How is breast cancer diagnosed?
Breast cancer is sometimes found after symptoms appear, but many women with early breast cancer have no symptoms. This is why getting the recommended screening tests (as described in the section, "Can breast cancer be found early?") before any symptoms develop is so important.
If something suspicious is found during a screening exam, or if you have any of the symptoms of breast cancer described below, your doctor will use one or more methods to find out if the disease is present. If cancer is found, other tests will be done to determine the stage (extent) of the cancer.
Signs and symptoms
Widespread use of screening mammograms has increased the number of breast cancers found before they cause any symptoms. Still, some breast cancers are not found by mammogram, either because the test was not done or because, even under ideal conditions, mammograms do not find every breast cancer.
The most common symptom of breast cancer is a new lump or mass. A painless, hard mass that has irregular edges is more likely to be cancerous, but breast cancers can be tender, soft, or rounded. They can even be painful. For this reason, it is important to have any new breast mass or lump checked by a health care professional experienced in diagnosing breast diseases.
Other possible signs of breast cancer include:
- Swelling of all or part of a breast (even if no distinct lump is felt)
- Skin irritation or dimpling
- Breast or nipple pain
- Nipple retraction (turning inward)
- Redness, scaliness, or thickening of the nipple or breast skin
- Nipple discharge (other than breast milk)
Sometimes a breast cancer can spread to lymph nodes under the arm or around the collar bone and cause a lump or swelling there, even before the original tumor in the breast tissue is large enough to be felt.
Medical history and physical exam
If you think you have any signs or symptoms that might mean breast cancer, be sure to see your doctor as soon as possible. Your doctor will ask you questions about your symptoms, any other health problems, and possible risk factors for benign breast conditions or breast cancer.
Your breasts will be thoroughly examined for any lumps or suspicious areas and to feel their texture, size, and relationship to the skin and chest muscles. Any changes in the nipples or the skin of your breasts will be noted. The lymph nodes in your armpit and above your collarbones may be palpated (felt), because enlargement or firmness of these lymph nodes might indicate spread of breast cancer. Your doctor will also do a complete physical exam to judge your general health and whether there is any evidence of cancer that may have spread.
If breast symptoms and/or the results of your physical exam suggest breast cancer might be present, more tests will probably be done. These might include imaging tests, looking at samples of nipple discharge, or doing biopsies of suspicious areas.
Imaging tests used to evaluate breast disease
Imaging tests use x-rays, magnetic fields, sound waves, or radioactive substances to create pictures of the inside of your body. Imaging tests may be done for a number of reasons, including to help find out whether a suspicious area might be cancerous, to learn how far cancer may have spread, and to help determine if treatment is working.
A mammogram is an x-ray of the breast. Screening mammograms are used to look for breast disease in women who are asymptomatic; that is, they appear to have no breast problems. Screening mammograms usually take 2 views (x-ray pictures taken from different angles) of each breast.
Diagnostic mammograms are used to diagnose breast disease in women who have breast symptoms (like a lump or nipple discharge) or an abnormal result on a screening mammogram. A diagnostic mammogram includes more images of the area of concern. In some cases, special images known as cone or spot views with magnification are used to make a small area of abnormal breast tissue easier to evaluate.
A diagnostic mammogram can show:
- That the abnormality is not worrisome at all. In these cases the woman can usually return to having routine yearly mammograms.
- That a lesion (area of abnormal tissue) has a high likelihood of being benign (not cancer). In these cases, it is common to ask the woman to come back sooner than usual for her next mammogram, usually in 4 to 6 months.
- That the lesion is more suspicious, and a biopsy is needed to tell if it is cancer.
Even if the mammograms show no tumor, if you or your doctor can feel a lump, a biopsy is usually needed to make sure it isn't cancer. One exception would be if an ultrasound exam finds that the lump is a simple cyst (a fluid-filled sac), which is very unlikely to be cancerous.
