Breast Cancer Tests

Breast cancer testing plays a key role in addressing many facets of the disease. There are tests to determine genetic risk, to enable people to detect the cancer at an early stage, to determine characteristics and possible spread of the disease to help guide treatments, to monitor the effectiveness of treatments, and to check for recurrences among long-term survivors of the disease. Below are various tests and screenings used for several such reasons:

Breast Self-Exam (BSE)

Young women need to know how their breasts normally look and feel. One way to help find any abnormality in the breast is through a breast self-exam, although it’s important to know that most early cancers of the breast cannot be detected by everyday look and feel.

BSE Steps

STEP1: Positioning. It’s usually better to be on your back rather than standing for the palpation (feeling) part of the test.

STEP 2: Preparation. Begin with your right hand above and behind your head. Lying on your back and raising your arm spreads the breast tissue across the chest wall for optimal thinness.

STEP 3: Movement. Using the three middle fingers of your left hand, make small, overlapping, circular motions on your right breast. Move up and down the breast from rib cage to collarbone, armpit to sternum.

STEP 4: Pressure. Change pressures on each spot to examine different depths of skin: light for the surface, medium in order to feel about a quarter-inch to a half-inch deeper, and firm to feel close to the chest and ribs.

Repeat on the other side. There likely will be a hardened ridge on the lower curve of each breast, but any other lumps, swellings, or changes should immediately be brought to the attention of your doctor.

STEP 5: Visual. Stand in front of the mirror and press firmly down on your hips with the heels of your palms (to tighten chest muscles for maximum visibility of abnormalities). Look for any skin or nipple changes including shape, contour, size, color, or skin texture (such as scales, sores, rashes, dimples, or puckering of the skin). Slightly raise each arm to easily feel the underarm areas for lymph node lumps.

Clinical Breast Exam (CBE)

An examination of your breasts in a medical office by a doctor, nurse, or physician assistant can provide a perfect opportunity to learn how to do a BSE if you don’t know how to or feel confident about it already.

A CBE is much the same as the BSE. The caregiver will look at your breast for any unusual shapes or changes in size, color, texture, and so on. The health care provider will also palpate (touch) your breasts with the same circular three-finger motion that is recommended for a BSE.

In most cases, a CBE is the best screening test option. But for women over age 40, mammograms are usually recommended, with a CBE utilized as an adjunct screening.

Screenings

Mammograms

A mammogram, or breast X-ray, can be used to screen for breast cancer in women who have no signs of the disease, or for diagnostic purposes if a woman has symptoms of breast cancer or when a screening mammogram has shown abnormal results.

Screening mammograms are used for women who have no symptoms but may be at an age—over 40 or 50 depending on your doctor’s advice—when checking regularly (every year or two, again depending on you and your doctor’s decision) is an important preventative approach. Women who have a higher-than-average risk of breast cancer may be advised by their doctor to have a mammogram before age 40.

In some cases, including when a woman is breast-feeding or has breast implants, mammograms can be especially useful, although special care must be taken to get an accurate image through denser breast tissues. Especially in the case of breast implants, it is important that the mammogram providers have experience in that area. Women with breast implants should generally continue to have regular mammograms. However, those women who have had an implant as part of reconstructive surgery following breast cancer surgery should ask their doctors whether a mammogram of the reconstructed breast is necessary.

Mammograms usually involve taking two views of each breast, but in some more complex situations, more images may be taken.

While some are concerned about the amount of radiation exposure from repeated X-rays, mammograms performed by modern equipment actually use very low levels of radiation. One mammogram gives off about the equivalent of radiation received by anyone on a cross-country commercial flight.

During a mammogram, each breast is squeezed between two photographic plates. This can cause some discomfort but is required in order to produce the best possible image for a radiologist to read correctly. An entire mammography session takes less than a half hour to complete.

The radiologist viewing your mammogram will look for different kinds of changes in your breast tissue:

• Calcifications. These mineral deposits may be small (microcalcifications) or large (macrocalcifications). The latter occur in about half the women over age 50 and one-tenth of those under age 50 and are almost always noncancerous. Microcalcifications, tiny specks of calcium in the breast tissue, may be of more concern to doctors depending on how they are shaped and clustered. In some cases, cancer may be suggested and a biopsy will be ordered; in other cases, doctors may not recommend a biopsy.
• Masses. These can be noncancerous cysts or solid tumors (fibroadenomas) or cancerous tumors, and may or may not be accompanied by calcifications. Cysts, which are fluid-filled sacs, can be confirmed by an ultrasound or by aspirating them (removing the fluid) with a thin, hollow needle. Masses that are not cysts normally will be biopsied. The size, shape, and edges of a mass may help a radiologist determine if a cancer is likely.

