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Detection and Diagnosis
Screening
Symptoms
Diagnosis
Additional Tests
A woman should talk with her health care provider about her personal risk of getting breast cancer. She should ask questions about when to start and how often to be checked for the disease. These decisions, like many other medical decisions, should fit each woman's needs.
Screening
for cancer before there are
symptoms
can be important. It can help doctors find and treat cancer early. Treatment is more likely to be effective when cancer is found early.
The health care provider may suggest screening tests to check for breast cancer before any symptoms develop:
Screening Mammogram
To find breast cancer early, the NCI recommends that:
- Women in their 40s and older should have mammograms (pictures of the breast made with x-rays) every one to two years.
- Women who are at higher than average risk of breast cancer should talk with their health care providers about whether to have mammograms before age 40 and how often to have them.
Screening mammograms can often show a breast lump before it can be felt. They also can show a cluster of very tiny specks of calcium. These specks are called
microcalcifications. Lumps or specks can be signs of cancer.
If the doctor sees an abnormal area on the mammogram, the woman may need more pictures taken. Also, the woman may need to have a biopsy. A biopsy is the only way to tell for sure if cancer is present.
(More information on biopsy is in the section on
Detection and Diagnosis.)
Mammograms are the best tool doctors have to find breast cancer early. However, it is good for a woman to keep in mind that:
- A mammogram may miss some cancers that are present. (This is called a "false negative.")
- A mammogram may show things that turn out not to be cancer. (This is called a "false positive.")
- Some fast-growing tumors may already have spread to other parts of the body before a mammogram detects them.
Mammograms (as well as dental x-rays, and other routine x-rays) use very small doses of radiation. Although the benefits nearly always outweigh the risks, repeated exposure to x-rays could be harmful. It is a good idea for a woman to talk with her health care providers about the need for each x-ray and to ask about the use of shields during the
x-ray to protect other parts of the body.
Clinical Breast Exam
During a clinical breast exam, the health care provider feels the breasts while the woman is standing or sitting up and lying down. The woman may be asked to raise her arms over her head, let them hang by her sides, or press her hands against her hips.
The health care provider looks for differences between the breasts, including unusual differences in size or shape. The skin of each breast is checked for a rash, dimpling, or other abnormal signs. The nipples may be squeezed to see if fluid is present.
Using the pads of the fingers to feel for lumps, the health care provider checks the entire breast, the underarm, and the collarbone area, first on one side, then on the other. A lump is generally the size of a pea before anyone can feel it. The lymph nodes near the breast may be checked to see if they are swollen.
A thorough clinical breast exam may take 10 minutes.
Breast Self-Exam
Some women perform monthly breast self-exams to check for any changes in their breasts. When a woman does this exam, it is important for her to remember that each woman's breasts are different, and that changes can occur because of aging, the menstrual cycle, pregnancy, menopause, or taking birth control pills or other hormones. It is normal for the breasts to feel a little lumpy and uneven. Also, it is common for a woman's breasts to be swollen and tender right before or during her menstrual period.
Women who notice anything unusual during a breast self-exam or at any other time should contact their health care provider.
Also, it is important to remember that breast self-exams cannot replace regular screening mammograms and clinical breast exams. Although breast self-exams lead to more breast biopsies, studies so far have not shown that breast self-exams reduce the number of deaths from breast cancer.
Breast cancer can cause changes that women should watch for:
- A change in how the breast or nipple feels
- A lump or thickening in or near the breast or in the underarm area
- Nipple tenderness
- A change in how the breast or nipple looks
- A change in the size or shape of the breast
- The nipple is turned inward into the breast
- The skin of the breast, areola, or nipple may be scaly, red, or swollen. It may have ridges or pitting so that it looks like the skin of an orange.
- Nipple discharge (fluid)
Although early breast cancer usually does not cause pain, a woman should see her health care provider about breast
pain or any other symptom that does not go away. Most often, these symptoms are not cancer, but it is important to check with the health care provider so that any problems can be diagnosed and treated as early as possible.
If a woman has a breast change, her doctor must determine whether it is due to breast cancer or some other cause.