Magnetic resonance imaging (MRI) of the breast
MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of body tissue and by certain diseases. A computer translates the pattern into a very detailed image of parts of the body. For breast MRI to look for cancer, a contrast liquid called gadolinium is injected into a vein before or during the scan to show details better.
MRI scans can take a long time—often up to an hour. You have to lie inside a narrow tube, face down on a platform specially designed for the procedure. The platform has openings for each breast that allow them to be imaged without compression. The platform contains the sensors needed to capture the MRI image. It is important to remain very still throughout the exam.
Lying in the tube can feel confining and might upset people with claustrophobia (a fear of enclosed spaces). The machine also makes loud buzzing and clicking noises that you may find disturbing. Some places will give you headphones with music to block this noise out. MRIs are also expensive, although insurance plans generally pay for them in some situations, such as once cancer is diagnosed.
MRI machines are quite common, but they need to be specially adapted to look at the breast. It's important that MRI scans of the breast be done on one of these specially adapted machines and that the MRI facility can also do a MRI guided biopsy if it is needed.
MRI can be used along with mammograms for screening women who have a high risk of developing breast cancer, or it can be used to better examine suspicious areas found by a mammogram. MRI is also used for women who have been diagnosed with breast cancer to better determine the actual size of the cancer and to look for any other cancers in the breast. It is not yet clear how helpful this is in planning surgery in someone known to have breast cancer. In someone known to have breast cancer, it is sometimes used to look at the opposite breast, to be sure that it does not contain any tumors.
If an abnormal area in the breast is found, it can often be biopsied using an MRI for guidance. This is discussed in more detail in the "Biopsy" section.
Ultrasound, also known as sonography, uses sound waves to outline a part of the body. For this test, a small, microphone-like instrument called a transducer is placed on the skin (which is often first lubricated with ultrasound gel). It emits sound waves and picks up the echoes as they bounce off body tissues. The echoes are converted by a computer into a black and white image that is displayed on a computer screen. This test is painless and does not expose you to radiation.
Ultrasound has become a valuable tool to use along with mammography because it is widely available and less expensive than other options, such as MRI. The use of ultrasound instead of mammograms for breast cancer screening is not recommended. Usually, breast ultrasound is used to target a specific area of concern found on the mammogram. Ultrasound helps distinguish between cysts (fluid-filled sacs) and solid masses and sometimes can help tell the difference between benign and cancerous tumors.
Ultrasound may be most helpful in women with very dense breasts. Clinical trials are now looking at the benefits and risks of adding breast ultrasound to screening mammograms in women with dense breasts and a higher risk of breast cancer.
This test, also called a galactogram, sometimes helps determine the cause of nipple discharge. In this test a very thin plastic tube is placed into the opening of the duct in the nipple that the discharge is coming from. A small amount of contrast medium is injected, which outlines the shape of the duct on an x-ray image and shows if there is a mass inside the duct.
Newer imaging tests
Newer tests like scintimammography and tomosynthesis are not used commonly and are still being studied to determine their usefulness. They are described in the section, "What's new in breast cancer research and treatment?"
These tests may be done for the purposes of research, but they have not yet been found to be helpful in diagnosing breast cancer in most women.
Nipple discharge exam
If you are having nipple discharge, some of the fluid may be collected and looked at under a microscope to see if any cancer cells are in it. Most nipple discharges or secretions are not cancer. In general, if the secretion appears milky or clear green, cancer is very unlikely. If the discharge is red or red-brown, suggesting that it contains blood, it might possibly be caused by cancer, although an injury, infection, or benign tumors are more likely causes.
Even when no cancer cells are found in a nipple discharge, it is not possible to say for certain that a breast cancer is not there. If a patient has a suspicious mass, it will be necessary to biopsy the mass, even if the nipple discharge does not contain cancer cells.
Ductal lavage and nipple aspiration
Ductal lavage is an experimental test developed for women who have no symptoms of breast cancer but are at very high risk for the disease. It is not a test to screen for or diagnose breast cancer, but it may help give a more accurate picture of a woman's risk of developing it.
