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Breast Cancer Diagnosis

Is your head swimming with the names of tests? What is involved? What are they testing for? Try to move one step at a time. Here is an overview of diagnostic tests you will probably either have to have, or will hear about.

Biopsy

Why it is done: A breast biopsy is done to take a small sample of your breast tissue. This is then sent to the laboratory. In this sample, doctors will look for abnormal cells. A breast biopsy is thought to be the first and best way to tell if there is cancer in your breast. There are several types of biopsies: fine needle aspiration, needle biopsy, incisional and excisional. A breast biopsy will help your doctor know whether your need surgery or treatment.

What you should know: The recovery time for non-surgical biopsies is relatively short. You will be bandaged and need an ice pack to reduce swelling. It's also recommended that you take a non-aspirin pain reliever with acetaminophen (like Tylenol). After taking it easy for a day, you should be able to return to your normal activities the next day. Recovery is a little different for surgical procedures, like incisional and excisional.

BRCA Gene Test

Why it is done: Two genes for breast cancer have been identified: BRCA1 and BRCA2. Women who have inherited mutations in these genes have a higher risk of developing either breast or ovarian cancer. A simple blood test uses DNA analysis to identify mutations (changes) in either of these genes. Your doctor may recommend this kind of testing if you have a family history of breast or ovarian cancer. This test is not routine.

Breast Cancer Core Needle Biopsy

Why it is done: A core needle biopsy is performed to analyze a lump. Usually it is a lump that shows up on a mammogram. The doctor uses a hollow needle that is not quite as thin as the one used for fine needle aspiration. The purpose of this test is to remove samples that are tiny—about the size of a grain of rice. These samples will be analyzed to look for features that show the presence of cancer.

Core needle biopsies can be guided either by ultrasound (ultrasound-guided core needle biopsy), MRI (MRI-guided core needle biopsy), or mammogram (stereotactic biopsy).

CT Scan

Why it is done: CT stands for computerized tomography. This type of diagnostic test takes X- ray views from different angles. This allows your doctor to see 3D views of the mass and tissues in your breast and other parts of the body. CT scans are done both in hospitals and outpatient settings. They only take a few minutes and are not painful at all. You will be slid into a donut shaped structure and have to lie very still. Most patients say the worst thing is feeling a bit claustrophobic in the machine. CT scans are commonly called CAT scans.

Estrogen Receptor Test

Why it is done: This test is done from the sample of breast tissue collected to find out if the cancer cells in your breast have estrogen receptors. The outcome of the test can be that the cells are either estrogen receptor-negative (ER-) or estrogen receptor-positive (ER+). If they are ER+ they may respond well to therapies that deprive them of estrogen.

Fine Needle Aspiration Biopsy

Why it is done: Fine needle biopsy is the simplest kind of biopsy. It is used to assess a lump in your breast. You will be asked to lie on a table, and the doctor will inject a very fine needle into the lump. This allows cells or fluid to be collected from the lump. Your doctor will then be able to determine whether the lump is a fluid-filled cyst or a solid mass.

Lymph Node Dissection

Why it is done: The purpose of this procedure is to see whether the cancer cells have spread to your lymph nodes. In this procedure, you will be given general anesthesia. The surgeon will make a two to three inch incision under your arm. Lymph nodes will be removed and sent to a pathologist who will examine them for signs of cancer. It can take a few days to get the report back.

What you should know: You may experience numbness in the back of the arm or the armpit. This is usually temporary. You might also experience weakness, lymphedema (swelling), tingling, or stiffness.

Mammogram/mammography

Why it is done: Traditionally, health care professionals have recommended that annual mammograms be done beginning at age 40—or earlier if there is a family history of breast cancer. A mammogram is an X-ray image of your breast. It does not hurt but may feel uncomfortable. In a mammogram, the technician presses your breasts between two firm surfaces. This spreads out the breast tissue and allows the X-ray machine to get good pictures of your breasts. Your doctor will use these pictures to check for changes in your breast tissue and also to check for cancer. Mammograms are also done once a lump is detected—to show a more detailed picture of the mass.

A new advancement in mammography is breast tomosynthesis, which creates a three- dimensional (3D) image of the breast. Tomosynthesis can be done along with a traditional digital mammogram, but it is not a replacement.

