Breast Cancer Diagnosis
If you notice changes to your breasts, experience symptoms of breast cancer, or have an abnormal mammogram result, your doctor will need to investigate further to make a diagnosis. Your doctor may start by performing a breast exam, which involves manually checking your breasts and armpit for lumps and abnormalities. If your doctor suspects breast cancer, they may order imaging tests to take a better look.
Most breast imaging is carried out with a mammogram or ultrasound.
- In a mammogram, x-ray pictures will be taken of the breasts from a few different angles. Your doctor can examine these images for signs of breast cancer.
- In an ultrasound, a device bounces high-energy sound waves off your tissue. The echo patterns create a picture referred to as a sonogram, which can be seen on the ultrasound machine.
Occasionally, doctors will use magnetic resonance imaging (MRI) or other specialized examinations.
Imaging exams
The first diagnostic procedure for breast cancer is typically an imaging exam. Breast imaging is usually carried out with a mammogram or ultrasound. Occasionally, doctors will use magnetic resonance imaging (MRI) or other specialized examinations. Learn more about imaging exams.
Biopsy
If the imaging exam shows an unusual or suspicious mass or skin thickening, doctors will need a tissue sample to make a definitive diagnosis. The process of retrieving and examining this tissue under a microscope is called a biopsy.
For breast cancer, patients usually undergo an image-guided core needle biopsy. During this procedure, a live image of the breast tissue is used help doctors guide the needle to the suspected cancer tissue. In many cases, this biopsy is performed during the initial imaging exam in order to speed up the diagnosis.
If the biopsy reveals cancerous tissue, additional images and biopsies may be needed to determine the exact scope of the disease. This part of the diagnosis shows whether the cancer has spread to nearby lymph nodes or other parts of the body.
Molecular diagnosis
If the patient is diagnosed with breast cancer, doctors will also analyze the cancer cells to determine the disease’s molecular receptor subtype. By understanding the subtype, they can develop a comprehensive, personalized treatment plan.
Some cases of breast cancer can be passed down from one generation to the next. Genetic counseling may be right for you. Learn more about the risk to you and your family in our prevention and screening section.
Getting a breast biopsy? You might be wondering what it is and how it works.
A breast biopsy is a diagnostic procedure in which a doctor removes a small amount of breast tissue to examine under a microscope. If the tissue sample shows cancer, the physician can have it analyzed further to provide the most accurate diagnosis — a critical first step in getting patients the best treatment possible for their particular type of breast cancer.
A biopsy may be ordered when:
- a mammogram or other breast imaging, such as an ultrasound, reveals an abnormality
- you feel a lump in your breast, and/or
- your doctor notices something suspicious, such as dimpling or a change in skin texture, during a clinical exam.
We spoke with breast surgical oncologist Makesha Miggins, M.D., to learn more. Here’s what she had to say.
What are the types of breast biopsies?
There are two main types of breast biopsy:
- A surgical breast biopsy is performed by a surgeon or radiologist in an operating room. It involves making an incision in the skin.
- A needle biopsy is performed by a radiologist in an exam room or radiology suite. It is done by inserting a needle through the skin.
There are two main subtypes of breast needle biopsy:
- fine needle aspiration uses a thin, hollow needle attached to a syringe, and
- core needle biopsy uses a larger needle that removes a small, tube-shaped piece of tissue with a spring-loaded device or a vacuum-assisted device.
It’s important to pinpoint all areas of concern and pull tissue from those exact spots. That's why doctors sometimes use an ultrasound — or a mammogram or MRI, in some cases — to guide a breast needle biopsy. Mammogram-guided biopsies are also sometimes called stereotactic biopsies.
Small metallic markers called clips may be placed in your breast and left there. This allows doctors to know the exact location of a previous biopsy, in case more tissue needs to be removed for analysis.
How painful is each kind of biopsy, and how long does it take to recover?
It’s hard to say how painful a breast biopsy is. Pain is so subjective, and each patient tolerates discomfort differently.
But most patients describe the sensation they feel during a biopsy as pressure, rather than pain. And radiologists and/or technicians are always on hand during needle biopsies to make sure patients feel calm, safe and comfortable during the procedure.
Most people have a short recovery time, but it can vary depending on the amount of bleeding and/or bruising. Core needle biopsies are more likely to result in bruising than breast fine needle biopsies, and it can take several weeks for that to go away.
Your doctor can answer questions about your specific recovery time and how to take care of an area that’s been biopsied.
Do any breast biopsies require general anesthesia or an overnight stay in the hospital?
A breast needle biopsy is done with local anesthesia, so it does not require general anesthesia. That means most people can return to their normal activities as soon as a needle biopsy is over.
