Diagnosing Breast Cancer

Diagnosing the Types & Stages of Breast Cancer

Breast cancer is the most common cancer in women. Breast cancer accounts for 30% of all new adult female cancer diagnoses, according to the American Cancer Society. Each year, many women undergo diagnostic tests for it, some of them resulting in a breast cancer diagnosis.

The entire process can be overwhelming. It often starts when a screening mammogram shows something suspicious, such as a breast calcification cluster. What are breast calcifications, and when are they a concern? They are deposits of calcium that become more common as you age. They are usually harmless when they are in a random pattern. An organized cluster may be a sign of cancer. Your doctor may also order diagnostic testing if there is a lump on your breast exam or you find a lump yourself. While male breast cancer is rare, breast cancer in men usually shows up as a lump as well.

The first step is to confirm whether the area is cancer or not. If it is cancer, your doctor will need to stage it and gather other information about it. This includes the specific types of breast cancer and whether it is hormone receptor positive or not. The process of staging gives your doctor an idea of the extent of cancer in your body.

For breast cancer, the stage depends on the size of the breast tumor and whether it has spread within the breast, to the lymph nodes, or to other organs or tissues. There are five breast cancer stages: 0, I, II, III and IV. The higher the number is, the more advanced or extensive the disease. Knowing the stage helps your doctor plan the best treatment and gives you information about your outlook, or breast cancer prognosis.

Diagnosing the types and stages of breast cancer consists of two main types of tests: imaging exams and breast biopsies.

Diagnostic Imaging Exams

Screening mammograms find most breast cancers, often in early stages before you can even feel a lump. If something suspicious shows up on a screening mammogram, you will get a call from the imaging center to come back for diagnostic testing. Your doctor may also send you for diagnostic imaging if you have a lump. There are three common types of imaging exams doctors use to get a better look at the area:

• Diagnostic mammogram, which provides a closer and more detailed view than a screening mammogram.
• Breast MRI (magnetic resonance imaging), which can show a better view of the breast tissue in some women. MRIs may also be useful for planning surgery.
• Breast ultrasound, which is often helpful for showing whether a lump is fluid filled or solid. A solid mass is more likely to be cancerous.

Breast centers know it is stressful to come in for diagnostic imaging. A radiologist will usually talk with you about the results right after these exams. The doctor may be able to tell from the imaging exams that the area is unlikely to be cancerous. If this is the case, you may just need follow-up screening within a few months to make sure there are no changes. If the doctor suspects cancer or is unsure about the area, you will need a breast biopsy.

Breast Biopsy

A biopsy is a procedure to take a tissue sample, in this case from the breast. It is the only way to know for sure whether the area is cancerous or not. There are three main types of breast biopsy procedures:

• Fine needle aspiration biopsy involves inserting a thin needle to take a sample of cells. Doctors typically use ultrasound to precisely locate the tumor and place the needle inside it. Doctors typically use fine needle biopsy when they suspect a fluid-filled cyst. The cyst often ruptures as soon as the needle penetrates it. Fine needle biopsy tends to give a lot of false negatives because it misses the cancer cells.
• Core needle biopsy involves a larger needle to withdraw a small cylinder of tissue. Doctors also use ultrasound guidance for this procedure. Core needle is the most common type of biopsy for diagnosing breast cancer. It is less invasive than surgical biopsy, yet is still highly accurate.
• Surgical biopsy involves making an incision into the breast to remove a sample of breast tissue. Doctors may remove part or all of the area, including the tumor. In some cases, this removes all of the cancer—like a lumpectomy. Surgical biopsy has the lowest rate of breast cancer misdiagnosis, but is the most invasive.

If cancer is present, staging breast cancer starts with the pathology report from your biopsy. Core and needle biopsy reports contain less information than a surgical biopsy report. Components of the pathology report may include:

• Type of breast cancer (described below)
• Size of the tumor
• Surgical margins, which reports whether the surgeon removed all of the tumor (margins negative) or if there may be residual cancer left behind
• Grade, or growth rate. The grade is an estimate of how fast or slow the cancer cells are likely to grow.
• HER2 (human epidermal growth factor receptor 2) status. HER2 is a marker present on the surface of some breast cancer cells.
• Hormone receptor status, which tells your doctor if the breast tumor feeds on hormones or not
• Lymph node tumor status
• Various tests indicating how likely the cancer is to spread—the aggressiveness of the cancer

All of this information will not be available with core or needle biopsies. Surgery will be necessary to stage your cancer after these biopsies.

What Are the Different Types of Breast Cancer?

There are several types of breast cancer, including:

• Ductal carcinoma in situ (DCIS): Also known as non-invasive breast cancer, this type of breast cancer is only in the cells lining the milk ducts. It remains in place, or in situ, and has not spread anywhere. This is a very early and highly treatable form of breast cancer. About 20% of new breast cancer cases are DCIS.
• Invasive ductal carcinoma: This form also starts in the milk ducts, but it has grown through the duct into the breast tissue. Staging will determine if it has invaded tissues outside the breast. It is the most common type.
• Invasive lobular carcinoma: Lobular means it starts in the milk-producing glands. It is invasive, so it has grown into surrounding breast tissue. Staging will tell if it has spread beyond the breast. About 10% of new cases are this type of breast cancer.
• Less common types: These relatively rare forms of breast cancer include inflammatory breast cancer, Paget’s disease of the nipple, Phyllodes tumor, and angiosarcoma.

After your doctor establishes the tumor stage, verifying how far the tumor has spread, you and your oncologist will begin to plan your treatment. Expert guidelines exist that recommend specific treatment strategies most likely to achieve superior outcomes for your individual case. Surgery with radiation is the main treatment for most breast cancers. The extent of surgery depends on the tumor stage and your preference. The breast cancer stage also tells your doctor whether chemotherapy should be part of your treatment. The hormone receptor status and HER2 status tells your doctor whether the tumor should respond to hormone therapy or targeted therapy.

Together, you and your doctor will decide on the most effective and acceptable treatment for you. Talk with your doctor about your options and the risks and benefits of each. In most cases, you can take some time to make decisions without endangering your health. It’s important to fully understand your treatment choices. Getting a second opinion can be useful for gathering information and making a decision.