Breast Cancer:
Diagnosis and Staging

This page covers tests that are often used to help diagnose and stage breast cancer.
Depending on the symptoms you have, you may also be asked to undergo other tests and investigations.

“Cancer has shown me what family is. It showed me a love that I never knew really existed.” 

 Michael Douglas 

Diagnostic Tests to Determine Cancer Type

Once the doctor is sure of an abnormality, a biopsy is done to determine further details about the type of cancer present.

Biopsy

What to expect

Biopsy involves the removal of a sample of breast cells or tissues for laboratory testing and is the only definitive method to diagnose breast cancer. It is a way to evaluate a suspicious area or lump in your breast to determine whether it is cancerous.

In order to perform the biopsy, your doctor will ask you to remove the clothes from the top half of your body or undress completely. It is important that you choose a doctor and clinical team that you are comfortable with to perform your procedure. 

For a few days after the biopsy, your breast may feel sore and bruised. Wearing a supportive bra can help with this. Don’t hesitate to talk to your clinical team about pain medication if you feel you might need it. The pain and bruising will generally subside in a couple of weeks. If it persists, please contact your doctor immediately. 

There are three types of biopsies used for breast cancer:

Fine-needle aspiration (FNA) biopsy is a quick, simple test in which a thin needle is used to remove tissue or fluid for examination under a microscope.
Core biopsy which involves the removal of a tissue sample using a wide needle for examination under a microscope. This procedure is also called core needle biopsy. Before your doctor starts the procedure, he or she will typically inject a local anaesthetic into the area to numb it. You may feel a little pain or a sensation of pressure for a short time during the biopsy.
Excisional biopsy which involves the removal of an entire lump or a portion of the tissue from a suspicious area for diagnosis. The doctor will make a cut in the skin to remove the portion of tissue. You will usually be given a general anaesthetic (i.e. you will be asleep) during the procedure. There will be stitches on the affected area – once you heal, you may need to have them removed by your doctor or they may dissolve on their own.
HER2/neu Test

What to expect

The human epidermal growth factor type 2 receptor (HER2/neu) test is a type of blood test used to measure how many HER2/neu genes there are and how much HER2/neu protein is made in a sample of tissue. If more HER2/neu genes or higher levels of HER2/neu protein than normal is detected, the cancer is called HER2/neu positive. This type of breast cancer is predicted to grow more quickly and spread to other parts of the body.

Gene Expression Tests

What to expect

Gene testing is done to check for gene mutations if you have a strong family history of breast cancer. In order to identify the cancer further, tissue samples are taken to test for changes in the BRCA1 & BRCA2 genes. These samples are usually removed during the biopsy. If your test result shows the presence of BRCA1 or BRCA2 genes, your doctor may want to perform additional testing on your children, parents, siblings or other family members that share their genes with you in order to determine their risk of developing breast cancer.

Diagnostic Tests to Determine
Stage and Spread of Cancer

Chest X-Ray

What to expect

A chest X-ray is a type of imaging study and is generally painless. An image of the organs and bones is taken by projecting an energy beam through the body onto film. It is important that you choose a doctor and clinical team that you are comfortable with to perform your X-ray.

If you are pregnant or breastfeeding, be sure to inform your doctor before the X-ray.

During a chest X-ray:

You may be asked to change into a hospital gown and remove your jewellery, watch, body piercings or any other accessory that contains metal.

The X-ray technician will direct you to stand next to a “plate”, which may contain X-ray film or special sensors to record the images.

Next, the technician will tell you how to stand and instruct you to hold your breath while the images are taken. This ensures that the chest is completely still so the images are clear.

Images will be taken of both the front and side views of your chest.

After the images have been captured, you can change and put on your jewellery and any other accessories you may have removed.

The X-ray should take about 10-15 minutes.

Bone Scan

What to expect

A bone scan is a type of imaging study and is generally painless. During the scan, an image of the bones is taken. It is typically more sensitive than an X-ray. It is important that you choose a doctor and clinical team that you are comfortable with to perform scan.

You may be asked to refrain from eating or drinking for a few hours before your scan. Be sure to inform your doctor prior to your scan if

You are pregnant or breastfeeding

You have previously had an allergic
reaction to contrast material

You are taking any vitamins, ayurvedic
medicines or homeopathic medicines

During a bone scan:

You may be asked to change into a hospital gown and remove your jewellery, watch, body piercings or any other accessory that contains metal. You may also be asked to empty your bladder.

You may be given a special dye (called contrast material) which can help highlight the bones of your body. The dye is typically administered by injection through a vein in your arm. You may need to wait for a few hours for your body to absorb the dye. Your doctor may ask you to drink plenty of fluids while you wait.

Next, a nurse or technician will take you to the room which contains the bone scanner. You will be asked to lie on a narrow table. The nursing staff may use straps to keep you in position. You can ask for a pillow if you are feeling uncomfortable. You will be asked to remain still for the duration of the scan.

