Breast Cancer

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The first step toward diagnosing breast cancer is a medical history and physical exam. Be prepared to answer questions about the occurrence of cancer—ovarian, cancer, and breast—including the age at which cancer was diagnosed in your family. You will be asked about the use of hormones, your reproductive history, and prior breast biopsies. During the physical exam, your doctor will examine your breast to look for visible signs of breast cancer which may include breasts that don't look the same, changes in skin texture or color, swelling, or redness. The exam will include palpating your breast to look for areas of tenderness or discrete lumps, assessing the nipple for discharge, and checking for enlarged lymph nodes in your armpit.

If there are no abnormal findings, your doctor will discuss the risks and benefits of a screening mammogram, taking into account your age and risk factors. If a breast cancer is suspected, you will likely need additional mammograms, ultrasound, and a breast biopsy. If cancer is confirmed, your doctor may recommend additional tests to characterize and stage the cancer. This may include a bone scan, CT scan, and hormone receptor testing.

This section includes information on:

  • Mammography
  • Ultrasound
  • Breast magnetic resonance imaging (MRI)
  • Biopsies
  • Sentinel node biopsy
  • Testing for hormone receptors
  • Grading cancer
  • Bone scan
  • Staging cancer
  • Mammography

    Mammograms, commonly used to screen for breast cancer, are X-rays of the breast tissue. If an abnormality is detected on a screening mammogram or if you have a breast lump or new breast changes, your doctor may recommend a diagnostic mammogram. Mammograms are also used to assess a healthy breast for abnormalities and help assess the extent of breast cancer.

    Ultrasound

    This technology employs sound waves to produce images of tissues within the body and is used at both the screening and diagnostic stages to distinguish fluid-filled cysts from solid tumors. It is safe, painless, and has no side effects. If the ultrasound finds a lump, the radiologist can use this test to help guide the breast biopsy. Most often, the radiologist will leave a marker at the site of the breast biopsy to help the surgeon locate the lump during surgery.

    Magnetic Resonance Imaging (MRI)

    An MRI scan can be used for screening women who have a high risk of getting breast cancer, or as part of the diagnostic work-up to evaluate areas of concern found on a mammogram. Your surgeon or breast team may request a breast MRI before surgery to help assess the extent of the cancer.

    An MRI machine uses a magnet and radio waves to create pictures of breasts, the chest wall, and armpits. Before a breast MRI, you receive an injection of contrast material to better show the details within the breast. An MRI scan requires the patient to lie on her stomach inside a narrow tube while the machine, which makes loud buzzing and clicking noises, creates the image of the breasts.

    Biopsies

    A sample of breast tissue is required to diagnose breast cancer. If mammography or any other screening method reveals a mass or lesion that a radiologist or surgeon believes may be cancerous, a biopsy will be performed to remove a sample of the suspicious tissue. The tissue sample is analyzed by a pathologist who can determine whether it is benign or cancerous. If the cells are cancerous, the pathologist can also determine the type of cells involved in the breast cancer, the aggressiveness or grade of the cancer, and whether or not the cancer cells have hormone receptors.

    The tissue sample may be removed by:

    Fine-needle aspiration biopsy: In a procedure resembling a blood draw, a fine, hollow needle is inserted into a lump or lesion and cells are drawn out for evaluation. This is usually performed when a fluid-filled mass is seen on an ultrasound image or your doctor detects a lesion during a clinical breast exam. If the fluid-filled cyst disappears after the aspiration, no further work-up is needed. You may be asked to return after four to six weeks to see if the fluid has re-accumulated. If the lump is solid, a core needle biopsy will be performed.

    Core needle biopsy: A hollow needle is used to take several rice-grain-size cores of tissue. With this type of biopsy, tissue structure as well as cells can be evaluated. This procedure is usually done on an outpatient basis, using a local anesthesia to minimize the discomfort. Ultrasound is used to guide the placement of the needle. When a suspicious area cannot be located by feel or ultrasound but is visible through mammography, the radiologist uses a mammogram to locate the area and to perform the core needle biopsy. When a mammogram is used to guide the core needle, the procedure is called a stereotactic biopsy.

