If you have any of the risk factors for breast cancer, you should be sure to talk with your doctor about them and discuss a periodic screening schedule that will increase the chances of detecting cancer early, when it is highly treatable. If you have close relatives with the disease, you may want to be tested to see if you have the BRCA1 or BRCA2 gene that can substantially increase your risk. If any of your relatives had the disease young - before menopause - you also may want to start breast cancer screening at a younger age than doctors usually recommend (most advise women to start being screened between age 40 and 50).

Even if you don’t have any of the risk factors, if you do experience any unusual pain or other lasting change in your breasts, you should make an appointment with your doctor right away to discuss it.

Diagnosing breast cancer

If you go to the doctor with concerns about your breast symptoms, you will likely be given a physical exam that may be followed by an imaging procedure such as a mammogram. After this, the doctor may tell you that no further tests or necessary, but if there is any concern, he or she may order a biopsy that removes a small portion of your breast tissue for testing. Details on all these procedures follow.

Medical history

When you visit the doctor, they will likely ask you questions about your family history of cancers, especially of the breast. They may also ask about your personal medical history to determine your risk factors for the disease.

Clinical breast exam

The doctor will likely examine both of your breasts and the lymph nodes that are located in the armpit region. They will check for any lumps and closely examine the shape, texture, and size of your breasts. They will ask if you feel any pain when they touch certain areas and they will examine how the breast tissue moves when they palpate it.

Diagnostic Mammogram

A mammogram is an x-ray of the breast. It involves placing the breast in between two plates and taking images of the tissue inside. A diagnostic mammogram takes clearer pictures than the routine screening mammogram; also, it can focus on specific areas of the breast in more detail.

Ultrasound

An ultrasound machine emits very high pitched sound waves that the human ear cannot hear but which can penetrate tissues. When the sound waves bounce back, their patterns can be used to create a computer-generated image of what’s inside. This is the same technology used in a prenatal sonogram. When used in the breast, the images generated by an ultrasound can show if a lump is solid, as tumors usually are, or a fluid filled cyst.

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) is another imaging technique. The MRI uses very powerful magnets to align the molecules within a tissue and visualize what is inside. MRI has the best resolution of all the imaging techniques but it requires a huge piece of specialized equipment that makes it also much more expensive. It is rarely used for routine screening but is the most accurate at finding tumors.

Biopsy

While imaging techniques may be able to determine if you have a tumor, no image can be used to tell if a tumor is cancer. The only way to know for sure is to take a sample of the tumor tissue and examine it under a microscope. The process of taking a sample is called a biopsy. If any suspicious growths are found with imaging, your doctor may refer you to a surgeon or a specialist for a biopsy. An imaging procedure such as ultrasound can be used to help guide the surgeon to the lump. After the biopsy, the sample is given to a pathologist who will examine it under the microscope and determine if the cells in the sample are cancerous. There are several ways to take a biopsy that differ in their level of invasiveness.

• Fine-needle aspiration involves inserting a thin needle into the lump and gently sucking out some of the fluid. The fluid can be examined by a pathologist for cancerous cells.
• Core biopsy (also called needle biopsy) involves using a much thicker needle to remove a portion of the tumor. A pathologist can examine the sample for cancerous cells.
• Surgical biopsy involves a surgeon cutting into the breast, locating the lump, and taking a sample. If the sample is just a portion of the lump, it is called an incisional biopsy and if the entire lump is removed it is called an excisional biopsy (or lumpectomy). A pathologist can then check the tissue for cancer cells.

A lymph node biopsy may also be done in which one or several of the “axillary” lymph nodes found in the armpit region nearest to the affected breast may be removed. These are then examined for signs of cancer. If no cancer is found, it is a good sign that the cancer has not spread, but if the lymph nodes do have cancer cells it is likely that metastasis is already underway.

Pathology

The pathologist will examine the sample tissue and determine if cancer is present. They can also determine which cells are affected, which tells you what type of cancer it is, and can grade the cancer based on its stage of progression. The main types of breast cancer are: lobular carcinoma in situ and ductal carcinoma in situ (both are really pre-cancers), invasive lobular carcinoma, invasive ductal carcinoma, medullary carcinoma, and inflammatory breast cancer. See “What are the different types of breast cancer?” for more information.

Breast cancer staging

Cancer grading (or staging) is a method for assessing cancer progression based on how abnormal and invasive the cells are and to what extent the cancer has spread. It can help provide a guide for treatment, give you a prognosis for recovery, and help you better prepare for the symptoms you are likely to experience. A preliminary grade may be assigned based on the pathology findings from a biopsy but often the grade is not known for sure until the entire tumor is removed and examined. The stages of breast cancer and the diagnostic criteria for each according to the National Cancer Institute can be found at http://www.cancer.gov/cancertopics/wyntk/breast/page9. While the official medical stages are somewhat more complicated, a simplified guide to staging is presented below.

Stage 0 is carcinoma in situ. There are two main types of carcinoma in situ: lobular and ductal. Neither is a true cancer (hence the zero grade) because they have not invaded surrounding tissue. Lobular carcinoma in situ (LCIS) is abnormal lobule cells that have accumulated enough mutations to invade the tissue surrounding the lobules but have not yet done so. Most often, LCIS does not actually become invasive. Ductal carcinoma in situ (DCIS) is abnormal duct cells that have not yet spread beyond the duct. DCIS may progress to invasive cancer if it is not treated.

Stage I is an early invasive breast cancer. It is true cancer because abnormal cells have invaded neighboring tissues, but no cancer cells have spread outside of the breast. The tumor is no more than 2 centimeters in diameter.

Stage II is one of the following:

• The tumor is no more than 5 centimeters across and the cancer has spread to the lymph nodes under the arm.
• The tumor is larger than 5 centimeters but the cancer has not spread to the lymph nodes under the arm.

Stage III is also called locally advanced cancer. It can be divided into three sub-stages.

• Stage IIIA is one of the following:

  • The tumor is no more than 5 centimeters across and the cancer has spread to underarm lymph nodes that are attached to each other or to other structures or the cancer may have spread to lymph nodes behind the breastbone.
  • The tumor is more than 5 centimeters across but does not grow into the chest wall or skin. The cancer has spread to underarm lymph nodes that are either alone or attached to each other or to other structures, or the cancer may have spread to lymph nodes behind the breastbone.

• Stage IIIB is a tumor of any size that has grown into the chest wall or the skin of the breast. It may be associated with swelling of the breast or with nodules (lumps) in the breast skin. The cancer may have spread to lymph nodes under the arm that are attached to each other or other structures or the cancer may have spread to lymph nodes behind the breastbone.

  • Inflammatory breast cancer is a rare type of breast cancer in which cancer cells accumulate in the lymph vessels in the skin of the breast and make it appear red and swollen. When a doctor diagnoses inflammatory breast cancer, it is always at least Stage IIIB but it could be more advanced.

• Stage IIIC is a tumor of any size. It has spread in one of the following ways:

  • The cancer has spread to the lymph nodes behind the breastbone and under the arm.
  • The cancer has spread to the lymph nodes above or below the collarbone.

Stage IV is distant metastatic cancer. The cancer has spread to other parts of the body remote from the chest and armpits.

Recurrent cancer is cancer that has returned after a period of remission when the patient was deemed cancer-free. It may recur in the breast or anywhere throughout the body.