Screening and Testing
Breast cancer screening means checking a woman’s breasts for changes before any signs or symptoms of the breast cancer emerge. A woman’s age, genetic factors, any history of cancer in the family or multiple breast surgeries, and diet all contribute to breast cancer risk. The sooner breast cancer gets diagnosed, better are the chances of getting a successful treatment. Screening of breast is important, to be familiar with how your breasts usually feel and look, and to report any changes to your doctor as soon as you feel any change or symptom.
The first act of defence against cancer is self-examination. Chances of catching breast cancer in an early stage are much higher if you are conducting regular and timely self-breast exam.
- Do a breast self-exam (BSE): this should happen once a month, ideally after the age of 20
- Get a clinical breast exam (CBE): make sure you visit your breast surgeon or gynaecologist once a year after the age of 30
- Get a mammogram: Once in two years between the age 40-50 yrs, and once every year over the age of 50 yrs. For some women, the doctor may recommend yearly mammograms .A mammogram catches up to 80% of diseases.
When to do Breast Self-Examination (BSE)?
- Menstruating women- 5 to 7 days after the beginning of period
- Menopausal women- same date each month (just for ease of remembering)
- Pregnant women- same date each month (just for ease of remembering)
How to do Breast Self-Examination (BSE)?
Do the following (it takes just 10 minutes):
- Lie down and put your left arm under your head with a small towel or sheet kept under your left shoulder. Use your right hand to examine your left breast. With your three middle fingers kept flat, move them gently in small circular motions over the entire breast, and check for any lump, hard knot or thickening. Area to be covered is from the collar bone to lower side of breast and under arms. Now, repeat the examination on the other side.
- Look at your breasts while standing in front of a mirror with your hands on your hips. Bend a little forward and look for lumps, new differences in size & shape, discolouration, swelling, dimpling or thickening of the skin. If you have bigger breasts, then pull up the breast to check the skin underneath.
- Squeeze the nipple of each breast gently between your thumb and index finger to see if there is any discharge.
In case of doubt, it’s always better to go for a clinical test. Breast-cancer-related tests fall into one or more of the following categories:
- Screening tests: Screening tests are given routinely to people who appear to be healthy and are not suspected of having breast cancer. Their purpose is to find breast cancer early, before any symptoms can develop and the cancer usually is easier to treat.
- Diagnostic tests: Diagnostic tests are given to people who are suspected of having breast cancer, either because of symptoms they may be experiencing or a screening test result. These tests are used to determine whether breast cancer is present or not and, if yes, whether it has spread beyond the breast or not. Diagnostic tests also are used to gather more information about the cancer to guide decisions about treatment.
Types of Diagnostic Tests:
- Breast exam
- Breast ultrasound
- Removing a sample of breast cells for testing (Biopsy)
- Breast magnetic resonance imaging (MRI)
- Monitoring tests: After breast cancer is diagnosed, many tests are done during and after treatment to monitor how well therapies are working. Monitoring tests also may be used to check for any signs of recurrence.
Several tests and procedures help to confirm a diagnosis.
Clinical Breast Exam
The doctor will clinically check the breasts for lumps and other symptoms. During the examination, you may need to lie down or sit with your arms in different positions.
Several tests can help detect breast cancer.
Mammogram: A mammogram is an X-ray picture of the breast. In screenings for breast cancer, mammograms are routinely administered to detect breast cancer in women who have no apparent symptoms. Diagnostic mammograms are used after if suspicious results from some other investigation is received or a need is felt after clinical breast examination.
Mammograms are usually advised for ladies over the age of 40 years as breast tissue is usually dense before this age and mammograms may not be able to pick up changes in dense breasts. However, if there is a suspicion, a doctor may advise this screening in ladies even below the age of 40 years.
A doctor will usually follow any suspicious results with further testing.
Ultrasound: This scan uses sound waves to help a doctor differentiate between a solid mass and a fluid-filled cyst. This is usually advised for females under the age of 40 years. However, this is also done in ladies above that age.
MRI: Magnetic Resonance Imaging (MRI) combines different images of the breast to help a doctor identify cancer or other abnormalities. A doctor may recommend an MRI as a follow-up to a mammogram or ultrasound. Doctors sometimes use them as a screening tool for those at higher risk of breast cancer.
The above screenings however are not conclusive in diagnosing breast cancer. If the reports indicate suspicion, then usually the next step is either to get biopsy or FNAC done.
BIRADS stands for Breast Imaging Reporting and Data System, and is a scheme for putting the findings from mammogram screening (for breast cancer diagnosis) into a small number of well-defined categories. Although BIRADS started out for use with breast screening mammography, it was later adapted for use with Magnetic Resonance Imaging (MRI) and breast ultrasound (US) as well.
The BIRADS assessment categories are:
2- benign findings
3- probably benign
4- suspicious abnormality
5- highly suspicious of malignancy
6- known biopsy with proven malignancy
A breast biopsy is a test that removes tissue or sometimes fluid from the suspicious area. The removed cells are examined under a microscope and further tested to check for the presence of breast cancer.
Biopsies can be taken in different ways depending upon doctor’s advice:
Needle biopsy is the most common type of biopsy. A sample of tissue is taken from a lump in the breast using a large needle.
Your doctor may suggest that you have a guided needle biopsy, usually guided by ultrasound or mammogram, or sometimes MRI, to obtain a more precise and reliable diagnosis of cancer.
During vacuum-assisted biopsy, a needle is attached to a gentle suction tube, which helps to obtain the sample and clear any bleeding from the area.