    Surgical biopsy: All or part of the suspicious tissues may be removed by surgery. Total removal of the tissue is called an excisional biopsy and partial removal is called an incisional biopsy. Most often, an excisional or incisional biopsy is done in the hospital's outpatient center, with the use of a local anesthesia to numb the area around the lump.

    Sentinel Node Biopsy

    One of the first places breast cancer will spread is the lymphatic system. A sentinel node biopsy checks for cancer in the lymph nodes that are the most likely to be the first affected by the cancer cells: those which initially receive lymph drainage from the area where the tumor is located. Nearly all women with invasive cancer will be advised to have these nodes examined. Some surgeons think it prudent to examine the underarm nodes of women with noninvasive ductal carcinoma in situ (DCIS) as well, especially if it is a high-grade tumor or there is reason to believe that DCIS is distributed throughout the breast.

    Finding the sentinel node requires considerable skill and experience. The surgeon can use one of two "tracers," materials that are injected in the breast and flow through the lymph channels into the axillary lymph nodes. The tracer contains a small amount of radioactive material. The surgeon then uses a hand-held Geiger counter to find out which lymph nodes the radioactive material went to. The second tracer is a blue dye, which also flows to the lymph nodes. By following the dye, the surgeon can identify the first lymph nodes reached. At the time of the biopsy, the surgeon will remove any other lymph nodes that feel suspicious. Once the sentinel node is removed, it will be analyzed by a pathologist. If a sentinel node is healthy, the chance of finding cancer in any of the remaining nodes is very small, and no other nodes need to be removed. If a sentinel lymph node is found to contain cancer, a second surgery known as an axillary dissection typically is done to remove and examine additional lymph nodes. If these nodes are found to contain cancer, the chances that the cancer has spread to other parts of the body will be greater. In that case, more aggressive medications or treatment will be recommended.

    Testing for Hormone Receptors

    If pathological examination finds breast cells to be malignant, further studies are done to see if the cancer cells have receptors that bind with the hormones estrogen and progesterone. Cancer cells with such receptors are called hormone-receptor positive. Women with receptor-positive cancers are better able to respond to hormonal therapy and thus tend to have a better prognosis. About two thirds of breast cancers have receptors for progesterone, estrogen, or both.

    Grading a Cancer

    Breast cancers are assigned a grade, which indicates the degree of abnormality of the cancer cells. The cancer grade is one of the factors that is used to determine treatment options.

    To grade a cancer, the pathologist examines a sample of tissue removed from the tumor under a microscope. The samples are graded from 1 to 3 based on how closely the cells resemble normal cells in size and shape, how much of the cancer is tubular in structure, and how many of the cells are dividing. Grade 1 cancers contain the most like-normal cells and are very well differentiated. Cells in grade 3 cancer have distorted shapes, are poorly differentiated, and tend to grow rapidly. In general, the lower-grade cancers tend to be slower growing. Individuals with tumor cells that are well differentiated and classified as grade 1 tend to have a better prognosis than do those with poorly differentiated cells of grade 3.

    Bone Scan

    A bone scan may be used during the staging process to determine if the cancer has spread to the bones. During a bone scan, the radiologist injects a small amount of a radioactive substance, a radiotracer, into a blood vessel in the arm. This substance will collect in the bones and can then be viewed using a gamma camera. The degree to which the bone takes up the tracer can indicate the presence of cancer. This process may take up to five hours to complete.

    Breast Cancer Staging

    The stage of a cancer refers to a scoring system that represents the extent of the disease. In most cases when someone presents with early form breast cancer, staging tests are not required. Staging tests may be recommended by your doctor based on the size of the cancer or new symptoms you may be experiencing.

