Step Three: Get Evaluated
Doctors diagnose breast cancer by the "triple test": physical exam, imaging, and biopsy. If you're at a comprehensive center that does it all, plan to be there much of the day.
The Exam
The breast surgeon will manually examine all breast tissue and lymph nodes. You will be examined sitting up and lying down. If the doctor can't find the lump, move into the same position you were when you felt it.
Imaging: Mammogram and Breast Ultrasound
You may have one or more types of imaging (ultrasound, mammogram or, less frequently, MRI). Which one you have first depends mostly on your doctor's suspicions about the type of lump, and may also depend upon when your last mammogram was performed.
Mammography is the only breast cancer screening tool for the general population, though high-risk women are sometimes screened with MRIs as well. Digital mammography, which allows for better imaging in women with dense breasts, has begun to replace the familiar “film screen” mammography for screening.
A mammogram done for diagnostic purposes provides views that magnify or compress specific regions of the breast. This will likely be ordered if there is a mass or if your screening mammogram shows microcalcifications (tiny calcium deposits) and/or dense tissue.
Because tumors can be diagnosed only via biopsy, you probably won't get a definitive diagnosis immediately after imaging unless this is a feature offered by a comprehensive breast center.
Mammogram
* In addition to the two basic views of each breast, the technician will take additional images of the area where the lump was found. The technologist may press on the spot with a compression paddle and also magnify the area to see if it has irregular borders or if the density disappears with compression. The radiologist will also look for microcalcifications, which can be associated with cancer. (Note: Not all cancers produce microcalcifications and not all calcifications indicate cancer.)
* Results ready: Immediately to a few days
* A mammogram can confirm a discrete mass but not definitively diagnose a malignancy (that's why you'll need a biopsy), so the radiologist will write up a detailed summary and send a report to you and/or your doctor.
* Ask your doctor when you should expect results. To avoid waiting, request that they be given by phone or sent via e-mail.
* If your mammogram doesn't show a mass, don't be surprised if you're sent for an ultrasound. Up to 20 percent of breast cancers are not seen on mammography, but only a small number will elude both mammography and ultrasound. If you feel a mass and the mammogram and ultrasound are both read as normal, you still need to see a breast surgeon. There are some cancers that will not be detected by either test!
After imaging, you'll be referred for a biopsy which may be performed by either a breast surgeon or breast radiographer. It is important to see a surgeon to establish a relationship so that he or she can evaluate your breast before the area is changed from a biopsy.
Ultrasound
* To evaluate a palpable lump or to look for a density found on a mammogram. An ultrasound may be able to determine if a mass is a fluid-filled cyst or a solid.
* Results ready: Immediately to a few days
* If it's a fluid-filled cyst: Your doctor may suggest that nothing be done right away, because the cyst may deflate on its own through your next menstrual cycle. But if the cyst is large, it can be aspirated with a small needle. (If the fluid is green, it is usually discarded) (See "Biopsy," below.) If you leave the cyst alone, watch to see whether it enlarges over the next few weeks; if it does, request an aspiration to be sure it is a cyst. Many women prefer to have the cyst drained so that they do not have to feel it.
* If it's not a simple cyst aspiration, a biopsy will be required.
Cancer can be diagnosed only through an examination of tissue under a microscope, therefore every solid mass or complex cystic mass should be biopsied. Don't assume needing a biopsy means that you have cancer: More than 60 percent of biopsies in women over 40 turn out to be benign.
Time frame: Many breast centers can schedule your biopsy on the same day or the day after your imaging. A referral to a breast surgeon should occur prior to a biopsy so that your breasts can be examined before the biopsy occurs. This is particularly important if you are diagnosed with cancer so that you have an established relationship with this individual and do not have to go on the hunt for a doctor in a state of panic.
Your doctor will recommend one of the following:
Needle Aspiration
* If your doctor suspects your lump is a fluid-filled cyst or if it appears to be a complex cyst, a thin needle, often guided by ultrasound, is inserted and the fluid is removed. This may be repeated several times. No anesthesia is required.
* Results ready: Immediately to two days
* If the fluid is green, the lump is a harmless cyst. Because aspiration causes a cyst to collapse, your treatment is complete. If the fluid is bloody, it is sent to a pathologist.
This biopsy can sometimes diagnose cancer but cannot determine cancer type or other details that are important for treatment. If the cytology is positive or suspicious, you'll probably need an US guided vacuum assisted or core needle biopsy.
Minimally Invasive Image Guided Breast Biopsy (considered “best practices” by the 2009 Consensus Conference on Image Detected Breast Cancer) :
Core-Needle Biopsy
* Under local anesthesia, a narrow needle is inserted multiple times, extracting thin cores of tissue that are sent to a pathologist.
* Results ready: Within two days
Vacuum-Assisted Biopsy
* Your breast is anesthetized with a local anesthesia, then a biopsy device is inserted into the breast. By using ultrasound as a guide, the doctor is able to extract larger cores of tissue. A marker is inserted to serve as a guide back to that area if a cancer is found or to mark the area for the future mammograms. Many masses are no longer palpable after the biopsy. The scar is as tiny as with a core-needle biopsy, but doctors get a lot more tissue to analyze so they’re less likely to miss the cancerous part.
* Results ready: Within two or three days
* Vacuum-assisted biopsies can also be performed to evaluate microcalcifications found on mammography. They are done with stereotactic (computer) guidance with the patient lying face down on a special mammography table.
Excisional Biopsy
* Doctors sometimes need to remove the entire lump, especially if other biopsy results aren't consistent with your doctor's expectation. If an ultrasound was suspicious for a cancer and the results were benign, there's always the possibility a benign core biopsy simply missed the cancerous tissue. Excisional biopsies are also indicated for large benign masses, masses under the nipple, masses very near the skin surface and occasionally in women with breast implants. The procedure is usually performed in the operating room under IV sedation and local anesthesia. Occasionally special stains are required for the pathologist to make a correct diagnosis.
* Results ready: From one to two days to a week
