be used to look for cancer that has spread from the breast to the lungs.
• Bone scan. A bone scan may be used to look for spread of cancer to the bones. A radioactive dye or tracer is injected into a patient’s vein, and then the scan is performed several hours later using a special camera. The tracer collects in areas of the bone that are healing, which occurs in response to damage from the cancer cells. The areas where the tracer collects appear dark, compared to healthy bone, which appears gray. Some cancers do not cause the same healing response and will not show up on the bone scan. Areas of advanced arthritis or healing after a fracture will also appear dark.
• Computed tomography (CT or CAT) scan. A CT scan may be used to look for tumors in organs outside of the breast, such as the lung, liver, bone, and lymph nodes. A CT scan creates a three-dimensional picture of the inside of the body with a special x-ray machine. A computer combines these images into a detailed, cross-sectional view that shows abnormalities, including most tumors. A CT scan can also be used to measure the tumor’s size and if it is shrinking with treatment. A contrast dye may be injected into a patient’s vein before the scan to provide better detail.
• Positron emission tomography (PET) scan. A PET scan may also be used to find out whether the cancer has spread to organs outside of the breast. Similar to a CT scan, a PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive sugar substance is injected into a patient’s vein. This sugar substance is then taken up by cells that use the most energy because they are actively dividing. Because cancer cells tend to use energy actively, they absorb more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body. Areas that are most active appear as bright spots, and the intensity of the brightness can be measured to better describe these areas. A combination PET/CT scan may also be used to measure the size of tumors and to determine the location of the bright spots more accurately. A PET/CT scan will also show any abnormalities in the bone, similar to the bone scan.

After diagnostic tests are completed, your doctor will review all of the results with you. If the diagnosis is cancer, these results also help the doctor describe the amount of cancer in the body; this is called staging. If there are suspicious areas found outside of the breast, at least one area may be biopsied if possible to confirm the diagnosis of cancer.

Staging is a way of describing where the cancer is located, how much the cancer has grown, and if or where it has spread. Doctors use diagnostic tests to find out the cancer's stage, so staging may not be complete until all the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's prognosis, which is the chance of recovery. There are different stage descriptions for different types of cancer.

TNM staging system

The most commonly used tool that doctors use to describe the stage is the TNM system. Doctors use the results from diagnostic tests and scans to answer these questions:

• Tumor (T): How large is the primary tumor? Where is it located?
• Node (N): Has the tumor spread to the lymph nodes? If so, where and how many?  
• Metastasis (M): Has the cancer metastasized to other parts of the body? If so, where and how much?

The results are combined to determine the stage of cancer for each person. There are five stages: stage 0 (zero), which is noninvasive ductal carcinoma in situ (DCIS), and stages I through IV (one through four), which are used for invasive breast cancer. The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments.

There are two types of TNM staging for breast cancer. First, the clinical stage is based on the results of tests done before surgery, which may include physical examination, mammogram, ultrasound, and MRI scans. Then, the pathologic stage is assigned based on the pathology results from the breast tissue and any lymph nodes removed during surgery. It is usually determined several days after surgery. In general, more importance is placed on the pathologic stage than the clinical stage.

Here are more details on each part of the TNM system for breast cancer:

Tumor (T)

Using the TNM system, the “T” plus a letter or number (0 to 4) is used to describe the size and location of the tumor. Some stages are divided into smaller groups that help describe the tumor in even more detail.

TX: The primary tumor cannot be evaluated.

T0: There is no evidence of cancer in the breast.

Tis: Refers to carcinoma in situ. The cancer is confined within the ducts or lobules of the breast tissue and has not spread into the surrounding tissue of the breast. There are three types of breast carcinoma in situ:

Tis (DCIS): DCIS is a noninvasive cancer, but if not removed it can develop into an invasive breast cancer later. DCIS means that cancer cells have been found in breast ducts and have not spread past the layer of tissue where they began.

Tis (LCIS): Lobular carcinoma in situ (LCIS) describes abnormal cells found in the lobules or glands of the breast. LCIS is not cancer, but it increases the risk of developing invasive breast cancer.

Tis (Paget’s): Paget’s disease of the nipple is a rare form of early, noninvasive cancer that is only in the skin cells of the nipple. Sometimes Paget’s disease is associated with another, invasive breast cancer. If there is also an invasive breast cancer present, it is classified according to the stage of the invasive tumor.

T1: The invasive part of the tumor in the breast is 20 millimeters (mm) or smaller in size at its widest area. This is a little less than an inch. This stage is then broken into three substages depending on the size of the tumor:

• T1a is a tumor that is larger than 1 mm, but 5 mm or smaller
• T1b is a tumor that is larger than 5 mm, but 10 mm or smaller
• T1c is a tumor that is larger than 10 mm, but 20 mm or smaller.

T2: The invasive part of the tumor is larger than 20 mm but not larger than 50 mm.

T3: The invasive part of the tumor is larger than 50 mm.

T4: The tumor falls into one of the following groups:

• T4a means the tumor has grown into the chest wall.
• T4b is when the tumor has grown into the skin.
• T4c is cancer that has grown into the chest wall and the skin.
• T4d is inflammatory breast cancer.

Node (N)

The “N” in the TNM staging system stands for lymph nodes. Lymph nodes located under the arm, above and below the collarbone, and under the breastbone are called regional lymph nodes. Lymph nodes in other parts of the body are called distant lymph nodes. As explained above, if the doctor evaluates the lymph nodes before surgery, based on other tests and/or a physical examination, a letter “c” for “clinical” staging is placed in front of the “N.” If the doctor evaluates the lymph nodes after surgery, which is a more accurate assessment, a letter “p” for “pathologic” staging is placed in front of the “N.” The information below describes the pathologic staging.

