How is breast cancer found?

The term screening refers to tests and exams used to find a disease like cancer in people who do not have any symptoms. The earlier breast cancer is found, the better the chances that treatment will work. The goal is to find cancers before they start to cause symptoms. The size of a breast cancer and how far it has spread are the most important factors in predicting the outlook for the patient. Most doctors feel that tests for finding breast cancer early save many thousands of lives each year. Following the guidelines given here improves the chances that breast cancer can be found at an early stage and treated with success.

ACS recommendations for finding breast cancer early

The ACS recommends the following guidelines for finding breast cancer early in women without symptoms:

Mammogram: Women age 40 and older should have a screening mammogram every year and should keep on doing so for as long as they are in good health. While mammograms can miss some cancers, they are still a very good way to find breast cancer.

Clinical breast exam: Women in their 20s and 30s should have a clinical breast exam (CBE) as part of a regular exam by a health expert at least every 3 years. After age 40, women should have a breast exam by a health expert every year. It might be a good idea to have the CBE shortly before the mammogram. You can use the exam to learn what your own breasts look and feel like.

Breast self-exam (BSE): BSE is an option for women starting in their 20s. Women should be told about the benefits and limits of BSE. Women should report any changes in how their breasts look or feel to a health expert right away.

Research has shown that BSE plays a small role in finding breast cancer compared with finding a breast lump by chance or simply being aware of what is normal for each woman. If you decide to do BSE, you should have your doctor or nurse check your method to make sure you are doing it right. If you do BSE on a regular basis, you get to know how your breasts normally look and feel. Then you can more easily notice changes. But it’s OK not to do BSE or not to do it on a fixed schedule.

The goal, with or without BSE, is to see a doctor right away if you notice any of these changes: a lump or swelling, skin irritation or dimpling, nipple pain or the nipple turning inward, redness or scaliness of the nipple or breast skin, or a discharge other than breast milk. But remember that most of the time these breast changes are not cancer.

Magnetic resonance imaging (MRI): Women at high risk should get an MRI and a mammogram every year (women who are at high risk have at least a 25% lifetime risk of breast cancer). Women at moderately increased risk should talk with their doctors about the benefits and limitations of adding MRI screening to their yearly mammogram. Yearly MRI screening is not recommended for women whose lifetime risk of breast cancer is less than 15%. To find out more about what makes someone high risk, as well as about the use of MRIs for breast cancer screening, please see our document, Breast Cancer.

Mammograms

A mammogram is an x-ray of the breast. A screening mammogram is used to look for breast disease in women who do not seem to have breast problems. A mammogram can also be used when women have symptoms such as a lump, skin change, or nipple discharge. This is called a diagnostic mammogram. Diagnostic mammograms are also used to follow up abnormal screening mammograms.

For the mammogram, you undress above the waist. You will have a wrap to cover yourself. A technologist (most often a woman) will position your breast for the test. The breast is pressed between 2 plates to flatten and spread the tissue. The pressure lasts only a few seconds while the picture is taken. The whole process takes about 20 minutes. Although this may cause some pain for a moment, it is needed to get a good picture. You should get your results within 30 days or even sooner.

Being called back to have more pictures taken doesn’t mean you have cancer. Nine out of 10 women who are called back for more pictures are not found to have cancer. And only 2 to 4 of every 1,000 mammograms leads to a diagnosis of cancer.

Very low levels of radiation are used. While many people are worried about exposure to x-rays, the low level of radiation used for mammograms does not increase the risk of breast cancer. You might think of it this way: if a woman with breast cancer is treated with radiation, she will get around 5,000 rads (a term used to measure radiation dose). If she had a mammograms every year from age 40 to age 90, she will have had 20 to 40 rads total.

Mammograms often don’t work as well in younger women, mostly because their breasts are dense and this can hide a tumor. This is also true for pregnant women and women who are breast feeding. Since most breast cancers occur in older women, this is usually not a major problem. But it is a problem for young women who have a genetic risk factor for breast cancer because they often get breast cancer at a younger age. For this reason, some doctors now suggest MRI along with mammograms for screening these women.

Digital mammograms: A digital mammogram is like a standard mammogram in that x-rays are used to produce an image of your breast. The main difference is that the image is recorded and stored on a computer instead of on x-ray film. Because the image is on a computer, it is easier for the doctor to adjust the image and see some areas more closely. Many centers do not offer the digital option, but it is becoming more widely used. Because digital mammograms cost more than standard mammograms, studies are now looking at which form of mammogram will help more women in the long run. At this point, they seem to be more helpful in younger women and those with dense breasts.

