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, and to determine characteristics and possible spread of the disease.
These tests guide treatment plans and monitor their effectiveness. They also check for recurrences among long-term cancer survivors. It’s important to understand the various screening and diagnostic tests used in cancer detection and treatment. Talk to your doctor if you have any concerns.
Monthly breast self-exams are important in helping women more easily recognize if there are any changes in their breasts from month to month. It’s important to note that most early cancers of the breast cannot be detected by everyday look and feel.
Step 1: Positioning. It’s usually better to be on your back rather than standing for the feeling (palpation) 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 tissue. Use light pressure 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.
Your doctor, nurse, or physician assistant can provide further instruction perfect on 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. They will also palpate (touch) your breasts with the same circular three-finger motion that is recommended for a BSE.
In many cases, routine CBE is a good screening test option. However, for women over age 40, mammograms are usually recommended in addition to the CBE.
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. Mammograms alone cannot provide definitive proof that cancer is present.
Some women are concerned about the radiation used in mammograms. Modern equipment uses very little radiation in the tests. In fact, one mammogram gives off about the same ionizing 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 between the ages of 50 and 74. 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.
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 changes in your breast tissue such as the following:
Calcifications. These mineral deposits may be small (microcalcifications) or large (macrocalcifications). Macrocalcifications 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 benign 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 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 present.
The American Cancer Society provides the following 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’s 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. This 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.
- 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.
Keep in mind that less than one-tenth of one percent of standard mammograms led to a cancer diagnosis. According to Breastcancer.org, 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.
Magnetic Resonance Imaging
For women at high risk for breast cancer, magnetic resonance imaging (MRI) 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 often 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 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. However, for some high-risk women, MRIs are essential.
Ultrasound uses sound waves to produce images. A small, handheld metal device (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 can distinguish a cyst from a tumor without aspirating the breast, and is often less expensive than MRI or CT scanning. 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.
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.
Blood and tissue tests analyzed in medical labs can serve numerous purposes. They help to determine genetic risk, diagnose, assess treatment options, and monitor post-treatment. The following 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 of breast or ovarian cancer can learn whether they have a BRCA mutation. BRCA genes are tumor suppressors. According to Breastcancer.org, 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.
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 whether they are malignant. The pathologist carefully records anything abnormal as this information can help determine appropriate cancer treatment.
Three kinds of biopsies together form the gold standard for tissue evaluation:
- 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 examine a suspected cystic lump to confirm that there is no cancer in a cyst.
- 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.
- 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.
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. If the initial tumor had expressed these antigens, these monitoring tests can indicate whether the cancer has recurred.