MRI

Why is it done: Magnetic resonance imaging (MRI) can be used to learn more about breast lumps or swollen lymph nodes that did not show up on a normal mammogram. MRIs are similar to CT scans. An MRI scan provides detailed pictures like CT scans. The difference is that MRI scans use radio waves and strong magnets instead of X-rays. The energy from the radio waves produces patterns. A computer takes these and turns them into detailed images of specific parts of your body.

What you should know: An MRI takes up to an hour. You may be placed inside a narrow tube. This can feel confining. There are newer, open MRI machines (not a tube) in many hospitals and clinics around the country.

PET Scan

Why it is done: PET stands for positron emission tomography. A PET scan uses a small amount of radioactive materials to get a picture of your tissues and organs. The radioactive material is injected. A PET scan is not used to diagnose breast cancer. Rather, it is used to assess whether the cancer has spread to your lymph nodes or other parts of your body. It can also determine whether treatment is working on breast cancer that has metastasized.

What you should know: There will be a cold sensation as the radioactive material moves up your arm. You will have to lie very still, and the test will be conducted in the same donut-shaped mechanism as a CT scan. Many people feel claustrophobic during CT or PET scans, but there is no pain involved in either test.

Progesterone Receptor Test

Why it is done: This blood test is done to find out if the cancer cells in your breast have progesterone receptors. The outcome of the test can be that the cells are either progesterone receptor negative (PR-) or progesterone receptor positive (PR+). If they are PR+ they may respond well to therapies that deprive them of progesterone.

Ultrasound for Breast Cancer

Why it is done: An ultrasound test uses high-frequency sound ways to create very precise images of masses in your body. In the procedure, you will lie on an examination table. The technician will first apply some gel to the outside of your breast. Then the technician will run a small hand-held device over the skin. The images will be transmitted onto a computer screen.

Surgical Biopsy

Why it is done: There are two types of surgical biopsies:

  • Incisional: A part of the mass in your breast is removed and sent for analysis.
  • Excisional: The entire mass in your breast is removed and studied. This is also called a wide local excision or lumpectomy.

Both types of surgical biopsies are routinely done in an operating room. You will most likely be sedated. You will also be given a local anesthetic to prevent pain.

What you should know: If the mass in your breast can't be felt, the radiologist may use a wire to direct the path to the mass for the surgeon. This is called wire localization. In this procedure, the tip of a very thin wire is placed within the tumor. Usually this is performed immediately before surgery.

Once the surgeon has removed either the entire mass or a sample, the tissue will be immediately sent to the hospital laboratory. The radiologist will check the edges of the tumor. These are called the margins. Ideally, all margins are clear. This outcome is called negative margins and means that all the cancer has most likely been removed. If the laboratory finds cancer cells in the margins (positive margins), then cancer is probably still in the breast. In this case, more tissue needs to be removed.

When your breast biopsy is done, your surgeon may place a very small stainless steel marker in your breast right at the site of the biopsy. This helps your doctor easily find the area that was biopsied. This helps your doctor monitor you; it also helps the surgeon should another procedure be needed.

Understanding Lymph and Lymph Nodes

Lymph fluid is a clear liquid that flows through your body and to many tissues of the body. It circulates plasma like fluid in your tissues to clean them and transports white blood cells and other immune cells in this fluid. Lymph fluid is taken away through your body's lymph system and eventually drains back towards the heart.

Your lymph nodes are the filters for the lymph fluid and immune cells in this system. They are designed to filter out bacteria, viruses, as well as cancer cells that have metastasized in order to prevent illness.

You can see how lymph nodes affect every part of your body. That's why it is very important to find out if the breast cancer has spread to them.

There are two types of lymph node biopsies used with breast cancer: sentinel lymph node biopsy and axillary lymph node dissection.

Sentinel Lymph Node Biopsy

A sentinel is defined as a watchdog or guard. The sentinel lymph node is the very first lymph node in your breast. In the treatment called sentinel lymph node dissection, the surgeon looks for this sentinel lymph node.