NX: The lymph nodes cannot be evaluated.

N0: No cancer was found in the lymph nodes.

N0(i+): When very small areas of “isolated” tumor cells are found in a lymph node under the arm, called the axillary lymph nodes. This is usually less than 0.2 mm or less than 200 cells. In this stage, the nodes are still called N0, but an “i+” is also listed.
N1mic: Cancer in the axillary lymph nodes is larger than 0.2 mm but less than 2 mm in size and can only be seen through a microscope. This is often called a micrometastasis.

N1: The cancer has spread to one to three axillary lymph nodes under the arm, and is at least 2 mm in size. This is called a macrometastasis. This category can include positive internal mammary lymph nodes if they are found during a sentinel lymph node procedure and not otherwise clinically detected. The internal mammary lymph nodes are located under the sternum or breastbone.

N2: The cancer within the lymph nodes falls into one of the following groups:

• N2a is when the cancer has spread to 4 to 9 axillary, or underarm, lymph nodes.
• N2b is when the cancer has spread to or to internal mammary lymph nodes without spread to the axillary nodes.

N3: The cancer falls within one of the following groups:

• N3a is when the cancer has spread to 10 or more lymph nodes under the arm or to those located under the clavicle, or collarbone.
• N3b is when the cancer has spread to the internal mammary nodes and the axillary nodes.
• N3c is when the cancer has spread to the lymph nodes located above the clavicle, called the supraclavicular lymph nodes.

If there is cancer in the lymph nodes, knowing how many lymph nodes are involved and where they are helps doctors to plan treatment. The pathologist can find out the number of axillary lymph nodes that contain cancer after they are removed during surgery. It is not common to remove the supraclavicular or internal mammary lymph nodes during surgery. If there is cancer in these lymph nodes, treatment other than surgery, such as radiation therapy, chemotherapy, and hormonal therapy is used.

Metastasis (M)

The “M” in the TNM system indicates whether the cancer has spread to other parts of the body.

MX: Distant spread cannot be evaluated.

M0: The disease has not metastasized.

M0 (i+): There is no clinical or radiographic evidence of distant metastases, but microscopic evidence of tumor cells is found in the blood, bone marrow, or other lymph nodes that are no larger than 0.2 mm in a patient without other evidence of metastases.

M1: There is evidence of metastasis to another part of the body, meaning there are breast cancer cells growing in other organs.

Cancer stage grouping

Doctors assign the stage of the cancer by combining the T, N, and M classifications. Most patients are anxious to learn the exact stage of the cancer. However, it is important to keep in mind that tumor biology, including the diagnostic markers outlined above, has a significant impact on the type of treatment that is recommended, as well as on the prognosis. Your doctor will generally confirm the stage of the cancer when the testing after surgery is finalized, usually about 5 to 7 days after surgery. When systemic or whole body treatment is given before surgery, called neoadjuvant therapy, the stage of the cancer is primarily determined clinically. Doctors may refer to stage I to stage IIA cancer as early stage, and stage IIB to stage III as locally advanced.

Stage 0: Stage zero (0) describes disease that is only in the ducts and lobules of the breast tissue and has not spread to the surrounding tissue of the breast. It is also called noninvasive cancer (Tis, N0, M0).

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Stage IA: The tumor is small, invasive, and has not spread to the lymph nodes (T1, N0, M0).

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Stage IB: Cancer has spread only to the lymph nodes, and is larger than 0.2 mm but less than 2 mm in size. There is either no evidence of a tumor in the breast or the tumor in the breast is 20 mm or smaller (T0 or T1, N1mic, M0).

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Stage IIA: Any one of these conditions:

• There is no evidence of a tumor in the breast, but the cancer has spread to the axillary lymph nodes but not to distant parts of the body. (T0, N1, M0).
• The tumor is 20 mm or smaller and has spread to the axillary lymph nodes (T1, N1, M0).
• The tumor is larger than 20 mm but not larger than 50 mm and has not spread to the axillary lymph nodes (T2, N0, M0).

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Stage IIB: Either of these conditions:

• The tumor is larger than 20 mm but not larger than 50 mm and has spread to one to three axillary lymph nodes (T2, N1, M0).
• The tumor is larger than 50 mm but has not spread to the axillary lymph nodes (T3, N0, M0).

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Stage IIIA: The cancer of any size has spread to 4 to 9 axillary lymph nodes, but not to other parts of the body (T0, T1, T2 or T3, N2, M0). Stage IIIA may also be a tumor larger than 50 mm that has spread to one to three lymph nodes (T3, N1, M0).

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Stage IIIB: The tumor has spread to the chest wall or caused swelling or ulceration of the breast or is diagnosed as inflammatory breast cancer. It may or may not have spread to the lymph nodes under the arm, but it has not spread to other parts of the body (T4; N0, N1 or N2; M0).

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Stage IIIC: A tumor of any size that has not spread to distant parts of the body but has spread to 10 or more axillary lymph nodes or the lymph nodes in the N3 group (any T, N3, M0).

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Stage IV (metastatic): The tumor can be any size and has spread to other organs, such as the bones, lungs, brain, liver, distant lymph nodes, or chest wall (any T, any N, M1). Metastatic cancer spread found when the cancer is first diagnosed occurs about 5% to 6% of the time. This may be called de novo metastatic breast cancer. Most commonly, metastatic breast cancer is found after a previous diagnosis of early breast cancer.

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Recurrent: Recurrent cancer is cancer that has come back after treatment, and can be either local or distant or both. If the cancer does return, there will be another round of tests to learn about the extent of the recurrence. These tests and scans are often similar to those done at the time of the original diagnosis.