Ductal lavage can be done in a doctor's office or an outpatient facility. An anesthetic cream is applied to numb the nipple area. Gentle suction is then used to help draw tiny amounts of fluid from the milk ducts up to the nipple surface, which helps locate the ducts' natural openings. A tiny tube (called a catheter) is then inserted into a duct opening. Saline (salt water) is slowly infused into the catheter to gently rinse the duct and collect cells. The ductal fluid is withdrawn through the catheter and sent to a lab, where the cells are looked at under a microscope.
Ductal lavage is not done for women who aren't at high risk for breast cancer. It is not clear if it will ever be useful. The test has not been shown to detect cancer early. It is more likely to be helpful as a test of cancer risk rather than as a screening test for cancer. More studies are needed to better define the usefulness of this test.
Nipple aspiration also looks for abnormal cells developing in the ducts, but is much simpler, because nothing is inserted into the breast. The device for nipple aspiration uses small cups that are placed on the woman's breasts. The device warms the breasts, gently compresses them, and applies light suction to bring nipple fluid to the surface of the breast. The nipple fluid is then collected and sent to a lab for analysis. As with ductal lavage, the procedure may be useful as a test of cancer risk but is not an appropriate screening test for cancer. The test has not been shown to detect cancer early.
A biopsy is done when mammograms, other imaging tests, or the physical exam finds a breast change (or abnormality) that is possibly cancer. A biopsy is the only way to tell if cancer is really present.
During a biopsy, a sample of the suspicious area is removed to be looked at under a microscope, by a specialized doctor with many years of training called a pathologist. The pathologist sends your doctor a report that gives a diagnosis for each sample taken. Information in this report will be used to help manage your care. For information to help you understand your pathology report, see Breast Pathology or call 1-800-227-2345.
There are several types of biopsies, such as fine needle aspiration biopsy, core (large needle) biopsy, and surgical biopsy. Each has its pros and cons. The choice of which to use depends on your specific situation. Some of the factors your doctor will consider include how suspicious the lesion appears, how large it is, where in the breast it is located, how many lesions are present, other medical problems you might have, and your personal preferences. You might want to discuss the pros and cons of different biopsy types with your doctor.
Fine needle aspiration biopsy
In a fine needle aspiration (FNA) biopsy, the doctor uses a very thin, hollow needle attached to a syringe to withdraw (aspirate) a small amount of tissue from a suspicious area, which is then looked at under a microscope. The needle used for an FNA biopsy is thinner than the ones used for blood tests.
If the area to be biopsied can be felt, the needle can be guided into the area of the breast change while the doctor is feeling (palpating) it.
If the lump can't be felt easily, the doctor might use ultrasound to watch the needle on a screen as it moves toward and into the mass.
A local anesthetic (numbing medicine) may or may not be used. Because such a thin needle is used for the biopsy, the process of getting the anesthetic may actually be more uncomfortable than the biopsy itself.
Once the needle is in place, fluid is drawn out. If the fluid is clear, the lump is probably a benign cyst. Bloody or cloudy fluid can mean either a benign cyst or, very rarely, a cancer. If the lump is solid, small tissue fragments are drawn out. A pathologist will look at the biopsy tissue or fluid under a microscope to determine if it is cancerous.
An FNA biopsy is the easiest type of biopsy to have, but it has some disadvantages. It can sometimes miss a cancer if the needle is not placed among the cancer cells. And even if cancer cells are found, it is usually not possible to determine if the cancer is invasive. In some cases there may not be enough cells to perform some of the other lab tests that are routinely done on breast cancer specimens. If the FNA biopsy does not provide a clear diagnosis, or your doctor is still suspicious, a second biopsy or a different type of biopsy should be done.
