Breast cancer – How is it diagnosed?

It’s essential that all women from puberty throughout life become familiar with their own breast feel and shape to pick up any abnormalities during a self-breast examination.

All abnormalities should precipitate a visit to a clinic or hospital, with a triple assessment done (clinical breast examination, imaging (mammogram and/or ultrasound), and pathological diagnosis (usually radiologically-guided needle biopsy) if required.

Currently the new international revised guidelines to screen is age 40.

The diagnostic journey

Breast cancer is diagnosed by a specialist breast radiologist. After a mammogram (age dependent) and ultrasound, a core biopsy will be performed.

Next ensure a specialist review by a multi-disciplinary team. Your team may suggest a breast MRI to have a better map view of both breasts (not always needed). 

Your oncologist will order a CT scan and blood tests if your cancer has spread to the glands. 

For cancers with a high Ki, triple-negative or HER2, a PET scan may be ordered.

Advanced cancers in the glands (lazy luminal A cancers) may require a bone scan; other advanced cancers are scanned depending on your symptoms. 

Blood tests should be done on all people but menopausal bloods only on women where it’s difficult to determine if they are in menopause.

Mammogram 

This is the principle imaging modality for breast cancer diagnosis and for screening programmes. It uses low-dose ionizing radiation (X-rays) to penetrate through the breast tissue onto a plate beneath the patient.

You will stand in front of the machine and the mammographer will position your breast between the two plastic paddles. You may be a bit uncomfortable but it isn’t painful, and only takes around 10 minutes. 

Ultrasound

Ultrasound is an important adjunct to mammography both in screening and diagnosis of breast lesions. It’s excellent at differentiation between solid and cystic lesions and can often be used to further visualise the extent of a malignant lesion seen on mammogram. Because it has a real time capability for imaging, it’s the method of choice for guiding biopsies and other interventional procedures, such as inserting markers.

Ultrasound is a particularly useful modality for imaging young women and women with dense breast tissue. Any woman under 35 should have an ultrasound considered before mammogram. Women over 35 should be offered an ultrasound in addition to mammogram.  

You lie flat on your back with your hands behind your head. Gel is squirted onto your breasts and the radiologist moves the ultrasound probe around each breast to get a picture. 

Biopsy

A core needle biopsy is the current gold standard for diagnosis in breast disease. The lump or area seen on the mammogram or ultrasound is biopsied for analysis by taking a core of tissue which is then sent for histopathology at a lab. By understanding the type of cells, the personality of the cancer is determined and what the best drugs or treatment strategies should be.

NOTE: You are under no obligation to have the biopsy at the radiology unit that performed the mammogram. You are also entitled to second opinions prior to biopsies. Don’t be pressured into same day biopsies without understanding costs.

Local anaesthetic is given but you are awake, and although the device used (either hand-driven device or a pneumatic gun) looks scary and intimidating, the extra tissue allows the pathologist to determine the type of cancer. 

Markers

If an abnormality is diagnosed, it needs to be marked. The tagging can be done at the time of the needle biopsy or after radiology and pathology review, and sometimes after further radiology studies, such as an MRI scan. 

Breast MRI

MRI uses a magnetic field; radio-frequency pulses produce detailed pictures. A contrast is used to make the breast tissue more visible and enhance any suspicious lesions. 

You will lie face down on a padded table with your breasts in cushioned openings. The table will slide into the MRI machine, which is a long, narrow tube. It’s usually 30 to 60 minutes.

Further investigations 

Once the cancer has been diagnosed, all patients should be discussed in a multi-disciplinary meeting prior to undergoing any treatment. Often the next investigations that are chosen are based on who is the next specialist you need to see. This can be due to the biological type of the cancer or the clinical stage that you are presenting.

• CT scans
• Bone scans
• Liver MRI 
• Brain scan
• PET scan
• Blood tests

Header image by Freepik