Diagnosis

If you have a symptom or screening test result that suggests cancer, your doctor must find out whether it is due to cancer or to some other cause. Your doctor may ask about your personal and family medical history. You may have a physical exam. Your doctor also may order a mammogram or other imaging procedure. These tests make pictures of tissues inside the breast. After the tests, your doctor may decide no other exams are needed. Your doctor may suggest that you have a follow-up exam later on. Or you may need to have a biopsy to look for cancer cells.

Clinical Breast Exam

Your health care provider feels each breast for lumps and looks for other problems. If you have a lump, your doctor will feel its size, shape, and texture. Your doctor will also check to see if it moves easily. Benign lumps often feel different from cancerous ones. Lumps that are soft, smooth, round, and movable are likely to be benign. A hard, oddly shaped lump that feels firmly attached within the breast is more likely to be cancer.

Diagnostic Mammogram

Diagnostic mammograms are x-ray pictures of the breast. They take clearer, more detailed images of areas that look abnormal on a screening mammogram. Doctors use them to learn more about unusual breast changes, such as a lump, pain, thickening, nipple discharge, or change in breast size or shape. Diagnostic mammograms may focus on a specific area of the breast. They may involve special techniques and more views than screening mammograms.

Ultrasound

An ultrasound device sends out sound waves that people cannot hear. The waves bounce off tissues. A computer uses the echoes to create a picture. Your doctor can view these pictures on a monitor. The pictures may show whether a lump is solid or filled with fluid. A cyst is a fluid-filled sac. Cysts are not cancer. But a solid mass may be cancer. After the test, your doctor can store the pictures on video or print them out. This exam may be used along with a mammogram.

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) uses a powerful magnet linked to a computer. MRI makes detailed pictures of breast tissue. Your doctor can view these pictures on a monitor or print them on film. MRI may be used along with a mammogram.

Biopsy

Your doctor may refer you to a surgeon or breast disease specialist for a biopsy. Fluid or tissue is removed from your breast to help find out if there is cancer.

Some suspicious areas can be seen on a mammogram but cannot be felt during a clinical breast exam. Doctors can use imaging procedures to help see the area and remove tissue. Such procedures include ultrasound-guided, needle-localized, or stereotactic biopsy.

Doctors can remove tissue from the breast in different ways:

• Fine-needle aspiration: Your doctor uses a thin needle to remove fluid from a breast lump. If the fluid appears to contain cells, a pathologist at a lab checks them for cancer with a microscope. If the fluid is clear, it may not need to be checked by a lab.
• Core biopsy: Your doctor uses a thick needle to remove breast tissue. A pathologist checks for cancer cells. This procedure is also called a needle biopsy.
• Surgical biopsy: Your surgeon removes a sample of tissue. A pathologist checks the tissue for cancer cells.
• An incisional biopsy takes a sample of a lump or abnormal area.
• An excisional biopsy takes the entire lump or area.

If cancer cells are found, the pathologist can tell what kind of cancer it is. The most common type of breast cancer is ductal carcinoma. Abnormal cells are found in the lining of the ducts. Lobular carcinoma is another type. Abnormal cells are found in the lobules.

Additional Tests

If you are diagnosed with cancer, your doctor may order special lab tests on the breast tissue that was removed. These tests help your doctor learn more about the cancer and plan treatment:

• Hormone receptor test: This test shows whether the tissue has certain hormone receptors. Tissue with these receptors needs hormones (estrogen or progesterone) to grow.
• HER2 test: This test shows whether the tissue has a protein called human epidermal growth factor receptor-2 (HER2) or the HER2/neu gene. Having too much protein or too many copies of the gene in the tissue may increase the chance that the breast cancer will come back after treatment.

Staging

To plan your treatment, your doctor needs to know the extent (stage) of the disease. The stage is based on the size of the tumor and whether the cancer has spread. Staging may involve x-rays and lab tests. These tests can show whether the cancer has spread and, if so, to what parts of your body. When breast cancer spreads, cancer cells are often found in lymph nodes under the arm (axillary lymph nodes). The stage often is not known until after surgery to remove the tumor in your breast and the lymph nodes under your arm.

These are the stages of breast cancer:

• Stage 0 is carcinoma in situ.
• Lobular carcinoma in situ (LCIS): Abnormal cells are in the lining of a lobule. (See picture of lobule on page 3.) LCIS seldom becomes invasive cancer. However, having LCIS in one breast increases the risk of cancer for both breasts.
• Ductal carcinoma in situ (DCIS): Abnormal cells are in the lining of a duct. DCIS is also called intraductal carcinoma. The abnormal cells have not spread outside the duct. They have not invaded the nearby breast tissue. DCIS sometimes becomes invasive cancer if not treated.

• Stage I is an early stage of invasive breast cancer. The tumor is no more than 2 centimeters (three-quarters of an inch) across. Cancer cells have not spread beyond the breast.

• Stage II is one of the following:
• The tumor is no more than 2 centimeters (three-quarters of an inch) across. The cancer has spread to the lymph nodes under the arm.
• The tumor is between 2 and 5 centimeters (three-quarters of an inch to 2 inches). The cancer has not spread to the lymph nodes under the arm.
• The tumor is between 2 and 5 centimeters (three-quarters of an inch to 2 inches). The cancer has spread to the lymph nodes under the arm
• The tumor is larger than 5 centimeters (2 inches). The cancer has not spread to the lymph nodes under the arm.

• Stage III is locally advanced cancer. It is divided into Stage IIIA, IIIB, and IIIC.
• Stage IIIA is one of the following:
• The tumor is no more than 5 centimeters (2 inches) across. The cancer has spread to underarm lymph nodes that are attached to each other or to other structures. Or the cancer may have spread to lymph nodes behind the breastbone.
• The tumor is more than 5 centimeters across. The cancer has spread to underarm lymph nodes that are either alone or attached to each other or to other structures. Or the cancer may have spread to lymph nodes behind the breastbone.

• Stage IIIB is a tumor of any size that has grown into the chest wall or the skin of the breast. It may be associated with swelling of the breast or with nodules (lumps) in the breast skin.
• The cancer may have spread to lymph nodes under the arm.
• The cancer may have spread to underarm lymph nodes that are attached to each other or other structures. Or the cancer may have spread to lymph nodes behind the breastbone.
• Inflammatory breast cancer is a rare type of breast cancer. The breast looks red and swollen because cancer cells block the lymph vessels in the skin of the breast. When a doctor diagnoses inflammatory breast cancer, it is at least Stage IIIB, but it could be more advanced.

• Stage IIIC is a tumor of any size. It has spread in one of the following ways:
• The cancer has spread to the lymph nodes behind the breastbone and under the arm.
• The cancer has spread to the lymph nodes above or below the collarbone.

• Stage IV is distant metastatic cancer. The cancer has spread to other parts of the body.
• Recurrent cancer is cancer that has come back (recurred) after a period of time when it could not be detected. It may recur locally in the breast or chest wall. Or it may recur in any other part of the body, such as the bone, liver, or lungs