Mammograms alone cannot provide definitive proof that cancer is present. To reach that diagnosis, a biopsy is necessary. A biopsy is a test in which a small bit of tissue is removed to be studied under a microscope.

Still, for finding breast cancers that cannot be felt, mammograms are crucial tools. In the past several years, cancer authorities have recommended that any woman over age 40 should get an annual mammogram. In late 2009, controversy surrounded the the U.S. Preventive Services Task Force’s updated recommendations created a stir when it suggested that only women over age 50 needed regular mammograms, and every other year was sufficient.

The resulting debate has once more placed the final decision on mammogram screening decidedly in the hands of patient and doctor. Any woman with significant risk factors for breast cancer should take a conservative approach with more frequent mammograms beginning at an earlier age.

The American Cancer Society provides useful suggestions to help ensure that your mammogram meets a high standard:

• An X-ray facility may not perform mammography without special certification from the U.S. Food and Drug Administration (FDA).  Make sure the certificate is viewable in the office.  Ask to see it if it is not prominently displayed.                          
• Only go to a facility that either performs many daily mammograms or does them exclusively.
• When you find a good facility, continue to go there as it will make comparison studies with older mammograms more convenient.
• When visiting a facility for the first time, bring a list of past mammograms, facilities, biopsies, or other breast treatments.  Dates, places, and doctors’ names are helpful to include.                  
• If you can, obtain past mammograms to take with you or have them sent to any new facility you use.                    
• Avoid scheduling your mammogram the week right before your period.  Pick a time of the month when your breasts are neither tender nor swollen.  This may help make the mammogram less uncomfortable and produce a better quality picture.                   
• Don’t wear antiperspirants or deodorants the day of the exam.  They can interfere with X-ray imaging.
• Tell the mammogram tech about any breast symptoms or issues you have at the time of the exam.
• Follow up by calling your doctor or facility if you do not hear from either within 10 days. Assume neither good nor bad news.

Finally, keep in mind that less than one-tenth of one percent of mammogram screenings lead to a cancer diagnosis. About 10 percent of women who have a mammogram will require further testing, but less than 10 percent of those will require a biopsy and about 80 percent of biopsies will not be cancer.           

Digital mammograms

A full-field digital mammogram (FFDM) is like a standard mammogram in that X-rays are used to produce an image of your breast. The differences are in the way the image is recorded, viewed by the doctor, and stored. To date, many mammogram centers are without the more costly digital mammography equipment. This should not deter women from getting their mammograms done as scheduled at a film-only facility.

Digital mammograms, according to some studies, may be more effective in catching cancers in women under 50 years of age and in those with dense breast tissue. If you are in one of those groups and believe that a film mammogram may not be accurate, you might consider having a digital mammogram. It’s essential that when looking for a digital mammogram imaging center, patients should seek out a mammography center that has an FDA-approval specifically for digital mammograms.

Magnetic resonance imaging

Magnetic resonance imaging (MRI) may be recommended along with an annual mammogram for women at high risk for breast cancer. MRIs use radio waves and magnets and can be viewed to examine areas identified by mammograms as suspicious. MRIs may be especially recommended for younger women at high risk because of a family history; their breast tissue is already denser, making mammograms less conclusive.

For optimal results, a contrast (gadolinium) is often injected into a small vein to enable breast tissue to be seen with far more clarity.

MRIs are very sensitive. In fact, they’re so sensitive that they are not recommended as a primary screening tool because too many results are false-positives, meaning more tests and unnecessary scares for women with average risks. But for some high-risk women, MRIs can be highly effective.

Not all MRI machines are appropriate for breast cancer studies. Make sure that any facility where you have one has a specially equipped breast MRI machine.

Breast ultrasound

Ultrasound uses sound waves to produce images of different body parts and organs. A transducer (a small, handheld, metal device) coated with ultrasound gel is placed over the skin and emits sound waves that bounce back to the device. This painless test produces computer images that can be studied on the monitor or in printouts.

Ultrasound is used mainly to further evaluate breast anomalies that are found during mammograms, not for primary screening. Some practitioners believe ultrasound may be helpful with interpreting mammograms of women who have particularly dense breast tissue.

