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Early Detection is Your #1 Goal
Breast Self Examination (BSE)
What to look for in breast self-examination
How to perform breast self-examination
Clinical Breast Exam
Mammography
How mammography works
The two types of mammograms
BI-RAD Scoring
The accuracy of mammography
Breast Ultrasound
Breast Biopsy
Needle biopsies
Marking systems
Surgical biopsy
The pathologist's role
Additional Breast Cancer Tests
Magnetic Resonance Imaging (MRI)
Computed Tomography (CAT Scan)
Bone Scan
Sentinel Node Detection
Blood Tests
Chest X-ray
Positron Emission Tomography (PET) Scan
Building Your Breast Cancer Defense Team
Your diagnostic team
Your treatment team
Your medical support team
Your personal support team
Breast Cancer Staging
Types of beast cancer
Understanding the staging system
The five stages of breast cancer

Breast cancer diagnosis has undergone a revolution in the past 20 years. Today, advanced technology makes it possible to detect cancer at the earliest stage. Ultimately, this is the key to successful treatment and recovery.

Early Detection is Your #1 Goal

Understanding the diagnosis of breast cancer can be confusing to say the least. There are so many terms and technologies, it can make your head spin. That's why it's a good idea to familiarize yourself with the landscape before going too far. Just remember one thing that's perfectly clear: no matter how a breast abnormality is discovered-whether through breast self-examination or an advanced detection technology-early detection is the overriding goal.

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Breast Self Examination (BSE)

If you're more than 20 years old, it's time to begin a systematic approach to examining your breasts. By doing such an exam regularly, you get to know how your breasts normally look and feel and can better detect any significant changes. If you notice anything out of the ordinary, see your health care provider as soon as possible.

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What to look for in breast self-examination

The most common signs of breast cancer are a new, firm lump or mass in your breast or a lump that seems to be growing. Sometimes breast cancer can spread to underarm lymph nodes and cause a lump or swelling there, even before a tumor in the breast is felt.

Other possible signs of breast cancer include:

• Swelling of all or part of the breast
• Skin irritation or dimpling
• Breast or nipple pain
• Nipple retraction (turning inward)
• Redness, scaliness or thickening of the nipple or breast skin
• Discharge other than breast milk

Make an appointment to see your doctor if you find any of these signs. Although it's statistically unlikely to be cancer, being safe is your best course of action.

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How to perform breast self-examination

• Lie down and place your right arm behind your head. This spreads the breast evenly over the chest wall as thinly as possible, making it much easier to feel all the tissue.
• Use the pads of your three middle fingers on your left hand to feel for lumps in the right breast. Use overlapping dime-sized circular motions.
• Use three different levels of pressure: light pressure to feel the tissue closest to the skin; medium pressure to feel deeper; and firm pressure to feel tissue close to your ribs. Use each pressure before moving on to the next spot.
• Use an up-and-down pattern, starting at an imaginary line drawn straight down your side from the underarm and moving across to the middle of the chest. Be sure to check the entire breast, from the rib below to the collarbone above.
• Repeat the exam on your left breast, using your right hand.
• While standing in front of a mirror, press your hands down firmly on your hips. Look at your breasts and nipples for any changes in size, shape, contour, color or skin health. Pressing down on the hips contracts your chest muscles so changes show up better.
• Examine each underarm with your arm only slightly raised so you can easily feel the area. Notice if you see or feel any changes there.

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Clinical Breast Exam

In a clinical breast exam (CBE) a doctor, nurse practitioner, nurse or doctor's assistant examines your breasts. He or she will first look for abnormalities in size, shape or skin changes. Then, using the finger pads, the examiner will gently palpate your breasts. The focus will be on your breast's shape and texture, location of any lumps and whether lumps are attached to the skin or lay deeper. Both of your underarms also will be examined. During the CBE is a good time for your doctor or nurse to teach you good BSE technique.

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Mammography

A mammogram is a type of X-ray, except that instead of taking pictures of bones, it images breast tissue. Mammograms might be the most important advancement in breast cancer detection during the past 30 years, since they can find breast cancers earlier and improve chances for a successful treatment. Physician's now recommend women over 40 get a mammogram every year. Mammograms are less effective in younger women, usually because their breasts are dense and can hide tumors. The same can also be true for pregnant women and women who are breast-feeding.