Help with mammogram costs

Medicare, Medicaid, and most private health plans cover all or part of the cost of this test. Call us at 1-800-227-2345 for information about facilities in your area. Breast cancer testing is available to women without health insurance and women who don’t have coverage for breast cancer screening. It may be free or offered at very little cost through a special program called the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). Your state’s Department of Health will have details about this program.

There is also a program to help pay for breast cancer treatment for women in need. To learn more about these programs, you can contact the Centers for Disease Control and Prevention at 1-800-CDC INFO (1-800-232-4636) or on the Internet at www.cdc.gov/cancer/nbccedp.

For more details about mammograms, please see our document, Mammograms and Other Breast Imaging Procedures.

Clinical breast exam

A clinical breast exam (CBE) is an exam of your breasts by a health expert such as a doctor, nurse practitioner, nurse, or physician assistant. For this exam, you undress from the waist up. The examiner will first look at your breasts for changes in size or shape. Then, using the pads of the fingers, she or he will gently feel your breasts for lumps. The area under both arms will also be checked. This is a good time to learn how to do breast self-exam if you don't already know how.

Breast awareness and breast self-exam

Women should be aware of how their breasts normally look and feel and report any changes to a doctor right away. Finding a change does not mean that you have cancer.

By being aware of how your own breasts look and feel, you are likely to notice any changes that might take place. You can also choose to use a step-by-step approach to checking your breasts on a set schedule. The best time to do breast self-examination (BSE) is when your breasts are not tender or swollen. If you find any changes, see a doctor right away.

Women with breast implants can do BSE. It may help to have the surgeon help you feel the edges of the implant so that you know where they are. It may be that the implants push out the breast tissue and actually make it easier to examine.

It's OK for women not to do BSE or to do it once in a while. We have detailed information on how to do BSE for women who want to do it. You can find it on our Web site or you can call and ask for it.

MRI (magnetic resonance imaging)

MRI scans use magnets and radio waves (instead of x-rays) to produce very detailed, cross-sectional images of the body. The most useful MRI exams for breast imaging use a contrast material that is put into a vein in the arm before or during the exam which helps the MRI to clearly show breast tissue details.

MRI scans can take a long time — often up to an hour. For a breast MRI, you have to lie inside a narrow tube, face down on a special platform. The platform has openings for each breast that allow the image to be taken without pressing on the breast. 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 close and might upset people with a fear of enclosed spaces.

For certain women at high risk for breast cancer, screening MRI is recommended along with a yearly mammogram. It is not generally recommended as a screening tool by itself because it may miss some cancers that mammograms would find. MRI also costs more than mammograms. Most major insurance companies will likely pay for a screening MRI if a woman can be shown to be at high risk, but it’s not yet clear if all companies will do so. More details about MRI can be found below.

Signs and symptoms of breast cancer

The widespread use of screening mammograms has increased the number of breast cancers found before they cause any symptoms, but some are still missed.

The most common sign of breast cancer is a new lump or mass. A lump that is painless, hard, and has uneven edges is more likely to be cancer. But some cancers are tender, soft, and rounded or even painful. So it's important to have anything new or unusual checked by a doctor.

Other signs of breast cancer include the following:

• Swelling of all or part of the breast
• Skin irritation or dimpling
• Breast pain
• Nipple pain or the nipple turning inward
• Redness, scaliness, or thickening of the nipple or breast skin
• A nipple discharge other than breast milk

Sometimes breast cancer can spread to lymph nodes under the arm or around the collarbone and cause a lump or swelling there, even before the tumor in the breast tissue is large enough to be felt.

If you have any symptoms that might be a sign of breast cancer, be sure see a doctor as soon as you can. After asking you some questions and doing a complete physical exam (including a clinical breast exam), your doctor may want to do more tests, such as those listed below.

Breast imaging tests

These tests use different methods to create pictures of the inside of your body. The tests may be done for a number of reasons: to help find out whether a suspicious area might be cancer, to learn how far cancer may have spread, and to help figure out if treatment is working.

Mammograms: Although mammograms are mostly used for screening, they can also be used if there is a breast problem. These are called diagnostic mammograms. This kind of mammogram might show that everything is OK and you can go back to having yearly mammograms. Or it might show that a biopsy should be done. Even if the mammogram doesn't show a tumor, if you or your doctor can feel a lump you may need a biopsy. The exception would be if ultrasound (see below) shows that the lump is a simple cyst (a fluid filled sac).

