Making The Diagnosis?

There are two ways of meeting difficulties. You alter the difficulties or you alter yourself to meet them.

— Phyllis Bottome

At the present time, finding breast cancer early is the best way to increase the chances of surviving the disease. Cancer found early can usually be treated successfully. Mammography, clinical breast examination and breast self-examination are three methods that are used to detect breast cancer early. These methods are described in Who’s at Risk and What Can You Do on page 14. However, those methods alone cannot diagnose breast cancer.

Other tests, such as ultrasound and MRI, are used to get a clearer picture of a breast lump or problem. If required, biopsies are used to find out whether a breast lump is benign (not cancer) or malignant (cancer). The only definite way to tell if breast cancer is present is with a biopsy.
Does breast cancer start as a lump in the breast?

Sometimes, but not always. Breast cancer can cause the following symptoms:

  • A change in how the breast or nipple feels
  • A lump or thickening in or near the breast, or in the underarm area
  • Nipple tenderness
  • A change in how the breast or nipple looks
  • A change in the size or shape of the breast
  • The nipple or skin is turned inward into the breast
  • The skin of the breast, areola or nipple may be scaly, red or swollen. It may have ridges or pitting so that it looks like the skin of an orange.
  • Nipple discharge (fluid).

Can breast cancer cause breast pain?
In most cases, early breast cancer does not cause pain. However, see your doctor or healthcare provider about breast pain or any other symptom that does not go away.Most often, these symptoms are not cancer, but it is important to see your doctor so that any problems can be checked and treated as early as possible.

Digital Mammograms - A New Kind of Mammogram
 Digital mammography takes electronic pictures of the breast and stores them on a computer (regular mammograms are created directly on film). A recent, large, clinical trial found that digital mammograms are better than regular mammograms for:

  • women with dense breasts,
  • women who haven’t gone through menopause or who just stopped having periods, and
  • women who are younger than age 50.

However, digital mammograms are not widely available yet, and the equipment costs much more than regular mammograms. If you have questions about mammograms, ask your doctor.

What do I do if I have a lump or some other change in my breast?
See your doctor. Your doctor can find out whether the lump is benign or something more serious, such as breast cancer. The doctor may want to do a physical exam, and may ask for your personal and family medical history. Most likely, you will need a diagnostic mammogram and an ultrasound.

A radiologist (a doctor who reads mammograms) will read the mammogram result and decide if you need further tests. In some cases, no further tests are needed, and no treatment is necessary. However, often a radiologist cannot say for sure whether the lump is or is not cancer based on the mammogram alone.

Most breast lumps that are biopsied are not cancer. Many of these lumps are harmless changes of normal tissue. Others may indicate a condition that requires follow-up.

Two other breast “imaging” tests are sometimes used along with a mammogram:

Ultrasound. This is a painless test using high-frequency sound waves. A handheld probe is pressed against the breast to show whether a lump is a fluid-filled cyst (not cancer) or solid tissue (may or may not be cancer).

Magnetic Resonance Imaging (MRI). A powerful magnet linked to a computer is used to make detailed pictures of tissue inside the breast. MRIs do not use X-rays. Dye is injected into a vein, and the patient lies on her stomach with her breast in a special “breast coil.” Then, the patient is moved in and out of a narrow tube.

MRI is expensive and only available in certain areas. It is used in special cases, such as checking younger women at very high risk for breast cancer, finding a lump that can be felt but wasn’t seen by mammograms or ultrasound, or seeing the difference between breast scar tissue and a possible cancer.

Questions to Ask Your Doctor

  • What type of biopsy do you recommend? Why?
  • How long will it take? Will I be awake? Will it hurt? Will I have anesthesia to numb the breast (local) or anesthesia to put me to sleep (general)?
  • How soon will I know the results?
  • Are there any risks? What are the chances of infection or bleeding after the biopsy?
  • If I do have cancer, who will talk with me about treatment options? And when?
Adapted from What You Need to Know About Breast Cancer, National Cancer Institute, 800.4.CANCER or http://www.cancer.gov.

OTHER DIAGNOSTIC TOOLS FOR FOLLOW-UP

Breast images alone (such as mammograms, ultrasound, MRI) are helpful, but they are often not enough to tell for sure whether a lump is benign or whether it is cancer. A doctor must remove fluid or tissue from the breast to learn whether cancer is present. This is called a biopsy. A diagnosis of breast cancer can only be made after seeing cancer cells in biopsied breast tissue under a microscope.

Doctors can remove tissue from the breast in several different ways:

Fine-needle aspiration. The doctor uses a thin needle to remove fluid and/or cells from the breast lump. Depending on what the sample looks like, it may or may not go to the lab where a pathologist looks at it with a microscope to check for cancer cells.

Core needle biopsy. The doctor uses a thicker needle to remove tiny samples of tissue from the breast lump. The tissue is sent to a lab to check for cancer cells. The doctor may first numb your breast in the area of the lump.

Surgical biopsy. In an incisional biopsy, the surgeon removes a small sample of the lump. In an excisional biopsy, the surgeon removes the entire lump and some surrounding tissue. In either biopsy, the tissue is sent to a lab to check for cancer cells.

Sometimes a lump that is found on a mammogram cannot be felt by you or your doctor. In these cases, the doctor can use different methods to help locate the lump in order to get a sample of the breast tissue. These methods include:

Stereotactic biopsy. The doctor uses a special biopsy needle, directed by a mammogram machine, to take a tissue sample. The area is first numbed well before inserting the biopsy needle. A small cut that does not require stitches is made for this biopsy. Using this method, a generous sample of tissue can be removed without surgery.