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How mammography works

Having a mammogram requires you to undress above the waist. A wrap will be provided by the facility for you to wear. A technician places your breast on the mammogram machine's lower plate, which is made of metal and has a drawer to hold the x-ray film or digital camera. The upper plate, made of plastic, is lowered to compress your breast for a few seconds while the technician takes the picture. The whole procedure lasts about 20 minutes. Try not to schedule a mammogram when your breasts might be tender, for example, before or during your period.

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The two types of mammograms

1. Screening mammograms-are used to look for breast disease in women who seem to have no breast problems and usually involve two views of each breast. For some patients, such as women with breast implants, more views may be needed. The goal of screening mammograms is to find cancers before they start to spread.

2. Diagnostic mammograms-are used to examine a woman with potential breast problems, such as a lump, nipple discharge or abnormality seen in a screening mammogram. A diagnostic mammogram can show that a lump is probably benign (non-cancerous) or that the abnormality is not worrisome. The mammogram also could suggest a biopsy is needed to get the whole story.

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BI-RAD Scoring

Each diagnostic mammogram is encoded with a number from 0 to 5 known as your BI-RAD score, which stands for Breast Imaging Reporting and Data System. These scores were developed to provide a consistent way for interpreting mammograms and to facilitate better follow-up and monitoring.

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The accuracy of mammography

Mammography is highly sensitive and accurate, but it isn't perfect. This is because every woman's breasts are different and there are many different definitions of what is "normal." Still, there are things you can do to ensure you get the most accurate results possible.

1. Ask to see the FDA certificate that is issued to the mammography facility. The FDA sets high professional standards of safety and quality for certified mammography services.
2. Use a facility that specializes in mammography or does many mammograms a day.
3. Once you know it's a high-quality facility, continue to go there regularly so your mammograms can be compared year-to-year.
4. If you're going to a facility for the first time, bring a list of the places, mammogram dates, biopsies or other breast treatments you've had.
5. If you've had mammograms at another facility, get those mammograms to bring with you to the new facility, or have them sent there, for comparison to the new ones.
6. Don't wear deodorant or antiperspirant. Some of these can interfere with mammogram images.
7. Schedule your mammogram when your breasts aren't tender or swollen to reduce discomfort and improve the images.
8. Describe any breast symptoms or problems you're having to your doctor or nurse before having the mammogram.

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Breast Ultrasound

Ultrasound, also known as sonography, uses high-frequency sound waves to image parts of the body. A small instrument called a transducer is placed on your skin. It emits sound waves and then picks up the echoes when they rebound. A computer converts these echoes into an image on a computer monitor.

Ultrasound has become a valuable tool to use with mammography, because it's widely available and less expensive than options like MRI. Usually, breast ultrasound is used to target a specific area of concern found on a mammogram. Ultrasound also helps distinguish between cysts (fluid-filled sacs) and solid masses and between benign and cancerous tumors. Ultrasound is especially helpful in women with high breast density such as young women.

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Breast Biopsy

The only sure way to confirm a diagnosis of breast cancer for sure is through a biopsy. This involves removing a small piece of the tumor and having it examined under a microscope by a pathologist-a specialist in tumor analysis. There are several types of biopsies, each with advantages and disadvantages. The best choice depends on your specific situation.

Knowing that you need to have a biopsy, it's only natural to be anxious. Still, as you're waiting for the results, consider this: 70 to 80 percent of biopsies done when doctors found an abnormality on a mammogram (when they couldn't feel a lump) turn out not to be cancer.

Click here to download Breast Biopsy brochure.

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Needle biopsies

Today three basic types of biopsies are performed with a needle system of one type or another.

Fine Needle Aspiration (FNA)-is done with a very thin needle connected to a syringe. It's used to withdraw a small amount of tissue from a suspicious area. If the area to be biopsied can be felt, the needle can be guided into by touch. However, if the lump can't be felt easily, the doctor might use ultrasound, stereotactic guidance or a CAT scan to steer the needle to the exact location. This is because FNA biopsies can miss the cancer if the needle isn't placed right in the tumor cells.