Core needle biopsy
A core biopsy uses a larger needle to sample breast changes felt by the doctor or pinpointed by ultrasound or mammogram. (When mammograms taken from different angles are used to pinpoint the biopsy site, this is known as a stereotactic core needle biopsy.) In some centers, the biopsy can be guided by an MRI scan.
The needle used in core biopsies is larger than the one used in FNA. It removes a small cylinder (core) of tissue (about 1/16- to 1/8-inch in diameter and ½-inch long) from a breast abnormality. Several cores are often removed. The biopsy is done using local anesthesia (where you are awake but the area is numbed) in an outpatient setting.
Because it removes larger pieces of tissue, a core needle biopsy is more likely than an FNA to provide a clear diagnosis, although it may still miss some cancers.
Vacuum-assisted biopsies can be done with systems such as the Mammotome® or ATEC® (Automated Tissue Excision and Collection). For these procedures the skin is numbed and a small incision (about ¼ inch) is made. A hollow probe is inserted through the incision into the abnormal area of breast tissue. The probe can be guided into place using x-rays or ultrasound (or MRI in the case of the ATEC system). A cylinder of tissue is then suctioned in through a hole in the side the probe, and a rotating knife within the probe cuts the tissue sample from the rest of the breast. Several samples can be taken from the same incision. Vacuum-assisted biopsies are done as an outpatient procedure. No stitches are needed, and there is minimal scarring. This method usually removes more tissue than core biopsies.
Surgical (open) biopsy
Usually, breast cancer can be diagnosed using needle biopsy. Rarely, surgery is needed to remove all or part of the lump for microscopic examination. This is referred to as a surgical biopsy or an open biopsy. Most often, the surgeon removes the entire mass or abnormal area as well as a surrounding margin of normal-appearing breast tissue. This is called an excisional biopsy. If the mass is too large to be removed easily, only part of it may be removed. This is called an incisional biopsy.
In rare cases, a surgical biopsy can be done in the doctor's office, but it is most often done in the hospital's outpatient department under a local anesthesia (where you are awake, but your breast is numbed), often with intravenous sedation (medicine given to make you drowsy). This type of biopsy can also be done under general anesthesia (you are asleep).
If the breast change cannot be felt, a mammogram may be used to place a wire into the correct area to guide the surgeon. This technique is called wire localization or stereotactic wire localization. After the area is numbed with local anesthetic, a thin hollow needle is placed in the breast, and x-ray views are used to guide the needle to the suspicious area. Once the tip of the needle is in the right spot, a thin wire is inserted through the center of the needle. A small hook at the end of the wire keeps it in place. The hollow needle is then removed. The surgeon can then use the wire as a guide to the abnormal area to be removed. The surgical specimen is sent to the lab to be looked at under a microscope (see below).
A surgical biopsy is more involved than an FNA biopsy or a core needle biopsy. It typically requires several stitches and may leave a scar. The larger the amount of tissue removed, the more likely it is that you will notice a change in the shape of your breast afterward.
Core needle biopsy is usually enough to make a diagnosis, but sometimes an open biopsy may be needed depending on where the lesion is, or if a core biopsy is not conclusive.
All biopsies can cause bleeding and can lead to swelling. This can make it seem like the breast lump is larger after the biopsy. This is generally nothing to worry about and the bleeding and bruising resolve quickly in most cases.
Lymph node dissection and sentinel lymph node biopsy
These procedures are done specifically to look for cancer in the lymph nodes. These are most often done after breast cancer is diagnosed, not as part of the initial breast biopsy. They are described in more detail in the section, "How is breast cancer treated?"
Laboratory examination of breast cancer tissue
The biopsy samples of breast tissue are looked at in the lab to determine whether breast cancer is present and if so, what type it is. Certain lab tests may be done that can help determine how quickly a cancer is likely to grow and (to some extent) what treatments are likely to be effective. Sometimes these tests aren’t done until the entire tumor is removed by either breast-conserving surgery or mastectomy.
If a benign condition is diagnosed, you will need no further treatment. Still, it is important to find out from your doctor if the benign condition places you at higher risk for breast cancer in the future and what type of follow-up you might need.
