Diagnosis

Symptoms

Breasts undergo changes throughout a woman's life, particularly the normal changes experienced during the menstrual cycle.

Some breast changes may be early signs of breast cancer, including:

  • a lump or lumpiness

  • thickening of the tissue

  • nipple changes; for example a blood-stained discharge from one nipple, an inverted nipple (unless the nipple has always been turned in), and a rash on a nipple

  • skin dimpling

  • a change in shape

  • a painful area

  • a rash or red marks which appear only on the breast.

Although these changes do not necessarily mean you have breast cancer, any breast change should be checked by a doctor.

“When I was diagnosed I felt totally shocked. I couldn’t remember much after I heard the word ‘cancer’. I was so pleased I had my partner there to write down what was said.” Mayuri

If you have a change in your breast, you may have several tests. Your general practitioner may arrange these tests or you may be referred directly to a breast specialist.

Physical examination

The doctor will take your medical history and examine your breasts.

Diagnostic imaging

A mammogram is a breast X-ray. It will give your doctor more information about any lump or other change noticed.

Occasionally, a lump that can be felt is not seen on a mammogram. Such a lump should not be ignored. Other tests will need to be done.

An ultrasound is a test using high frequency sound waves to help detect lumps or other changes.

An MRI scan is a scan that uses magnetic resonance to detect abnormalities in the breast. Occasionally, an MRI is recommended in young women when their breast tissue is very dense. This type of scan is sometimes used in lobular carcinomas to make sure there is not more than one cancer present, and it can check the other breast. It can also be used to check the breast if a mammogram is negative but the specialist is still concerned about the lump or changes in the breast.

Fine needle aspiration

A fine needle aspiration can be done in your specialist’s rooms, in a hospital outpatient department, or at a laboratory by a pathologist. A very narrow needle is used to take some cells from the lump. These cells are then sent to a laboratory for examination. A fine needle aspiration may cause a little discomfort but is not usually any more painful than a blood test. Results from this test may be available immediately or take some time, depending upon where it is done.

Biopsy

Often, a biopsy will be necessary. A biopsy is the removal of a sample of a lump or the entire lump for examination under a microscope.

Core biopsy

A larger needle than that used for fine needle aspiration is used to obtain a sliver of tissue from the lump. This is done with a local anaesthetic. It can be done by a radiologist under ultrasound guidance or in a mammogram machine (stereotactic core biopsy). Sometimes, it is done by palpation (feeling) of the lump by the specialist.

Open biopsy

Sometimes, a surgical or open biopsy is necessary to remove the whole lump. This small operation is usually done under general anaesthetic, although occasionally a local anaesthetic is all that is needed. To have an open biopsy, you may need to stay in hospital overnight.

Hook wire biopsy

If the abnormality in the breast can only be detected by the mammogram (your doctor cannot feel your lump), a fine guide wire may be inserted in the breast to mark the area of the breast to be removed. This takes place in the radiology department under local anaesthetic. The abnormality is then removed, as in an open biopsy, under general anaesthetic and sent to the laboratory for testing.

Further tests

If the lump is a cancer, hormone receptor tests will be done using immuno-histochemistry (IHC) on the sample that was removed. These tests show whether the cancer cells have special ‘markers’ on them called hormone receptors (oestrogen/progesterone). If these markers are present, the cancer is described as ‘hormone receptor positive’, and the cancer is more likely to respond to hormone treatment if this is needed later.

HER2 tests

HER2 is a growth factor protein which tells breast cancer cells to grow. Approximately one in five breast cancers makes too much of this protein, which means that the cancer is more aggressive. This is often called HER2 positive breast cancer.

Two tests are available to check HER2–IHC and FISH. IHC is used first and if it is not a clear result then the FISH test is used.

If tests show that you have HER2 positive cancer, this will influence future choices of chemotherapy, hormones, or monoclonal antibodies. The most commonly used monoclonal antibody drug is called trastuzumab (Herceptin) which targets the growth factor protein. A diagnosis of breast cancer can be very stressful, see the pages on support for information that you may find helpful.