Core Needle Biopsy (CNB)-is similar to FNA, except the needle is slightly larger and extracts small cylinders of tissue. Although CNB is slightly more invasive than FNA, it usually provides more detailed information. CNB is the most common form of biopsy because it provides accurate information, causes less discomfort than surgery and doesn't leave a scar. In the case of a lump or calcification that can't be felt, the doctor can use ultrasound or a stereotactic guidance to zoom in, just as with FNA.

Vacuum-Assisted Biopsy-Several advanced devices use a small rotating cutter and vacuum to remove biopsy samples. Once again, if the lesion can't be felt, the needle is guided using a stereotactic or ultrasound system. These newer biopsy methods remove more tissue than a core biopsy, further increasing the potential for an accurate diagnosis and decreasing the need for additional biopsies. With this knowledge, your doctor will be able to make a highly accurate analysis and advise you of all your treatment options before taking further steps. With vacuum-assisted biopsy systems such as the SenoRx Encor®, your actual breast biopsy procedure takes just minutes in a comfortable outpatient setting and is a simple, painless procedure.

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Marking systems

When a lump is discovered but can't be felt, you may require wire localization in order to "mark" the location of the lesion. Using ultrasound or stereotactic mammography, the radiologist inserts a fine wire attached to a tiny hook into your breast at the site of the lesion. This marker shows the surgeon precisely what to remove during a needle or surgical biopsy. To enable surgeons to more easily locate a lesion and place the needle, SenoRx invented a unique marker called Gel Mark® Ultra that can only be seen by ultrasound. Using a portable ultrasound system to clearly visualize the marker, the surgeon can choose the best way to remove the lesion to get good cosmetic results. SenoRx has expanded the Gel Mark® line into a complete family of advanced biopsy site marking systems that offer visualization in not only ultrasound, but also under mammography and MRI. Using a marker assists physicians to clearly identify the biopsy site for follow up examination.

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Surgical biopsy

Your doctor also may choose to perform a biopsy surgically. A surgical biopsy is performed under local anesthesia, sometimes with sedation. Most surgical biopsies are excisional, meaning the surgeon removes the whole tumor. A biopsy also can become a lumpectomy when the edges of the removed tissue are free from cancer cells. Usually, when an excisional biopsy is done, the surgeon tries to take a rim of normal tissue, too. That way, if cancer is diagnosed, the lumpectomy is already done. A surgical biopsy takes about an hour and causes minimal pain that goes away in a few days.

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The pathologist's role

No matter what kind of biopsy is done, a pathologist will examine the removed tissue under a microscope. The aim is to identify the cells and see if they're benign or malignant. Your pathology report holds the keys to your diagnosis, treatment and probable outcome. In other words, it's a document you definitely want to go over in detail with your doctor. By understanding what your findings really mean, you'll be in a better position to discuss treatment options with your medical team.

What the pathologist looks for

If cancer cells are found, the pathologist looks further to find out:

• The type of cancer
• Its size
• How aggressive it is
• Other cell characteristics that affect your treatment options
• Whether or not cancer cells are found on the edges of the tissue removed (to see if all the cancer was removed)
• Whether cells in the lymph nodes show signs of cancer

The pathologist also grades the cancer based on how closely the biopsy sample resembles normal breast tissue.

Grade 1—(well differentiated) cancers have relatively normal-looking cells that do not appear to be growing rapidly and are arranged in small tubules.
Grade 2—(moderately differentiated) cancers have features between grades 1 and 3.
Grade 3—(poorly differentiated) cancers, the highest grade, lack normal features and tend to grow and spread more aggressively.

Other pathology tests

The pathologist also may perform tests for:

Estrogen receptors and progesterone receptors-The results of these tests are important, because ER positive tumors can be treated with drugs that block the action of the hormones.
HER-2/neu (c-erb R2)-Determining your HER-2/neu level helps your oncologist decide if you're a good candidate for treatment with a drug called Herceptin.
Growth rate-Having a high percentage of cells in the S-phase (the cell phase when DNA makes copies of itself) indicates more rapid tumor growth and a more dangerous tumor.
Ploidy-Ploidy refers to the amount of DNA cancer cells contain and can help determine your likely outcome.
p53-p53 is a suppressor gene that protects the body against cancer.
Vascular or lymphatic invasion-Microscopic examination can show if the tumor is invading lymph ducts or blood vessels, which would indicate a more aggressive tumor.
Gene patterns-Looking at the patterns of genes can help when deciding whether additional treatments or combination treatments might be helpful.