During the scan, a device that has a sensitive camera will pass back and forth over your body.

The technicians will be seated in a separate room, but they will be able to see and hear you. You may be asked to communicate with them via intercom. They may ask you to hold your breath at certain times to improve image quality.

The scan will usually take 30 minutes to an hour to complete.

After the scan, you may receive special instructions regarding the contrast material. For example, your technician or doctor may ask you to wait for a few minutes to ensure that you do not have an allergic reaction. You may also be told to drink plenty of fluids to help your kidneys flush out the contrast material through your urine.

CT Scan

What to expect

A CT (computerized tomography) scan is an imaging study and is generally painless. It uses X-rays to take multiple images of the body from different angles to recreate three-dimensional pictures of your internal organs on a computer. It is important that you choose a doctor and clinical team that you are comfortable with to perform your CT scan.

You may be asked to refrain from eating or drinking for a few hours before your scan. Be sure to inform your doctor prior to your scan if

You are pregnant or breastfeeding

You have any metal or electronic
devices implanted in your body (such
as a pacemaker or metal pins)

You are afraid of enclosed spaces
(claustrophobic)

You have previously had an allergic
reaction to contrast material

You are taking any vitamins, ayurvedic
medicines or homeopathic medicines

During a CT scan

You may be asked to change into a hospital gown and remove your jewellery, watch, body piercings or any other accessory that contains metal. You may also be asked to empty your bladder.

You may be given a special dye (called contrast material) which can help highlight the areas of your body that are being examined. The dye can be given to you by mouth (in a drink), by injection through a vein in your arm or by an enema in your rectum. You may need to wait for 30 minutes to an hour for your body to absorb the dye.

Next, a nurse or technician will take you to the room which contains the CT scanner. You will be asked to lie on a narrow, motorized table that will slide you into the machine. The nursing staff may use straps to keep you in position. You can ask for a pillow if you are feeling uncomfortable. You will be asked to remain still for the duration of the scan.

As the table moves you into the CT scanner, various detectors and X-ray tubes will rotate around you. Each rotation will produce several cross-section images of your body. You may hear some buzzing or whirring noises – try not to be alarmed and remember to stay still.

The technicians will be seated in a separate room, but they will be able to see and hear you. You may be asked to communicate with them via intercom. They may ask you to hold your breath at certain times to improve image quality.

The scan will usually take 20-30 minutes to complete.

After the scan, you may receive special instructions regarding the contrast material. For example, your technician or doctor may ask you to wait for a few minutes to ensure that you do not have an allergic reaction. You may also be told to drink plenty of fluids to help your kidneys to flush out the contrast material through your urine.

PET Scan

What to expect

PET (Positron emission tomography) scan is a process that uses radioactive glucose to detect malignant tumour cells in the body. Malignant tumour cells show up brighter in the picture because they are more active and take up more glucose than normal cells do. The scan is generally painless. It is important that you choose a doctor and clinical team that you are comfortable with to perform your PET scan. Some hospitals have a combined PET/CT scanner.

You may be asked to refrain from eating or drinking for a few hours before your scan. Be sure to inform your doctor prior to your scan if:

You are pregnant or breastfeeding

You have any metal or electronic
devices implanted in your body (such
as a pacemaker or metal pins)

You are afraid of enclosed spaces
(claustrophobic)

You have previously had an allergic
reaction to contrast material

You are taking any vitamins, ayurvedic
medicines or homeopathic medicines

During a PET scan:

You may be asked to change into a hospital gown and remove your jewellery, watch, body piercings or any other accessory that contains metal. You may also be asked to empty your bladder.

You may be given a special dye (called contrast material) which can help highlight the areas of your body that are being examined. The dye can be given to you by mouth (in a drink), by injection through a vein in your arm or by an enema in your rectum. You may need to wait for 30 minutes to an hour for your body to absorb the dye.

Next, a nurse or technician will take you to the room which contains the PET scanner. You will be asked to lie on a narrow, motorized table that will slide you into the scanner. The nursing staff may use straps to keep you in position. You can ask for a pillow if you are feeling uncomfortable. You will be asked to remain still for the duration of the scan.

As the table moves you into the PET scanner, the machine will begin to rotate around you. Each rotation will produce several cross-section images of your body. You may hear some buzzing or whirring noises – try not to be alarmed and remember to stay still.

The technicians will be seated in a separate room, but they will be able to see and hear you. You may be asked to communicate with them via intercom.

The scan will usually take about 30 minutes to an hour to complete.

After the scan, you may receive special instructions regarding the contrast material. For example, your technician or doctor may ask you to wait for a few minutes to ensure that you do not have an allergic reaction. You may also be told to drink plenty of fluids to help your kidneys to flush out the contrast material through your urine.

MRI Scan

What to expect

Magnetic resonance imaging (MRI) scan is a procedure in which an MRI scanner uses a high-powered magnet and a computer for comprehensive images of the internal organs and surrounding structures. MRI scans normally add supplementary information about anomalies in the stomach and may be recommended only in select cases. The scan is generally painless. It is important that you choose a doctor and clinical team that you are comfortable with to perform your MRI scan.