Here's how the procedure works. A dye and/or radioactive substance is injected close to the nipple making the procedure uncomfortable. This substance goes into your lymph nodes. Your surgeon identifies the first lymph node that the dye reaches as the sentinel lymph node. This is the first node that cancer cells might spread to after the breast. There can be more than one sentinel node. Once your surgeon identifies your sentinel node or nodes, they will be removed and checked for cancer.

This procedure is called sentinel node biopsy.

The advantage to sentinel node biopsy is that the surgeon does not have to remove 10 or more lymph nodes and analyze all of them for cancer. Instead, the focus can be on the node(s) that are most likely to be cancerous. If they are clean, chances are good that other nodes have not been affected. Removal of 10 or more lymph nodes is considered a sentinel node dissection,

Who should have this procedure?

This procedure is recommended for women who have relatively small breast cancers (no more than 2 centimeters) and who have lymph nodes that don't feel abnormal before surgery. Sentinel node biopsy is not advised for:

  • Anyone likely to have cancer in the lymph nodes.
  • Women with previous surgery or treatment that could have changed the lymph drainage system.
  • Women who have had chemotherapy before surgery to shrink the size of a large tumor or to treat many lymph nodes.

What to Expect

Prior to surgery, the radiologist will inject a radioactive liquid or a blue dye or both into the area around your areola. Then the surgeon watches to see where the dye travels and concentrates. This will be the sentinel node. Once the sentinel node and a couple of nodes close to it are removed, your surgeon will examine them for cancer. Then they are sent on to pathology to be examined under a microscope.

If the sentinel mode does not show any cancer, then most likely the other lymph nodes are clean as well, and the cancer has probably not spread. If the sentinel node does show cancer, you may require additional treatment like:

  • Removing more nodes for evaluation during the same procedure
  • A second procedure to remove more nodes
  • Radiation of the surrounding lymph nodes.

Axillary Lymph Node Dissection

Your underarm is known as the “axilla” area. There are 3 general levels of axillary lymph nodes:

  • Level I: the bottom level located beneath the lower edge of your pectoralis muscle—part of the chest muscles.
  • Level II: located underneath the pectoralis muscle.
  • Level III: located above the pectoralis muscle.

An axillary lymph node dissection is a surgery that typically removes the lymph nodes in levels I and II. If you have invasive breast cancer, this procedure will frequently go together with a mastectomy. It can also be done at the same time as a lumpectomy. In some cases, it can be as a separate surgery after a lumpectomy and with a separate incision.

Your surgeon will typically remove several lymph nodes, often between 5 and 30 lymph nodes during this procedure. These lymph nodes will be analyzed for the presence of cancer. Your doctor will let you know if any lymph nodes show cancer (and, if so, how many). The total number of lymph nodes showing cancer is important.

Keep in mind that:

  • Your surgeon will probably remove any lymph nodes that feel or look cancerous.
  • Each woman has a different number of lymph nodes located under her arm. Some women may have fewer than 10 and some may have 30 or more.

What to Expect

The actual lymph node surgery takes approximately one hour. You will have a 2-3 inch incision in the skin crease under your arm. You will be given general anesthesia. If you are having a modified radical mastectomy, the lymph node surgery will take place at the same time. In the case of a lumpectomy surgery, the lymph node dissection surgery may happen at the same time or as a separate procedure scheduled at another time.

Once the lymph nodes are removed, the pathologist examines them under the microscope for signs of cancer. It can take days before the pathologist's report is available. This is because the pathologist has to carefully analyze the piece of fatty tissue taken from under the arm in order to find all the lymph nodes and test them.

Understanding the Risks

When you have an axillary lymph node surgery, you may encounter:

  • Decreased feeling or numbness in the back of your arm or armpit. This is because sometimes the nerve is damaged, cut or stretched during surgery.
  • Numbness, weakness, stiffness, tingling or lymphedema on the surgery side is common. Physical therapy and exercise can reduce the chances of these occurring.
  • Inflammation of the veins in your arm on the side of the surgery. This is treated with ice and sometimes mild anti-inflammatory medicines like Tylenol to reduce the inflammation.
  • Risk of infection in the surgical area. Your doctor will tell you what signs of infection to look for such as redness, drainage, or fever The infection usually responds well to treatment with medicines.