A surgical breast biopsy may require general anesthesia but typically won’t require an overnight hospital stay. So, if you undergo that type of biopsy, you should feel ready to resume normal activities by the next day.
How do doctors determine which biopsy is best for a particular patient?
Radiologists determine how much tissue is needed and what kind of imaging will best allow them to see it for a needle biopsy.
Surgical biopsies are only needed if an area of concern can’t be needle-biopsied or more tissue is needed to make an accurate diagnosis.
Is there ever a time when a patient should ask their doctor for a biopsy?
In most cases, you should not have to ask for a breast biopsy. Doctors only want to do one when it’s absolutely necessary. So, they will only recommend it if there’s a suspicious finding on a mammogram, ultrasound or MRI, or a concerning clinical finding.
If your scans are normal and you don’t have any worrisome symptoms, there’s no need for a biopsy.
What are the potential risks of a breast needle biopsy?
All medical procedures come with some element of risk. The most common ones following any type of breast biopsy are:
- pain
- bleeding
- infection
The risk of infection at the biopsy site is very small, and any bleeding is usually minor and resolves on its own. Pain and discomfort can normally be managed with over-the-counter pain relievers, such as Tylenol or ibuprofen.
Keep in mind that we won’t recommend a breast biopsy unless it’s really needed. So, if your doctor suggests one, you can trust that it’s because the benefits of getting a breast biopsy far outweigh the risks.
How long does a breast biopsy take?
The actual biopsy itself is very short. It only takes about a minute or so.
But first, we have to find the right area, then perform the biopsy, and then take another image to confirm that any clips we left behind are in the right place(s).
The entire process can take a couple of hours.
Why should you have your breast biopsy done at MD Anderson?
Our radiologists receive specialized training in both breast imaging techniques and how to perform breast biopsies.
Our pathologists specialize in specific diseases as well, so they are incredibly skilled at identifying abnormalities in breast tissue.
Each year, our breast radiologists perform more than 2,000 ultrasound-guided biopsies, 750 stereotactic biopsies and 250 MRI-guided breast biopsies. So, our doctors perform virtually every type of breast biopsy routinely.
MD Anderson also provides comprehensive cancer care. That means if a breast biopsy reveals cancer, our specialized team of breast surgical oncologists, medical oncologists and radiation oncologists will work together to develop a treatment plan personalized for you.
Our team approach ensures that you'll have access to any additional support services you might need, such as physical therapists, dietitians and social work counselors. So, patients who come to MD Anderson can expect to receive expert care from people who specialize in breast cancer from diagnosis to treatment and survivorship. We’re experts at every stage of cancer care.
Is there anything else readers should know about breast biopsies?
If you hear odd noises during your breast biopsy, don’t be alarmed. A loud snap or pop is usually just the needle being deployed. And a drilling sound is very common with vacuum-assisted devices.
Remember: most breast biopsies do not end in a cancer diagnosis. Between 75% and 80% of all breast biopsies turn out to be benign. That means they’re not cancerous.
Request an appointment at MD Anderson online or by calling 1-877-632-6789.
Breast cancer staging
A cancer’s stage is used to describe the extent of the cancer in the patient’s body. Doctors use the stage to plan treatment and make a prognosis.
Breast cancer staging systems
(source: National Cancer Institute)
There are two staging systems used in the United States for breast cancer. Several factors are used in these systems, including:
- The cancer’s molecular subtype.
- The cancer’s grade. Grading describes a cancer based on how abnormal the cancer cells and tissue look under a microscope and how quickly the cancer cells are likely to grow and spread. Low-grade cancer cells look more like normal cells and tend to grow and spread more slowly than high-grade cancer cells.
- The cancer’s TNM status. The TNM system describes the disease by:
- Tumor (T): The size and location of the tumor.
- Lymph node (N): The size and location of lymph nodes where cancer has spread.
- Metastasis (M): The spread of cancer to other parts of the body.
The stages used in the U.S. are:
- Clinical Prognostic Stage: This is used first to assign a stage for all patients based on health history, physical exam, imaging tests (if done), and biopsies. The Clinical Prognostic Stage is described by the TNM system, tumor grade and biomarker status (ER, PR, HER2). In clinical staging, mammography or ultrasound is used to check the lymph nodes for signs of cancer.
- Pathological Prognostic Stage: This system is used for patients who have surgery as their first treatment. The Pathological Prognostic Stage is based on all clinical information, biomarker status, and laboratory test results from breast tissue and lymph nodes removed during surgery.
TNM System
The TNM system plays a key part in breast cancer staging. It describes the cancer in the by tumor, node and metastasis.
Tumor (T). The size and location of the tumor.
- Primary tumor cannot be assessed.
- T0: No sign of a primary tumor in the breast.