If the diagnosis is cancer, there should be time for you to learn about the disease and to discuss treatment options with your cancer care team, friends, and family. It is usually not necessary to rush into treatment. You might want to get a second opinion before deciding what treatment is best for you.
Type of breast cancer
The tissue removed during the biopsy (or during surgery) is first looked at under a microscope to see if cancer is present and whether it is a carcinoma or some other type of cancer (like a sarcoma). If there is enough tissue, the pathologist may be able to determine if the cancer is in situ (not invasive) or invasive. The biopsy is also used to determine the cancer's type, such as invasive ductal carcinoma or invasive lobular carcinoma. The different types of breast cancer are defined in the section, "What is breast cancer?"
With an FNA biopsy, not as many cells are removed and they often become separated from the rest of the breast tissue, so it is often only possible to say that cancer cells are present without being able to say if the cancer is in situ or invasive.
The most common types of breast cancer, invasive ductal and invasive lobular cancer, generally are treated in the same way.
Breast cancer grade
A pathologist also assigns a grade to the cancer, which is based on how closely the biopsy sample looks like normal breast tissue and how rapidly the cancer cells are dividing. The grade can help predict a woman's prognosis. In general, a lower grade number indicates a slower-growing cancer that is less likely to spread, while a higher number indicates a faster-growing cancer that is more likely to spread. The tumor grade is one factor in deciding if further treatment is needed after surgery.
Histologic tumor grade (sometimes called the Bloom-Richardson grade, Nottingham grade, Scarff-Bloom-Richardson grade, or Elston-Ellis grade) is based on the arrangement of the cells in relation to each other: whether they form tubules; how closely they resemble normal breast cells (nuclear grade); and how many of the cancer cells are in the process of dividing (mitotic count). This system of grading is used for invasive cancers but not for in situ cancers.
- Grade 1 (well differentiated) cancers have relatively normal-looking cells that do not appear to be growing rapidly and are arranged in small tubules.
- Grade 2 (moderately differentiated) cancers have features between grades 1 and 3.
- Grade 3 (poorly differentiated) cancers, the highest grade, lack normal features and tend to grow and spread more aggressively.
Ductal carcinoma in situ (DCIS)
DCIS is also graded, but the grade is based only on how abnormal the cancer cells appear (nuclear grade). The presence of necrosis (areas of dead or degenerating cancer cells) is also noted. The term comedocarcinoma is often used to describe DCIS with prominent necrosis.
Other important factors that can affect the prognosis for a woman with DCIS, include the surgical margin (how close the cancer is to the edge of the specimen) and the size (amount of breast tissue affected by DCIS). In situ cancers that are large, have a high nuclear grade, or necrosis are more likely to contain an area of invasive cancer and are also more likely to come back after treatment. If cancer cells are at or near the edge of the sample it also raises the risk of DCIS coming back later.
Estrogen receptor (ER) and progesterone receptor (PR) status
Receptors are proteins in or on certain cells that can attach to certain substances, such as hormones, that circulate in the blood. Normal breast cells and some breast cancer cells contain receptors that attach to estrogen and progesterone. These 2 hormones often fuel the growth of breast cancer cells.
An important step in evaluating a breast cancer is to test a portion of the cancer removed during the biopsy (or surgery) to see if they have estrogen and progesterone receptors. Cancer cells may contain neither, one, or both of these receptors. Breast cancers that have estrogen receptors are often referred to as ER-positive (or ER+) cancers, while those containing progesterone receptors are called PR-positive (or PR+) cancers. If either type of receptor is present, the cancer is said to be hormone receptor-postive.
Hormone receptor–positive breast cancers tend to grow more slowly and are much more likely to respond to hormone therapy than breast cancers without these receptors.
All breast cancers, should be tested for these hormone receptors either on the the biopsy sample or when they are removed with surgery. About 2 of 3 breast cancers have at least one of these receptors. This percentage is higher in older women than in younger women.
