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 limitations 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.

Women at high risk: Women with a higher risk of breast cancer should talk with their doctor about the best screening plan for them. This might mean starting mammograms when they are younger, having extra screening tests (such as an MRI), or having exams more often.

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.

During a mammogram, the breast is pressed between 2 plates to flatten and spread the tissue. The pressure lasts only for a few seconds. Although this may cause some pain for a moment, it is needed to get a good picture. 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.

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 pressure lasts only a few seconds while the picture is taken. The whole process takes about 20 minutes. You should get your results within 30 days or even sooner.

About 1 in 10 women who get a mammogram will need more pictures taken. But most of these women do not have breast cancer, so try not to worry if this happens to you. Only 2 to 4 of every 1,000 mammograms leads to a diagnosis of cancer.

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 new 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)

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.

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. So it's important to have anything 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 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.

Imaging tests

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 cyst.

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.

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

MRI scans: MRI scans can be used along with mammograms for screening women who have a high risk of getting breast cancer. Or they can be used to look at areas of concern found on a mammogram. MRI is also used for women who have breast cancer in order to help figure out the size of the cancer.

MRI scans use radio waves and strong magnets instead of x-rays to make pictures. A contrast material called gadolinium is often put into a vein before the scan to better show details. MRI scans can take a long time -- often up to an hour. You have to lie inside a narrow tube, which may upset people with a fear of enclosed spaces. The machine makes loud buzzing and clicking noises that you may find disturbing. Some places will give you headphones with music to block this out.

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 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. 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.

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

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, 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.

If the biopsy does not give a clear answer, or your doctor is still not sure, a second biopsy 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. It is used to remove one or more cores of tissue. 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). 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 as an outpatient procedure. No stitches are needed, and there is only a little scarring. This method usually removes more tissue than core biopsies.

Surgical biopsy: Sometimes 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 you less aware of the process. Ask your doctor which kind of biopsy you will have and what you can expect during and after the test.

Biopsy lab tests: 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 to tell the type of cancer it is and show whether it is invasive or not.

Breast cancer grade

If it is cancer, the biopsy sample is also 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 the need for further treatment after surgery.

Hormone receptor status

Receptors are proteins on the outside surfaces of 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 estrogen and/or progesterone. If it does, it is often referred to as ER-positive or PR-positive. Such cancers tend to have a better outlook than cancers without these receptors because they are much more likely to respond to hormone treatment. 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 HER-2/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, "How is breast cancer treated?" for more information on these drugs.

Other lab tests may also be done to help figure out how quickly the cancer is growing and what treatments might work best.

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.

Last Medical Review: 09/29/2009
Last Revised: 09/29/2009