A mammogram cannot show for sure whether or not cancer is present. If your mammogram shows something that could be cancer, a sample of breast tissue is removed and looked at under a microscope. This is called a biopsy (see below).

MRI scans: The use of this test for screening was discussed earlier. MRI can also be used to look at areas of concern found on a mammogram. MRI is also sometimes used for women who are known to have breast cancer in order to help figure out the size of the cancer.

Breast ultrasound: An ultrasound uses sound waves to outline a part of the body. The sound wave echoes are picked up by a computer to create a picture on a computer screen.

Ultrasound is a good test to use along with mammograms because it is widely available and costs less than other tests. But ultrasound should not be used instead of mammograms. Usually, it is used to look at a certain area of concern found by the mammogram. It sometimes helps to tell the difference between cysts and solid masses (tumors) without using a needle to draw out fluid.

Ductogram (also called a galactogram): This is a special kind of x-ray that is sometimes helpful in finding the cause of a nipple discharge. It is not used very often. A very thin plastic tube is placed into the opening of the duct at the nipple. A dye is injected to outline the shape of the duct on an x-ray picture. It will show if there is a tumor inside the duct. If there is a discharge, the fluid can be tested for cancer cells.

There are several other tests that can help tell the doctor more about your situation. Feel free to ask your doctor to explain any test to you. You can also contact us for more information.

Biopsy

A biopsy is done when other tests show that you might have breast cancer. The only way to know for sure is for you to have a biopsy. During this test, cells from the area of concern are removed so they can be studied in the lab. There are several kinds of biopsies. The doctor will use the one best for you.

Types of biopsies

Fine needle aspiration (FNA) biopsy: For this test, a very thin (fine), hollow needle is used to pull out fluid or tissue from the lump. The needle used in an FNA is thinner than the one used for blood tests. Your doctor might use ultrasound to guide the needle into the lump. Medicine may be used to make the skin numb.

If the fluid drawn out is clear, the lump is most likely a benign cyst (not cancer). Bloody or cloudy fluid can mean either a cyst or, very rarely, cancer. If the lump is solid, small pieces of tissue are taken out. These will be looked at under a microscope to see if they are cancer.

An FNA biopsy is the easiest type of biopsy to have, but it has some downsides. 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 tell whether the cancer is invasive. In some cases there may not be enough cells to do some of the other lab tests that are needed. If the FNA does not give a clear answer, a second FNA or a different type of biopsy may be needed.

Core needle biopsy: The needle used for this test is larger than the one for fine needle biopsy, so it can remove more tissue. It is used to remove one or more cores (pieces) of tissue. Because more tissue is removed, a core needle biopsy is more likely than an FNA to provide a clear result. It is less likely to miss a cancer, although that is still possible, and often there are enough cells to do other tests. The biopsy is done with local anesthesia (the area is numbed) in an outpatient setting.

Vacuum-assisted biopsies: These can be done with systems such as the Mammotome^® or ATEC^® (Automated Tissue Excision and Collection) under the guidance of a mammogram or MRI. First the skin is numbed and a small cut (incision) is made. A hollow probe is put through the cut into the breast tissue. A piece of tissue is sucked out. Several samples can be taken from the same cut. Vacuum-assisted biopsies are done on an outpatient basis. No stitches are needed, and there is only a little scarring. This method usually removes more tissue than core biopsies.

Surgical (open) biopsy: Most often, breast cancer can be found using needle biopsy. Rarely surgery is needed to remove all or part of a lump so it can be looked at under a microscope. The whole lump as well as some normal tissue around it may be taken out. Most often this is done in the hospital’s outpatient center. Local anesthesia is used (the area around the lump is numbed) and you may also be given drugs to relax you and make drowsy. It can also be done under general anesthesia (you are asleep). Ask your doctor which kind of biopsy you will have and what you can expect during and after the test.

Lymph node dissection and sentinel lymph node biopsy

These procedures are done to look for cancer in the lymph nodes. They are described in more detail in the section, “How is breast cancer treated?”

Lab exams of breast tissue

The tissue removed during a biopsy is looked at in the lab to see whether it is benign (not cancer) or cancer. If it is not cancer, then no more treatment is needed. If it is cancer, the biopsy can help the doctor decide what type of cancer it is and show whether it is invasive or not. Other lab tests may also be done to help figure out how quickly the cancer is growing and what treatments might work best. Some of these include:

Breast cancer grade: If a biopsy sample is cancer, it is given a grade from 1 to 3. Cancers that look more like normal breast tissue tend to grow and spread more slowly. As a rule, a lower grade number means a slower-growing cancer, while a higher number means a faster-growing cancer. The grade helps predict the outcome (prognosis) for the woman. The tumor grade is one factor in deciding if further treatment is needed after surgery.