- Tis: Carcinoma in situ. There are 2 types of breast carcinoma in situ:
- Tis (DCIS): DCIS is a condition in which abnormal cells are found in the lining of a breast duct. The abnormal cells have not spread outside the duct to other tissues in the breast. In some cases, DCIS may become invasive breast cancer that is able to spread to other tissues. At this time, there is no way to know which lesions can become invasive.
- Tis (Paget disease): Paget disease of the nipple is a condition in which abnormal cells are found in the skin cells of the nipple and may spread to the areola. It is not staged according to the TNM system. If Paget disease AND an invasive breast cancer are present, the TNM system is used to stage the invasive breast cancer.
- T1: The tumor is 20 millimeters or smaller. There are 4 subtypes of a T1 tumor depending on the size of the tumor:
- T1mi: the tumor is 1 millimeter or smaller.
- T1a: the tumor is larger than 1 millimeter but not larger than 5 millimeters.
- T1b: the tumor is larger than 5 millimeters but not larger than 10 millimeters.
- T1c: the tumor is larger than 10 millimeters but not larger than 20 millimeters.
- T2: The tumor is larger than 20 millimeters but not larger than 50 millimeters.
- T3: The tumor is larger than 50 millimeters.
- T4: The tumor is described as one of the following:
- T4a: the tumor has grown into the chest wall.
- T4b: the tumor has grown into the skin—an ulcer has formed on the surface of the skin on the breast, small tumor nodules have formed in the same breast as the primary tumor, and/or there is swelling of the skin on the breast.
- T4c: the tumor has grown into the chest wall and the skin.
- T4d: inflammatory breast cancer—one-third or more of the skin on the breast is red and swollen (called peau d’orange).
Lymph Node (N). The size and location of lymph nodes where cancer has spread.
When the lymph nodes are removed by surgery and studied under a microscope by a pathologist, pathologic staging is used to describe the lymph nodes. The pathologic staging of lymph nodes is described below.
- NX: The lymph nodes cannot be assessed.
- N0: No sign of cancer in the lymph nodes, or tiny clusters of cancer cells not larger than 0.2 millimeters in the lymph nodes.
- N1: Cancer is described as one of the following:
- N1mi: cancer has spread to the axillary (armpit area) lymph nodes and is larger than 0.2 millimeters but not larger than 2 millimeters.
- N1a: cancer has spread to 1 to 3 axillary lymph nodes and the cancer in at least one of the lymph nodes is larger than 2 millimeters.
- N1b: cancer has spread to lymph nodes near the breastbone on the same side of the body as the primary tumor, and the cancer is larger than 0.2 millimeters and is found by sentinel lymph node biopsy. Cancer is not found in the axillary lymph nodes.
- N1c: cancer has spread to 1 to 3 axillary lymph nodes and the cancer in at least one of the lymph nodes is larger than 2 millimeters. Cancer is also found by sentinel lymph node biopsy in the lymph nodes near the breastbone on the same side of the body as the primary tumor.
- N2: Cancer is described as one of the following:
- N2a: cancer has spread to 4 to 9 axillary lymph nodes and the cancer in at least one of the lymph nodes is larger than 2 millimeters.
- N2b: cancer has spread to lymph nodes near the breastbone and the cancer is found by imaging tests. Cancer is not found in the axillary lymph nodes by sentinel lymph node biopsy or lymph node dissection.
- N3: Cancer is described as one of the following:
- N3a: cancer has spread to 10 or more axillary lymph nodes and the cancer in at least one of the lymph nodes is larger than 2 millimeters, or cancer has spread to lymph nodes below the collarbone.
- N3b: cancer has spread to 1 to 9 axillary lymph nodes and the cancer in at least one of the lymph nodes is larger than 2 millimeters. Cancer has also spread to lymph nodes near the breastbone and the cancer is found by imaging tests;
or
- cancer has spread to 4 to 9 axillary lymph nodes and cancer in at least one of the lymph nodes is larger than 2 millimeters. Cancer has also spread to lymph nodes near the breastbone on the same side of the body as the primary tumor, and the cancer is larger than 0.2 millimeters and is found by sentinel lymph node biopsy.
- N3c: cancer has spread to lymph nodes above the collarbone on the same side of the body as the primary tumor.
When the lymph nodes are checked using mammography or ultrasound, it is called clinical staging. The clinical staging of lymph nodes is not described here.
Metastasis (M). The spread of cancer to other parts of the body.
- M0: There is no sign that cancer has spread to other parts of the body.
- M1: Cancer has spread to other parts of the body, most often the bones, lungs, liver, or brain. If cancer has spread to distant lymph nodes, the cancer in the lymph nodes is larger than 0.2 millimeters. The cancer is called metastatic breast cancer.