Ultrasound can also be a valuable tool for imaging other kinds of breast masses, such as cysts or lipomas. Ultrasound is the only way to distinguish a cyst from a tumor without aspirating the breast, and it can also be useful as a complementary test to needle biopsies. While widely in use, safe, and relatively simple, the ultimate usefulness of an ultrasound may well depend on the operator’s experience and expertise.

Ductogram

A ductogram, or galactogram, can help diagnose the cause of nipple discharge. Most nipple discharges are the result of an injury, infection, or benign growth; these discharges can be red or brownish-red and possibly cancerous. If the discharge is milky or clear green, cancer is not likely.

In a ductogram, a microthin tube is placed into the end of the duct at the nipple. With the help of contrast material, an X-ray image is created that will show any growth inside the duct.

Lab Tests

Blood and tissue tests analyzed in medical labs can serve numerous purposes: determining genetic risk, diagnosing, assessing treatment options, or monitoring post-treatment. Here are the major lab tests for breast cancer:

Breast Cancer gene 1 (BRCA1) or Breast Cancer Gene 2 (BRCA2) gene mutation tests

Women at high risk because of family history or ovarian cancer can learn whether they have a BRCA mutation. BRCA genes are tumor suppressors, and if a mutation on one of these genes is found, the risk for breast cancer will increase up to 80 percent. Nonetheless, less than 10 percent of breast cancer cases occur in women with BRCA mutations.

Biopsy

Doctor Performing a Biopsy

This is a test in which a small bit of tissue is removed and studied under a microscope. Biopsies are virtually painless and rapid results can be obtained from a well-run lab. Changes in cells that can indicate that they are malignant include the size of cell nuclei and the increased division of cells, which pathologists can detect. The pathologist carefully records exactly how the cells appear abnormal as this information can help determine the treatment for the breast cancer. Three kinds of biopsies together form the gold standard for tissue evaluation:

• A fine-needle aspiration biopsy is used when the lump is solid. The doctor inserts a thin needle and retracts a tiny piece of tissue for study by the pathologist. In some cases, the doctor may want to aspirate a suspected cystic lump to confirm that there is no cancer in a cyst.
• A core needle biopsy involves using a larger needle and tube to extract a sample of tissue up to the size of a pen. The needle is guided by feel, mammography, or ultrasound. A computerized version that is gaining popularity for its accuracy is called stereotactic biopsy.
• A surgical (or “open”) biopsy is when a surgeon removes part (incisional biopsy) of all (excisional biopsy, wide local excision, or lumpectomy) of a lump for evaluation under a microscope. If the lump is small or hard to locate by touch, the surgeon may use a procedure called stereotactic wire localization to map out a route to the mass prior to the surgery.  

Cytology

If the biopsy establishes or confirms a breast cancer diagnosis, the doctor will order one or more tests on the cancer cells. These tests will provide a general prognosis for the patient and help the doctor develop a treatment plan. Two tests—on the Her-2/neu gene and estrogen/progesterone receptors—are particularly useful.

The Her-2/neu (Human Epidermal growth factor Receptor 2) oncogene tracks to a receptor for a growth factor that causes cells to proliferate. In up to 30 percent of invasive breast cancers, the Her-2/neu gene is amplified and its protein overexpressed. Such tumors are therefore quite susceptible to treatment by Herceptin (trastuzumab), a chemotherapeutic agent that specifically binds to the overproduced protein and limits tumor growth.

The status of estrogen and progesterone receptors provides another strong prognostic tool, as elevated levels of these hormones can promote growth of cancer cells in the breast. If you have estrogen or progesterone receptor positivity, you’re a better candidate for anti-hormone therapy, and women with hormone-receptor positive cancers usually have a better prognosis than women with cancers without these receptors.

Prognosis and monitoring tests

There are several blood and tissue tests that can be used to provide a prognosis or help assess ongoing status of the cancer patient. Oncotype DX and MammaPrint tests, for example, together measure up to 90 tumor genes and can be used in specific types of patients to determine the risk for recurrence, risk for metastatic cancer, and possible usefulness of certain chemotherapies or hormone therapy. DNA Ploidy and Ki-67 Antigen tests can measure the rate of tumor cell growth. The faster such growth, the worse the prognosis. Finally, CA15-3 and CA27.29 are blood tests that measure levels of cancer antigens expressed. These monitoring tests can indicate whether a recurrence has happened.