Diagnosing breast cancer

Tests at the breast cancer clinic

If you have suspected breast cancer, either due to your symptoms or because your mammogram has shown an abnormality, you will be referred to a specialist breast cancer clinic for further tests.

Mammogram and breast ultrasound

If you have symptoms and have been referred by your GP, you will have a mammogram to produce an X-ray of the breasts. You may also need an ultrasound scan. If your cancer was detected through the NHS Screening Programme, you may need another mammogram or ultrasound scan.

If you are under 35, your doctor may suggest you have a breast ultrasound scan only. Younger women have denser breasts, which means a mammogram is not as effective as ultrasound in detecting cancer.

Ultrasound uses high-frequency sound waves to produce an image of the inside of your breasts. The image produced will show any lumps or abnormalities present in your breasts. Your doctor may also suggest a breast ultrasound if they need to know whether a lump in your breast is solid or contains liquid.

Biopsy

A biopsy involves taking a sample of tissue cells from your breast and testing them to see if they are cancerous. You may also need a scan and a needle test on lymph nodes in your armpit (axilla) to see if these are also affected. Biopsies can be taken in different ways and the type you have will depend on what your doctor knows about your condition. Different methods of carrying out a biopsy are outlined below.

• Needle aspiration may be used to test a sample of your breast cells for cancer or to drain a benign cyst (a small fluid-filled lump). Your doctor will use a small needle to extract a sample of cells, without removing any tissue.
• Needle biopsy is the most common type of biopsy. A sample of tissue is taken from a lump in your breast using a large needle. You will have a local anaesthetic, which means you will be awake but your breast will be numb. Your doctor may suggest you have a guided needle biopsy (usually this is guided by ultrasound or X-ray but sometimes MRI is used) to obtain a more precise and reliable diagnosis of cancer and to distinguish it from any non-invasive change, in particular ductal carcinoma in situ (DCIS).
• Vacuum-assisted biopsy (mammotome biopsy). The needle may be attached to a gentle suction tube which helps to obtain the sample and clear any bleeding from the area.

Want to know more?

• Breakthrough Breast Cancer: Diagnosing breast cancer
• Breast Cancer Care: Your breast clinic appointment  (PDF, 656Kb)
• Breast Cancer Care: Your pathology report
• Macmillan: How breast cancer is diagnosed
• Cancer Research UK: Diagnosing breast cancer

Further tests for breast cancer

If the diagnosis of breast cancer is confirmed, more tests will be needed to determine the stage and grade of the cancer, and to work out the best method of treatment.

Scans and X-rays

Computerised tomography (CT) scans, or chest X-ray and liver ultrasound scans, may be needed to check whether the cancer has spread to the lungs or liver. An MRI scan of the breast may be needed to clarify or to assess the extent of disease within the breast.

If your doctor thinks that the cancer could have spread to your bones, you may need a bone scan. Before you have a bone scan, a substance containing a small amount of radiation, known as an isotope, will be injected into a vein in your arm. This will be absorbed into your bone if it has been affected by cancer. The affected areas of bone will show up as highlighted areas on the bone scan, which is carried out using a special camera.

Tests to determine specific types of treatment

You will also need to have tests that show whether the cancer will respond to specific types of treatment. The results of these tests can give your doctors a more complete picture of the type of cancer you have and how best to treat it.

• Hormone receptor test. In some cases, breast cancer cells can be stimulated to grow by hormones that occur naturally in your body, such as oestrogen and progesterone. If this is the case, the cancer may be treated by stopping the effects of the hormones or by lowering the level of these hormones in your body. This is known as hormone therapy. A sample of cancer cells will be taken from your breast and tested to see if they respond to either oestrogen or progesterone. If the hormone is able to attach to the cancer cells (using a hormone receptor) then they are known as hormone receptor positive
• HER2 test. While hormones can encourage the growth of some types of breast cancer, other types are stimulated by a protein called human epidermal growth factor receptor 2 (HER2). These types of cancer may be treated using drugs to block the effects of HER2. This is known as biological therapy or targeted therapy

Want to know more?

Breast Cancer Care: Diagnosis.

Stage and grade of breast cancer

Stage of breast cancer

When your breast cancer is diagnosed, the doctors will give it a stage. The stage describes the size of the cancer and how far it has spread. Sometimes, ductal carcinoma in situ (DCIS) is described as Stage 0. Other stages of breast cancer describe invasive breast cancer.

• Stage 1. The tumour measures less than 2cm and the lymph nodes in the armpit are not affected. There are no signs that the cancer has spread elsewhere in the body
• Stage 2. The tumour measures between 2cm and 5cm or the lymph nodes in the armpit are affected, or both. There are no signs that the cancer has spread elsewhere in the body
• Stage 3. The tumour measures between 2cm and 5cm and may be attached to structures in the breast, such as skin or surrounding tissues. The lymph nodes in the armpit are affected. However, there are no signs that the cancer has spread elsewhere in the body
• Stage 4. The tumour is of any size and the cancer has spread to other parts of the body (metastasis)

This is a simplified guide. Each stage is divided into further categories called A, B and C. If you are not sure what stage you have, ask your doctor.

TNM staging system

The TNM staging system may also be used to describe breast cancer. It can provide accurate information about the diagnosis. T describes the size of the tumour, N describes whether cancer has spread to the lymph nodes and M gives an indication of whether the cancer has spread to other parts of the body.

Grade of breast cancer

The grade describes the appearance of the cancer cells.

• Low grade (G1) – the cells, although abnormal, appear to be slow growing
• Medium grade (G2) – cells look more abnormal than low-grade cells
• High grade (G3) – cells look even more abnormal and are more likely to grow more quickly

Want to know more?

• Cancer Research UK: TNM breast cancer staging
• Cancer Research UK: Number stages of breast cancer
• Breakthrough Breast Cancer: Staging and grading
• Macmillan: Staging and grading of breast cancer