Ultrasound-guided biopsy. This is the same type of biopsy as stereotactic biopsy, except that ultrasound is used to guide the biopsy needle instead of a mammogram machine.

Needle-localized biopsy. A radiologist places a very thin wire (about the size of a thick strand of hair) into the lump, which has been located using mammogram or ultrasound, whichever method finds the area best. A surgeon then performs an excisional biopsy.

INFLAMMATORY BREAST CANCER
Not all breast cancer involves a lump. Inflammatory breast cancer (IBC) is an aggressive form of breast cancer that usually grows in sheets rather than a solid tumor. It can spread throughout the breast without a detectable lump.

Symptoms are similar to those of mastitis, a benign breast infection. IBC is frequently misdiagnosed. For more information, see the Advanced Breast Cancer chapter on page 66.

What is a PET scan?
PET (positron emission tomography) imaging is a diagnostic exam that takes pictures of biological changes in your body. A PET image can help tell your doctor whether a tumor is benign or malignant, and if cancer has spread to other parts of your body. It can also be used to examine the effects of cancer therapy by looking at biochemical changes in the cancer. A radiologist specially trained in PET interprets the results of your scan and provides them to your doctor. PET scans can be more valuable when they are part of a larger diagnostic work-up, such as comparing the PET scan with other diagnostic imaging studies (CT scan or MRI).

On the path to diagnosis, or when having any kind of medical tests, it is highly recommended that you ask questions to help you understand why a test is being done and what it will tell you and your doctor. The more informed you are, the better you will feel about making decisions for treatment, if necessary.

New Advances
Advances in breast cancer diagnosis and treatment are constantly being made. One interesting new breakthrough is the Oncotype DX™ lab test. It is ordered by doctors for certain women with early stage breast cancer. The test analyzes 21 genes in tumor tissue and is used to predict how an individual’s cancer is likely to behave in the future. This helps doctors tailor treatment to the individual patient.

Material in this section was gathered, in part, from National Cancer Institute educational publications (800.4.CANCER or http://www.cancer.gov.)

RESOURCES

Organizations

American Cancer Society (ACS)
800.ACS.2345 or 866.228.4327 (TTY)
http://www.cancer.org
Provides information and services for all forms of cancer, diagnosis, treatment and many other topics. Has free booklets relating to breast cancer, including mammography, biopsies, and talking with your doctor.

American College of Radiology (ACR)
703.648.8900 or 800.227.5463
http://www.acr.org
Provides information about mammography and other tests used to detect breast cancer.

EduCare, Inc.
803.796.6100
http://www.educareinc.com
Has informational materials about breast cancer, breast lumps, breast pain and breast discharge available as books and teaching sheets.

National Cancer Institute’s Cancer Information Service
800.4.CANCER (800.422.6237) or 800.332.8615 (TTY)
http://www.cancer.gov
One of the best resources available for cancer patients, this government organization provides the toll-free hotline above in English and Spanish, and booklets to answer questions about any type of cancer, including breast cancer, mammograms, breast changes and other topics.

Susan G. Komen Breast Cancer Foundation
800.I’M.AWARE (800.462.9273)
http://www./a>.org.komen
This foundation for breast cancer research, education, screening and treatment has a toll-free helpline
(above) and booklets for callers with breast health/cancer concerns.

Y-ME National Breast Cancer Organization
312.986.8338 or 800.221.2141
800.986.9505 (Spanish)
http://www.y-me.org
Y-ME offers breast cancer education, support and a national 24-hour toll-free breast cancer information hotline. Free information includes,“Understanding Your Pathology Report.”

Books and More
Bosom Buddies: Lessons and Laughter on Breast Health and Cancer,
by Rosie O’Donnell and Deborah Axelrod, MD, FACS, with Tracy Chutorian Semier (1999).
Addresses questions about breast health and breast cancer in an easy-to-read and lighthearted manner.

Dr. Susan Love’s Breast Book, 4th rev. ed.,
by Susan M. Love, MD, with Karen Lindsey (2005).
Discusses all conditions of the breast, including breast cancer. An excellent general reference.

The Breast Book,
by Miriam Stoppard, MD (1996).
Comprehensive, well-illustrated guide to breast care provides women with useful information about all stages of the disease, with particular emphasis on early detection and treatment of breast cancer.

The Complete Book of Breast Care,
by Niels H. Lauersen, MD, PhD, and Eileen Stukane (1998).
A good general reference on the breasts covering everything from exercise and nutrition through treatment and research.

Working With Your Doctor: Getting the Healthcare You Deserve (Patient-Centered Guides),
by Nancy Keene (1998).
Talks about how to get the most out of your relationship with your doctor and how to be an active participant in your healthcare with many examples from patients and doctors.

Web Sites
Biopsy Report: A Patient’s Guide
http://www.cancerguide.org/pathology.html
Has information on types of biopsies, procedures and a glossary of pathology terms.

Breastcancer.org
http://www.breastcancer.org
This web site has comprehensive information about prevention, BSE, mammography, diagnostic tests, treatment and many other issues. Information is written by oncology doctors and nurses.

Breast Cancer: Help Me Understand It!
http://www.surgery.wisc.edu/breast_info/laybreastca.html
Written by a physician who had breast cancer to clarify information about breast cancer and to help women make choices about treatment.

RadiologyInfo
http://www.radiologyinfo.org
Public information site designed to anser questions related to many radiologic procedures and therapies available. Developed jointly by the American College of Radiology and the Radiological Society of North America.