Breast Fine Needle Aspiration (FNA)
Needle aspiration may be used to test a sample of your breast cells for cancer or drain a small fluid-filled lump (benign cyst). Doctor will use a small needle to extract a sample of cells, without removing any tissue.
Cancer cells are given a grade when they are removed from the breast and checked in the lab. The grade is based on how much the cancer cells look like normal cells. The grade is used to help predict your outcome (prognosis) and to help figure out what treatments might work best.
A lower grade number (1) usually means the cancer is slower-growing and less likely to spread.
A higher number (3) means a faster-growing cancer that’s more likely to spread.
Hormone receptor status
Breast cancer cells taken out during a biopsy or surgery will be tested to see if they have certain proteins that are estrogen or progesterone receptors. When the hormones estrogen and progesterone attach to these receptors, they fuel growth of cancers. Cancers are called hormone receptor-positive or hormone receptor-negative based on whether they have these receptors (proteins).
Breast cancer cells may have one, both, or none of these receptors.
ER-positive: Breast cancers that have estrogen receptors are called ER-positive (or ER+) cancers.
PR-positive: Breast cancers with progesterone receptors are called PR-positive (or PR+) cancers.
Hormone receptor-positive: If the cancer cell has one or both of the receptors above, it’s known as hormone-receptive positive (also called hormone-positive or HR+).
Hormone receptor-negative: If the cancer cell has neither the estrogen nor the progesterone receptor, it’s called hormone-receptor negative (also called hormone-negative or HR-).
HER2 (human epidermal growth factor receptor 2) is a gene that can play a role in the development of breast cancer. Your pathology report should include information about HER2 status, which tells you whether HER2 is playing a role in the cancer. Breast cancers with HER2 gene amplification or HER2 protein overexpression are called HER2-positive in the pathology report. HER2-positive breast cancers tend to grow faster and are more likely to spread and come back compared to HER2-negative breast cancers. But there are medicines specifically for HER2-positive breast cancers.
BRCA1 & BRCA2
BRCA stands for BReast CAncer which is usually classified into Breast cancer Type 1 and Type 2. There are two genes, namely, BRCA1 and BRAC2 which are found in every normal individual. The proteins produced by BRCA1 and BRCA2 ensure stability of cell’s genetic material. Mutation in BRCA1 and BRCA2 makes the cells likely to develop additional genetic changes that can lead to breast cancer.
People who have inherited mutations in BRCA1 and BRCA2 tend to develop breast and ovarian cancers at younger ages than people who do not have these mutations and have nearly 50-80% chances of developing breast or ovarian cancers. These tests may be performed if the doctor, after taking a thorough family history and risk assessment, considers it highly likely that the individual is carrying the mutation.
If an individual is found to have this genetic mutation, she and her family members may be advised to go for preventive surgeries like removal of both breasts and ovaries or preventive hormonal medications or be kept under close observation with repeated regular imaging tests.
Further tests for breast cancer
If a diagnosis of breast cancer is confirmed, more tests will be needed to determine the stage and grade of the cancer, and the best method of treatment.
Scans and X-rays
A CT scan, chest X-ray and liver ultrasound scan may be needed to check whether the cancer has spread. Usually doctors ask to get a CT scan of the chest and abdomen CT scan. An MRI of the breast is recommended for very small lumps in the breast or if the mammogram is not conclusive. If doctor thinks the cancer could have spread to your bones, you may also need a bone scan. A PET scan is not mandatory and may be considered in special situations.
Prognosis for Breast Cancer
A prognosis is the doctor’s best estimate of how cancer will affect someone and how it will respond to treatment. Prognosis and survival depends on many factors. Only a doctor familiar with your medical history, type, stage and characteristics of your cancer, the treatments chosen and the response to treatment can put all the information together with survival statistics to arrive at a prognosis. Doctors use different prognostic factors for newly diagnosed and recurrent breast cancers.
The following are prognostic for breast cancer when it is first found and diagnosed:
The stage is the main prognostic factor for breast cancer. There is less risk of early stage breast cancer to come back (recur) so it has a more favourable prognosis. Breast cancer diagnosed at a later stage has a greater risk of recurrence, so it has a less favourable prognosis.
Cancer spreading to lymph nodes
Breast cancer that has spread to lymph nodes has a higher risk of coming back and a less favourable prognosis than breast cancer that has not spread to the lymph nodes.
The tumour size will affect prognosis no matter how many lymph nodes have cancer in them.
Low-grade tumours have a better prognosis because they grow slower and are less likely to spread than high-grade tumours.
Hormone receptor status
Hormone receptor–positive tumours usually have a good prognosis. They are often less aggressive, are lower grade and have a lower risk of spreading.
HER2-positive breast cancer is more aggressive and more likely to spread than HER2-negative breast cancer. They are also more likely to come back after treatment.
Age at diagnosis
Women younger than 35 years of age tend to be diagnosed with more aggressive, higher grade tumours. Their breast cancer is often more advanced at the time of diagnosis.
Length of time before the cancer recurs
The longer the period of time before breast cancer comes back, the better the prognosis. Women whose breast cancer comes back more than 5 years after their diagnosis usually have a better outcome than those who have a recurrence less than 2 years after diagnosis.
Where the cancer recurs
Cancer that comes back in the breast (called a local recurrence) after a lumpectomy and radiation therapy has a more favourable prognosis than cancer that comes back in other organs (called distant recurrence, or distant metastasis).
The common sites for distant metastasis are the bones, lung, liver or brain.