Benefits and Drawbacks

Any lymph node surgery can cause side-effects like numbness and discomfort. For this reason, the fewer lymph nodes removed the better. However, many doctors favor the traditional lymph node approach instead of the sentinel node biopsy. With the traditional approach, there isn't the chance of having to go back in again if the sentinel node shows cancer.

If you've been diagnosed with breast cancer, it's important to explore all options related to breast cancer treatment.

Finding an Oncologist

The first step on the breast cancer treatment journey is to find an oncologist (medical or surgical) who inspires trust. It may seem overwhelming to choose an oncologist. First, start with referrals from your primary care physician, specialist, or insurance carrier. Talk to family and friends who may have recommendations.

Here are some things to consider when choosing an oncologist:

  • Is the oncologist board certified?
  • How much experience does he or she have in treating breast cancer?
  • Do you feel comfortable talking with this doctor? Does he or she listen well?
  • Is the staff compassionate? Is the environment a good one or do you feel rushed?
  • What hospital(s) does this oncologist see patients in?
  • What are the office hours?
  • What if you have an emergency? Can you call?
  • Can this doctor be contacted after hours?

You will be spending a lot of time with the oncologist and staff nurses and technicians, so it's important to feel comfortable with them.

As you and your doctor explore the treatment options open to you, make sure you find out the answers to the following:

  • What are the chances my cancer will come back after this treatment?
  • What do we do if the cancer comes back or the treatment doesn't work?
  • Will I lose my hair?
  • Will it hurt?
  • Will there be scars?

I found a lump. What questions should I ask?

  • What else could cause a lump besides cancer?
  • How common are lumps in the breast?
  • What kind of test do I need? A mammogram or ultrasound? What's the difference?
  • Will I definitely know something once I get further testing? Can the test be inconclusive?
  • What is an MRI?
  • I've heard that a lump can be aspirate What does this involve? Who does this?

The diagnosis is breast cancer. What questions should I ask?

  • What kind of breast cancer do I have? What stage is it?
  • How big is the tumor?
  • Has the cancer spread to my lymph nodes or other parts of my body? If so, what affect does that have on my treatment options?
  • What kinds of tests will be done on the tumor?
  • How will these tests determine my options for treatment?
  • Who is in charge of my care now?
  • What do you recommend for treatment?

I'm supposed to have a biopsy. What do I need to know?

  • Where will I have the biopsy done? Will the whole lump be removed or just part?
  • Can the lump be aspirated?
  • How long does the procedure take?
  • Will the procedure be done outpatient? Will I be awake, and will I feel anything?
  • Should I take my regular medications before the biopsy?
  • Will the biopsy leave a scar?
  • What is the recovery like from a biopsy? Will I be sore?
  • When will I be able to resume my normal activities?
  • After the biopsy, how long will it be before I know the results?
  • If the biopsy shows cancer, who will recommend the treatment?

The diagnosis is cancer. What questions do I ask about treatment options?

  • Will I need chemotherapy?
  • Is it possible to do a lumpectomy and save my breast? Will I need radiation afterwards?
  • After my surgery, will I need more treatment? Radiation? Chemotherapy?
  • What is hormonal therapy, and will I need it?
  • If I need a mastectomy, can reconstruction be done at the time of the surgery? Is it better to wait until later?
  • If I choose not to have reconstruction, what options do I have in terms of prostheses?
  • Will my insurance cover my specific type of treatment?
  • Is there a clinical trial for people with my type of breast cancer? Where can I learn more about clinical trials?

The diagnosis is cancer and surgery is recommended. What questions should I ask?

  • What type of surgery am I going to have? Why is it recommended?
  • How long will I be in the hospital?
  • What care or help will I need once I go home from the hospital?
  • How will I feel after the surgery? How long will it be before I can resume my normal activities?
  • Are there some common side effects after this type of surgery?
  • Where will the surgical scar be? Will it fade over time?
  • If I'm having a lumpectomy, will my breast feel different after surgery?
  • What risks are associated with this surgery?
  • What treatments will I need after the surgery?
  • When will I find out the results of the surgery?
  • How long before I have a follow-up appointment?
  • What is lymphedema and how can I reduce the possibility of getting it?
  • Where can I find a breast cancer support group?