Hormone receptor status: Hormone receptors are proteins in cells that can attach to hormones in the blood. Estrogen and progesterone are hormones that often attach to these receptors on some breast cancer cells to fuel their growth. The biopsy sample can be tested to see whether it has receptors for these hormones. If it does, it is often referred to as ER-positive, PR-positive, or just hormone receptor-positive. Hormone receptor-positive cancers tend to grow more slowly, and they are much more likely to respond to hormone treatment than breast cancers without these receptors. About 2 out of 3 breast cancers have at least one of these receptors.

HER2/neu status: About 1 out of 5 breast cancers have too much of a protein called HER2/neu. Tumors with increased levels of HER2/neu are called “HER2-positive.” These cancers tend to grow and spread faster than other breast cancers.

HER2/neu testing should be done on all newly diagnosed breast cancers. HER2-positive cancers can be treated with drugs that target the HER2/neu protein, such as trastuzumab (Herceptin^®) and lapatinib (Tykerb^®). See the section, "Targeted therapy for breast cancer" to learn more about these drugs.

Tests of gene patterns: Research has shown that looking at the patterns of a number of genes at the same time can help tell whether or not an early breast cancer is likely to come back after the first treatment. This can help when deciding whether more treatment, such as chemotherapy, might be useful. There are now 2 of these tests which look at different sets of genes: Oncotype DX^® and MammaPrint^®. While some doctors are using these tests (along with other information) to help make decisions about offering chemotherapy, others are waiting for more research to show whether they are really helpful.

Classifying breast cancer

Research on patterns of genes has also suggested some new ways of grouping breast cancers. The current types of breast cancer are based largely on how tumors look under a microscope. A newer system, based on molecular features, may be better able to predict outlook and response to some breast cancer treatments.

Tests to find breast cancer spread

Based on the results of your physical exam and biopsy, your doctor may want you to have certain tests such as those listed below to check for signs of cancer spread. Blood tests may also be done to look at your overall health and can sometimes show whether the cancer has spread to certain organs.

Chest x-ray: This test may be done to see whether the cancer has spread to the lungs.

Bone scan: This test can help show whether the cancer has spread to the bones. For this test, a very low dose of radioactive material is put into a vein. The bone attracts this material which shows up on the scan as a “hot spot.” These hot spots could be cancer, but other problems like arthritis can also cause them. Other tests or even biopsy samples of the hot spots may be needed.

CT scan (computed tomography): A CT scan is a special type of x-ray. Pictures are taken from different angles and these are combined by a computer to make a detailed picture of the organs. In women with breast cancer, this test is most often used to look at the chest and/or belly (abdomen) to see if the cancer has spread to other organs. It can also be used to guide a biopsy needle into an area of concern.

Before the CT scan, you may be asked to drink a contrast liquid to outline your intestines. After the first set of pictures is taken you may get an IV (intravenous) line through which a contrast dye is put into your blood. A second set of pictures is then taken.

The contrast may 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 happen. Before you have this test be sure to tell your doctor if you have ever had a reaction to any contrast material used for x-rays.

CT scans take longer than regular x-rays. You need to lie still on a table while they are being done. You might feel a bit confined by the ring you have to lie in while the pictures are being taken.

MRI (magnetic resonance imaging): An MRI scan takes pictures using radio waves and strong magnets instead of x-rays. This test can be helpful in looking at the brain and spinal cord. MRIs can be a more uncomfortable than CT scans because they take longer and you need to lie in a narrow tube while the test is done. The machine also makes a loud, thumping noise that you may find disturbing. Some centers provide headphones with music to block out the noise. You might have the option of having the scan in a less confining machine known as an “open” MRI machine.

Ultrasound: In most cases, this test involves a wand that gives off sound waves being placed on the skin to take pictures of the inside of the body. A gel is often put on the skin first. This test is described in the “Breast Imaging Tests” section above. But ultrasound can also be used to look for cancer that has spread to some other parts of the body.

PET scan (positron emission tomography): This test uses a form of sugar that contains a radioactive atom. The sugar is put into a vein and travels throughout the body. Cancer cells absorb high amounts of this sugar. A special camera can then spot these cells. PET is useful when the doctor thinks the cancer might have spread but doesn’t know where. Special machines are able to do both a PET and CT scan at the same time. So far, most studies show PET scans are not very helpful in most cases of early breast cancer, but they may be used when there is a large tumor or when the cancer is known to have spread.