About 1 of 5 breast cancers have too much of a growth-promoting protein called HER2/neu (often just shortened to HER2). The HER2/neu gene instructs the cells to make this protein. Tumors with increased levels of HER2/neu are referred to as HER2-positive.
Women with HER2-positive breast cancers have too many copies of the HER2/neu gene, resulting in greater than normal amounts of the HER2/neu protein. These cancers tend to grow and spread more aggressively than other breast cancers.
All newly diagnosed breast cancers should be tested for HER2/neu because HER2-positive cancers are much more likely to benefit from treatment with drugs that target the HER2/neu protein, such as trastuzumab (Herceptin®) and lapatinib (Tykerb®). See the section, "How is breast cancer treated?" for more information on these drugs.
Testing of the biopsy or surgery sample is usually done in 1 of 2 ways:
- Immunohistochemistry (IHC): In this test, special antibodies that identify the HER2/neu protein are applied to the sample, which cause cells to change color if many copies are present. This color change can be seen under a microscope. The test results are reported as 0, 1+, 2+, or 3+.
- Fluorescent in situ hybridization (FISH): This test uses fluorescent pieces of DNA that specifically stick to copies of the HER2/neu gene in cells, which can then be counted under a special microscope.
Many breast cancer specialists feel the FISH test is more accurate than IHC. However, it is more expensive and takes longer to get the results. Often the IHC test is used first. If the results are 1+ (or 0), the cancer is considered HER2-negative. People with HER2-negative tumors are not treated with drugs (like trastuzumab) that target HER2. If the test comes back 3+, the cancer is HER2-positive. Patients with HER2-positive tumors may be treated with drugs like trastuzumab. When the result is 2+, the HER2 status of the tumor is not clear. This usually leads to testing the tumor with FISH. Some institutions also use FISH to confirm HER2 status that is 3+ by IHC and some perform only FISH.
A newer type of test, known as chromogenic in situ hybridization (CISH), works similarly to FISH, by using small DNA probes to count the number of HER2 genes in breast cancer cells. But this test looks for color changes (not fluorescence) and doesn't require a special microscope, which could make it less expensive. Right now, it is not being used as much as IHC or FISH.
Tests of ploidy and cell proliferation rate
The ploidy of cancer cells refers to the amount of DNA they contain. If there's a normal amount of DNA in the cells, they are said to be diploid. If the amount is abnormal, then the cells are described as aneuploid. Tests of ploidy may help determine prognosis, but they rarely change treatment and are considered optional. They are not usually recommended as part of a routine breast cancer work-up.
The S-phase fraction is the percentage of cells in a sample that are replicating (copying) their DNA. DNA replication means that the cell is getting ready to divide into 2 new cells. The rate of cancer cell division can also be estimated by a Ki-67 test. If the S-phase fraction or Ki-67 labeling index is high, it means that the cancer cells are dividing more rapidly, which indicates a more aggressive cancer.
Tests of gene patterns
Researchers have found that looking at the patterns of a number of different genes at the same time (sometimes referred to as gene expression profiling) can help predict whether or not an early stage breast cancer is likely to come back after initial treatment. Two such tests, which look at different sets of genes, are now available: the Oncotype DX® and the MammaPrint®
Oncotype DX®: The Oncotype DX test may be helpful when deciding whether additional (adjuvant) treatment with chemotherapy (after surgery) might be useful in women with certain early-stage breast cancers that usually have a low chance of coming back (stage I or II estrogen receptor–positive breast cancers without lymph node involvement). Recent data has shown it may also be helpful for patients with positive lymph nodes.
The test looks at a set of 21 genes in cells from tumor samples to determine a 'recurrence score', which is a number between 0 and 100:
- Women with a recurrence score of 17 or below have a low risk of recurrence (cancer coming back after treatment) if they are treated with hormone therapy. These women would probably not benefit from chemotherapy.