    The information used to stage that is collected during breast cancer surgery includes the size of primary tumor (T), presence of cancer cells in the axillary lymph nodes under the arm (N), and the presence of cancer cells in other parts of the body (M). Additional information from blood tests such a complete blood count, chest x-ray, mammogram of the other breast, breast MRI, computerized tomography (CT) scan, and positron emission tomography (PET) scan may also be used to stage breast cancer. Your doctor will choose which tests are appropriate for you.

    The stage and the cancer type are used by the oncologist to develop a sense of the overall prognosis and determine the options for adjuvant or preventive therapy such as chemotherapy, radiation therapy, targeted therapy, and hormonal therapy. Because the treatment options and prognoses are constantly changing, it is best to review this information very carefully with your doctor.

    Breast cancer stages range from 0 to IV. As a general rule, Stage 0, I, and II are early-stage cancers; Stage III and IV are late-stage cancers. In general, the early-stage breast cancers are associated with a better prognosis.

    Stage 0: These cancers are described as noninvasive or in situ (in place), otherwise known as ductal carcinoma in situ (DCIS). There are abnormal or precancerous cells in the lining of a duct, but the cells have not spread into normal breast tissue. With treatment, the five-year survival rate for Stage 0 breast cancer is about 99 percent.

    Stage I: An early stage of invasive cancer in which the cancer cells remain localized; they have not spread to lymph nodes or outside the breast. The tumor is 2 centimeters (about the size of a shelled peanut) or less in diameter. Following surgery, doctors may recommend radiation treatments, chemotherapy, or hormonal therapy. About 6 of every 10 women diagnosed with breast cancer are classified as stage I, with a five-year survival rate of approximately 90 to 95 percent for patients who pursue treatment.

    Stage II and stage III together account for slightly more than 3 out of every 10 breast cancer diagnoses. For these women, the cancer is considered localized and nearly 85 percent are expected to survive five years or more.

    Stage II: The cancer is contained within the breast but there may be lymph-node involvement. This stage includes four different scenarios:

    • Tumor is 2 centimeters or less in diameter and a small number of lymph nodes are affected.
    • Tumor is 2 to 5 centimeters in diameter.
    • Tumor exceeds 5 centimeters in size but has not reached the lymph nodes.
    • No tumor, and cancer cells are found in less than four axillary lymph nodes.
    • For patients with Stage II breast cancer, additional therapy may be recommended following surgery such as radiation, chemotherapy, and hormonal treatment depending upon the individual's situation.

      Stage III: includes three scenarios:

      • IIIA Tumor is larger than 5 centimeters and more than four axillary lymph nodes affected, but the lymph nodes have not grouped together.
      • IIIB Tumor is less than 5 centimeters, the cancer cells have spread into nearby lymph nodes, and the nodes are growing into each other or the surrounding tissue (stroma). There is no evidence of spread to distant sites. Also known as locally advanced cancer, this stage can correspond to inflammatory breast cancer.
      • IIIC Tumor is less than 5 centimeters and the cancer cells have spread to lymph nodes under the arm and above the collarbone. There is no evidence of spread to distant sites.
      • Stage III breast cancers require more aggressive treatment. Radiation therapy may be recommended following surgery as well as other adjuvant or preventive therapies such as chemotherapy, hormone therapy, and targeted therapy. Chemotherapy may be recommended prior to surgery, referred to as neoadjuvant therapy, depending on the individual's situation.

        Stage IV: Regardless of tumor size, cancer cells have reached the lungs, liver, brain, bones, or other sites distant from the breast. Stage IV breast cancer, also known as metastatic breast cancer, accounts for about 1 out of every 20 women diagnosed with breast cancer. Currently, treatment of these advanced cancers focuses on slowing the progression of the disease to improve the quality of life as opposed to curing the cancer. Treatment options include chemotherapy, radiation therapy, biological therapy, and hormone therapy. Although a woman may live for many years with stage IV breast cancer, it is likely the disease will eventually become life-threatening. Nationally, just over 23 percent of women with stage IV breast cancer are expected to survive five years or longer.

        Last reviewed on 3/28/10

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