Tests and Screening

Breast cancer testing plays a key role in addressing the many aspects of the disease. There are tests to determine genetic risks, to detect cancer at an early stage, to determine characteristics and possible spread of the disease. These tests guide treatment plans and monitor their effectiveness. And they check for recurrences among long-term cancer survivors. Below are various tests and screenings used in cancer detection and treatment.

Breast Self-Exam (BSE)

Monthly breast self-exams are important so women can more easily recognize if there are any changes in their breasts from month to month. Although it is important to note 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 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)

Your doctor, nurse, or physician assistant can provide further instruction perfect on how how to perform a BSE if you don’t 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, etc. 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 in addition to the CBE.

SCREENINGS

Mammograms

A mammogram, or breast X-ray, can be used to screen for breast cancer in women who may or may not have signs of the disease.  This test can reveal breast irregularities that are too small to be felt with a manual exam. 

Some women are concerned about the radiation used in mammograms. But modern equipment uses very little radiation in the tests. In fact, one mammogram gives off about the same radiation that an airline passenger would receive on a cross-country flight. 

Regular screening mammograms every two years are commonly prescribed for an additional measure of detection for women aged 50 to 74 years. A mammogram every two years (or the frequency recommended by your doctor) can reveal any changes over time. Women who have a higher-than-average risk of breast cancer may be advised to have a mammogram before age 40, and annually after that.

Mammograms can be especially useful is a woman is breast feeding or has breast implants, although special care must be taken to get an accurate image through the denser 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.

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. These 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 suspected and a biopsy will be ordered.
  • Masses. These can be non-cancerous cysts or solid tumors (fibroadenomas). Or they could be cancerous tumors that may or may not be accompanied by calcifications. Cysts, 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 will usually be biopsied. The size, shape, and edges of a mass may help a radiologist determine if 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 and studied under a microscope. 

There is some disagreement over how often women should have mammograms. In late 2009, the U.S. Preventive Services Task Force suggested that only women over age 50 needed mammograms, and only every other year. This news caused some controversy. However, the most recent guidelines suggest is any woman over age 40 have an annual mammogram.

The resulting debate has once more placed the final decision on mammogram screening in the hands of the patient and her 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.

Keep in mind that less than one-tenth of one percent of standard mammograms led to a cancer diagnosis. About 10 percent of women who have a mammogram will require further testing. And less than 10 percent of those will require a biopsy and about 80 percent of those biopsies will not show 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

For women at high risk for breast cancer, an MRI (magnetic resonance imaging) may be used along with a standard mammogram. MRIs use radio waves and magnets to study areas that the mammogram flagged as unusual. MRIs may be especially useful for younger women at high risk because of a family history of cancer. If their breast tissue is already dense, standard mammograms are not very effective.

With an MRI, a contrast dye (gadolinium) is often injected into a small vein to help breast tissue be seen more clearly.

MRIs are very sensitive. In fact, they are so sensitive that they are not recommended as a primary screening tool. They can result in false positives, meaning more tests and unnecessary scares for women with average risks. But for some high-risk women, MRIs are essential.

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. A small, handheld metal device, called a transducer, is coated with ultrasound gel and moved around over the breast. The transducer 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 mainly used to study anything found during a mammogram.  Ultrasounds are not for primary screening. Some doctors find ultrasounds help with reading mammograms of women with dense breast tissue.

Ultrasound can also be a valuable tool for examining breast cysts or lymphomas. Ultrasound is the only way to distinguish a cyst from a tumor without aspirating the breast.  It can also be useful as a companion test for needle biopsies. Ultrasound is widely used and very safe, but it is only truly useful in the hands of an experienced technician.

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. When these discharges are red or brownish-red they might be cancerous. If the discharge is milky or clear green, cancer is unlikely.

In a ductogram, a micro thin 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

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, such as the size of the nuclei or speed of cell division, can indicate they are malignant. The pathologist carefully records anything abnormal as this information can help determine the cancer treatment.

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 will be. Finally, CA15-3 and CA27.29 are blood tests that measure levels of cancer antigens expressed. These monitoring tests can indicate whether the cancer has recurred.