The woman has a physical exam. The doctor asks about her personal and family medical history. She may have a mammogram or other
imaging procedure that makes pictures of tissues inside the breast. After the tests, the doctor may decide that no further tests are needed and no treatment is necessary. Or the woman may need a biopsy to examine the suspicious area for cancer cells.
Clinical Breast Exam
The health care provider feels each breast for lumps and looks for other problems. If a woman has a breast lump, the health care provider can tell a lot about it by feeling it and the tissue around it. Benign lumps often feel different from cancerous ones. The health care provider can check the size, shape, and texture of the lump and feel whether it moves easily. Lumps that are soft, smooth, round, and movable are likely to be benign. A hard, oddly shaped lump that feels firmly attached within the breast is more likely to be cancer.
Diagnostic Mammography
Diagnostic mammograms
involve x-ray pictures of the breast to get clearer, more detailed pictures of any area that looks abnormal on a screening mammogram. They also are used to help the doctor learn more about unusual breast changes, such as a lump, pain, thickening, nipple discharge, or change in breast size or shape. Diagnostic mammograms may focus on a specific area of the breast. They may involve special techniques and more views than screening mammograms.
Ultrasonography
Using high-frequency sound waves,
ultrasonography
(ultrasound) can often show whether a lump is a fluid-filled cyst (not cancer) or a solid mass (which may or may not be cancer). The doctor can view these pictures on a monitor. After the test, the pictures can be stored on video and printed out. This exam may be used along with a mammogram.
Magnetic Resonance Imaging
For
magnetic resonance imaging
(MRI), a powerful magnet linked to a computer is sometimes used to make detailed pictures of tissue inside the breast. The doctor can view these pictures on a monitor and can print them on film. MRI may be used along with a mammogram.
Biopsy
Often, fluid or tissue must be removed from the breast to help the doctor learn whether cancer is present. This is called a biopsy. For the biopsy, the doctor may refer the woman to a surgeon or breast disease specialist.
Sometimes a suspicious area that can be seen on a mammogram cannot be felt during a clinical breast exam. The doctor can use imaging devices to help see the area to then obtain tissue. Such procedures include
ultrasound-guided,
needle-localized, or
stereotactic biopsy.
Doctors can remove tissue from the breast in different ways:
- Fine-needle aspiration: The doctor uses a thin needle to remove fluid and/or cells from a breast lump. If the fluid appears to contain cells, it goes to a lab where a pathologist uses a microscope to check for cancer cells. If the fluid is clear, it may not need to be checked by a lab.
- Core biopsy: The doctor uses a thick needle to remove breast tissue. A pathologist checks for cancer cells. This procedure is also called a needle biopsy.
- Surgical biopsy: In an incisional biopsy, the surgeon removes a sample of a lump or abnormal area. In an excisional biopsy, the surgeon removes the entire lump or abnormal area. A pathologist examines the tissue for cancer cells.
If cancer cells are found, the pathologist can tell what kind of cancer it is. The most common type of breast cancer is ductal carcinoma. It begins in the lining of the ducts. Another type, called
lobular carcinoma, begins in the lobules.
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A woman who needs a biopsy may want to ask her doctor the following questions:
- What kind of biopsy will I have? Why?
- How long will it take? Will I be awake? Will it hurt? Will I have anesthesia? What kind?
- How soon will I know the results?
- Are there any risks? What are the chances of infection or bleeding after the biopsy?
- If I do have cancer, who will talk with me about treatment? When?
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If the diagnosis is cancer, the doctor may order special lab tests on the tissue that was removed. The results of these tests help the doctor learn more about the cancer and plan appropriate treatment.
Many women with breast cancer will have the
hormone receptor test.
It shows whether the cancer needs hormones
(estrogen or progesterone) to grow. The result helps the doctor plan treatment.
Sometimes a sample of breast tissue is checked for the human
epidermal growth factor receptor-2
(HER2)
or the
HER2/neu gene.
The presence of the HER2 receptor or gene may increase the chance that the breast cancer will come back.
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