- Women with a score of 18 to 30 are at intermediate risk and some might benefit from chemotherapy.
- Women with a score of 31 or more are at high risk and are likely to benefit from chemotherapy in addition to hormone therapy.
The test estimates risk, but it cannot tell for certain if any particular woman will have a recurrence. It is a tool that can be used, along with other factors, to help guide women and their doctors when deciding whether more treatment might be useful.
MammaPrint®: This test can be used to help determine how likely certain early-stage (stage I or II) breast cancers are to recur in a distant part of the body after initial treatment. It can be used for either ER-negative or ER-positive tumors.
The test looks at the activity of 70 different genes to determine if the cancer is low risk or high risk.
Usefulness of these tests: While many doctors use these tests (along with other information) to help make decisions about offering chemotherapy, others are waiting for more research to prove they are helpful. These tests are now being looked at in large clinical trials. In the meantime, women may want to discuss with their doctors whether or not these tests might be useful for them.
Classifying breast cancer
Research on patterns of gene expression has also suggested some newer ways to classify breast cancers. The current types of breast cancer are based largely on how tumors look under a microscope. A newer classification, based on molecular features, divides breast cancers into 4 groups. This testing, called the PAM50, is currently available but is not used as yet to make treatment decisions:
Luminal A and luminal B types: The luminal types are estrogen receptor (ER)–positive. The gene expression patterns of these cancers are similar to normal cells that line the breast ducts and glands (the inside of a duct or gland is called its lumen). Luminal A cancers are low grade, tend to grow fairly slowly, and have the best prognosis. Luminal B cancers generally grow somewhat faster than luminal A cancers and their outlook is not quite as good.
HER2 type: These cancers have extra copies of the HER2 gene and sometimes some others. They usually have a high-grade appearance under the microscope. These cancers tend to grow more quickly and have a worse prognosis, although they often can be treated successfully with targeted therapies such as trastuzumab (Herceptin) and lapatinib (Tykerb) which are usually given along with chemotherapy.
Basal type: Most of these cancers are of the so-called triple-negative type, that is, they lack estrogen or progesterone receptors and have normal amounts of HER2. The gene expression patterns of these cancers are similar to cells in the deeper basal layers of breast ducts and glands. This type is more common among women with BRCA1 gene mutations. For reasons that are not well understood, this cancer is also more common among younger and African-American women.
These are high-grade cancers that tend to grow quickly and have a poor outlook. Hormone therapy and anti-HER2 therapies like trastuzumab and lapatinib are not effective against these cancers, although chemotherapy can be helpful. A great deal of research is being done to find better ways to treat these cancers.
It is hoped that these new breast cancer classifications might someday allow doctors to better tailor breast cancer treatments, but more research is needed in this area before this will be possible.
Imaging tests that look for breast cancer spread
Once breast cancer is diagnosed, one or more of the following tests may be done. These tests aren’t often done for early breast cancer. Which tests (if any) are done depends on how likely it is the cancer has spread, based on the size of the tumor, the presence of lymph node spread, and any symptoms you are having.
This test may be done to see whether the breast cancer has spread to your lungs.
If they haven't been done already, more extensive mammograms may be done to get more thorough views of the breasts. This is to check for any other abnormal areas that could be cancer as well. This test is described in the section, "How is breast cancer diagnosed?"
A bone scan can help show if a cancer has spread (metastasized) to your bones. It can be more useful than standard x-rays because it can show all of the bones of the body at the same time and can find small areas of cancer spread not seen on plain x-rays.
For this test, a small amount of low-level radioactive material is injected into a vein (intravenously, or IV). The substance settles in areas of bone changes throughout the entire skeleton over the course of a couple of hours. You then lie on a table for about 30 minutes while a special camera detects the radioactivity and creates a picture of your skeleton.