You may be asked to refrain from eating or drinking for a few hours before your scan. Be sure to inform your doctor prior to your scan if:

You are pregnant or breastfeeding

You have any metal or electronic
devices implanted in your body (such
as a pacemaker or metal pins)

You are afraid of enclosed spaces
(claustrophobic)

You have previously had an allergic
reaction to contrast material

You are taking any vitamins, ayurvedic
medicines or homeopathic medicines

During a MRI scan:

You may be asked to change into a hospital gown and remove your jewellery, watch, body piercings or any other accessory that contains metal. You may also be asked to empty your bladder.

You may be given a special dye (called contrast material) which can help highlight the areas of your body that are being examined. The dye is typically administered by injection through a vein in your arm. You may need to wait for 30 minutes to an hour for your body to absorb the dye.

Next, a nurse or technician will take you to the room which contains the MRI machine. You will be asked to lie on a narrow, motorized table that will slide you into the machine. The nursing staff may use straps to keep you in position. You can ask for a pillow if you are feeling uncomfortable. You will be asked to remain still for the duration of the scan.

As the table moves you into the MRI machine, the machine creates a strong magnetic field around you and radio waves are directed at your body. You may hear repetitive noises such as thumping or tapping – try not to be alarmed and remember to stay still. You can request earplugs or have music playing to help you block out the noise.

The technicians will be seated in a separate room, but they will be able to see and hear you. You may be asked to communicate with them via intercom.

The scan will usually take about 30 minutes to an hour to complete.

After the scan, you may receive special instructions regarding the contrast material. For example, your technician or doctor may ask you to wait for a few minutes to ensure that you do not have an allergic reaction. You may also be told to drink plenty of fluids to help your kidneys to flush out the contrast material through your urine.
How breast cancer is staged

The results of your diagnostic tests will help your doctor determine the size and position of the cancer, and whether it has spread. This is called staging. Knowing the stage and grade of your cancer will help your doctor plan the best course of treatment for you.

There are different systems for describing the stage of breast cancer.

THE TNM STAGING SYSTEM

The TNM staging system gives the complete stage of the cancer

T describes the size of the tumour.

N describes whether the cancer has spread to the lymph nodes and which nodes are involved. For example, N0 means no lymph nodes are affected. N1 means there are cancer cells in 1 to 3 of the lymph nodes.

M describes whether the cancer has spread to another part of the body. For example, M0 means the cancer has not spread (metastasised) to other parts of the body

Sometimes the final TNM staging may not be certain until surgery is completed, since the issue samples removed during the procedure will need to be analysed further.

THE NUMBER STAGING SYSTEM

Stomach cancer can also be divided into four number stages.

Stage I breast cancer is when the cancer is 2cm or smaller. There may be no cancer cells or a small number of cancer cells in the lymph nodes in the armpit. In some cases, the cancer cannot be found in the breast, but the cancer cells may have spread to lymph nodes in the armpit.

Stage II breast cancer is when the cancer is 2-5cm or bigger. It may or may not have spread to the lymph nodes under the arm. In some cases, the cancer cannot be found in the breast, but the cancer cells may have spread to lymph nodes in the armpit or the breast bone.

Stage III breast cancer is sometimes called locally advanced breast cancer. At this stage, the cancer has spread to the lymph nodes in the armpit and sometimes to other lymph nodes nearby. It may have spread to the skin of the breast or to the chest muscle. The skin may be red, swollen or have broken down. In some cases, the cancer cannot be found in the breast, but the cancer cells may have spread to lymph nodes or the breast bone.

Stage IV breast cancer is also called secondary or metastatic breast cancer. This is when the cancer has spread to other parts of the body, such as the bones, the liver or lungs.

GRADING

The grade of a cancer gives an idea of how slowly or quickly it might grow. The grade is based on how the cancer cells look under a microscope when they are compared with normal cells.

Grade 1 (low grade cancer)
The cancer cells look similar to normal cells (they are well differentiated). They usually grow slowly. These cancer cells are less likely to spread.

Grade 2 (moderate or intermediate-grade cancer)
The cancer cells look more abnormal and grow slightly faster than grade 1 cells.

Grade 3 (high-grade cancer)
The cancer cells look very different from normal cells (they are poorly differentiated). They may grow more quickly than grade 1 or 2 cells.

Treatment options for breast cancer

The decision about the best course of treatment is based on these test results and the type, stage, grade and size of your tumour. Treatments like surgery, chemotherapy, hormone therapy and radiation therapy are some of the options used for breast cancer. Refer to this section to understand the types of cancer treatments for breast cancer and possible side effects. Read more

Your cancer journey

Everyone deals with a breast cancer diagnosis and treatment in a different way. Refer to this section tounderstand various aspects of your cancer journey and the road to recovery. Read more
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