Areas of bone changes appear as "hot spots" on your skeleton—that is, they attract the radioactivity. These areas may suggest the presence of metastatic cancer, but arthritis or other bone diseases can also cause the same pattern. To distinguish between these conditions, your cancer care team may use other imaging tests such as simple x-rays or CT or MRI scans to get a better look at the areas that light up, or they may even take biopsy samples of the bone.
Computed tomography (CT) scan
The CT scan is an x-ray test that produces detailed cross-sectional images of your body. Instead of taking one picture, like a regular x-ray, a CT scanner takes many pictures as it rotates around you while you lie on a table. A computer then combines these pictures into images of slices of the part of your body being studied. In women with breast cancer, this test is most often used to look at the chest and/or abdomen to see if the cancer has spread to other organs such as the lungs or liver.
Before any pictures are taken, you may be asked to drink 1 to 2 pints of a liquid called oral contrast. This helps outline the intestine so that certain areas are not mistaken for tumors. You may also receive an IV (intravenous) line through which a different kind of contrast dye (IV contrast) is injected. This helps better outline structures in your body.
The injection might cause some flushing (a feeling of warmth, especially in the face). Some people are allergic and get hives. Rarely, more serious reactions like trouble breathing or low blood pressure can occur. Medicine can be given to prevent and treat allergic reactions. Be sure to tell the doctor if you have ever had a reaction to any contrast material used for x-rays.
CT scans take longer than regular x-rays, but in general are very quick. You need to lie still on a table while they are being done. During the test, the table moves in and out of the scanner, a ring-shaped machine that completely surrounds the table. You might feel a bit confined by the ring while the pictures are being taken.
CT guided needle biopsy: If an abnormality is seen on a CT scan, but it is not clear if it is cancer, it may need to be biopsied. The biopsy can be done using the CT scan to precisely guide a biopsy needle into a suspected area of cancer spread. For this procedure, you remain on the CT scanning table while a radiologist advances a biopsy needle through the skin and toward the location of the mass. CT scans are repeated until the doctors are sure that the needle is within the mass. A fine needle biopsy sample (tiny fragment of tissue) or a core needle biopsy sample (a thin cylinder of tissue about ½-inch long and less than 1/8-inch in diameter) is then removed and sent to be looked at under a microscope.
Magnetic resonance imaging (MRI) scan
This use of this test to look at the breast was discussed earlier in this section.
MRI scans are also used to look for cancer that has spread to various parts of the body, just like CT scans. MRI scans are particularly helpful in looking at the brain and spinal cord.
There are some differences between using this test to look at the breast and other areas of the body. First, you will lie face up in the machine. Second, the contrast material called gadolinium is not always needed to look at other areas of the body. Also, you might have the option of having the scan in a less confining machine known as an "open" MRI machine. The images from an open machine are not always as good, though, so this might not always be an option.
The use of this test to look at the breast was discussed earlier in this section. But ultrasound can also be used to look for cancer that has spread to some other parts of the body.
Abdominal ultrasound can be used to look for tumors in your liver or other abdominal organs. When you have an abdominal ultrasound exam, you simply lie on a table and a technician moves the transducer on the skin over the part of your body being examined. Usually, the skin is first lubricated with gel.
Positron emission tomography (PET) scan
For a PET scan, glucose (a form of sugar) that contains a radioactive atom is injected into the bloodstream. Because cancer cells in the body are growing rapidly, they absorb large amounts of the radioactive sugar. After about an hour, a special camera is used to create a picture of areas of radioactivity in the body.
A PET scan is useful when your doctor thinks the cancer might have spread but doesn't know where. The picture is not finely detailed like a CT or MRI scan, but it provides helpful information about your whole body. Some newer machines are able to do both a PET and CT scan at the same time (PET/CT scan). This lets the radiologist compare areas of higher radioactivity on the PET with the appearance of that area on the CT.
So far, most studies show PET scans aren't very helpful in early breast cancer, but they may be used for very large tumors, inflammatory breast cancer, or for breast cancers that are known to have spread.
Last Medical Review: 08/23/2012
Last Revised: 02/26/2013