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Additional Breast Cancer Tests

Though a biopsy can show if cancer is present, it can't tell whether it's spread to other body parts. To find this out, more tests are needed.

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Magnetic Resonance Imaging (MRI)

MRI uses a combination of magnetic energy and radio waves to create images of the inside of your body. It's painless, doesn't expose you to x-rays and takes about an hour. Women at high risk for breast cancer should get an MRI and a mammogram every year. Women at moderately increased risk should talk with their doctors about adding MRI to their yearly mammogram. If MRI is used, it's in addition to, not instead of, a screening mammogram. This reason is, although MRI is a more sensitive than mammography, it can still miss some cancers a mammogram might see.

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Computed Tomography (CAT Scan)

Basically, a CAT scan is an x-ray that produces detailed, 3D images of your body. Instead of taking one picture, the scanner takes many pictures as it rotates around you while you lie on a table. A computer combines these pictures into image slices of the part of your body being studied. This test can help tell whether your cancer has spread into your liver or other organs. CAT scans can also be used for multi-dimensional guidance of a biopsy needle when extra precision is needed.

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Bone Scan

A bone scan can help show whether a cancer has spread (metastasized) to your bones. To find out, traces of low-level radioactive material are injected into a vein. They settle into areas of new bone growth throughout your entire skeleton in a few hours. Then you lay on a table while a special camera images your skeleton. Areas of new bone growth appear as hot spots that attract the radioactivity and might show where cancer has spread.

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Sentinel Node Detection

Lymphatic mapping with sentinel node biopsy is one of the most interesting developments in surgical oncology. Researches have discovered that when cancer advances it travels to the lymph nodes. The first lymph node is called the "Sentinel" lymph node. If no cancer is discovered in the "Sentinel" lymph node then the cancer has not spread and there is no need to perform an "Axillary Lymphadenectomy" where all the lymph nodes are removed. To locate the "Sentinel" lymph node an isotope is injected into the breast which then travels to the "Sentinel" lymph node and the nodes beyond. The isotope emits a gamma wave which can be detected with a gamma probe.

Gamma Finder® by SenoRx is the first cordless Gamma detection device to be introduced to the market. The small light weight probe is highly sensitive to detecting gamma waves and is easy for the surgeon to manipulate to locate the "Sentinel" node.

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Blood Tests

Blood tests might be done to measure enzymes in your bones and liver. Abnormal results could show cancer has spread. If so, more extensive tests would be done, such as a bone scan, CAT scan or MRI.

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Chest X-ray

Your doctor might suggest a traditional chest x-ray to see whether the cancer has spread to your lungs. Finding cancer in the lungs means the cancer has first spread through your blood stream, which raises concern.

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Positron Emission Tomography (PET) Scan

PET scans involve injecting blood sugar (glucose) containing radioactive atoms into your blood. Because cancer cells grow rapidly, they absorb large amounts of the radioactive sugar. A special camera can then create a picture of areas of radioactivity in the body. PET is useful when your doctor thinks the cancer may have spread, but doesn't know for certain to where.

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Building Your Breast Cancer Defense Team

In the unlikely event you're diagnosed with breast cancer, it's still no time to panic. On the contrary, now's the time to regroup and arm yourself with knowledge. Now's the time to keep your eyes focused on the endgame-GETTING WELL. On of the keys is to build the best possible cancer defense team. Many people will be involved, so it pays to know their roles.

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Your diagnostic team

Primary Care Physician (PCP)-probably first discovered the lump or was the one you reported it to. Since most PCP's aren't breast cancer experts, yours probably will refer you to a cancer treatment specialist. Radiologist-specializes in tests used to detect cancer including mammography, ultrasound, MRI and CAT scanning.
Pathologist-examines the tissue removed during a biopsy and writes the report that helps you and your doctors choose the best treatment.

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Your treatment team

Medical oncologist-specializes in anti-cancer drugs or chemotherapy.
Radiation oncologist-specializes in using high-energy x-rays for cancer treatment.
Anesthesiologist-administers drugs or gases that put you to sleep before surgery.
Reconstruction surgeon-specializes in cosmetic surgery, such as breast reconstruction after mastectomy.
Surgical oncologist-is in charge of any surgical aspects of your treatment.

Your medical support team

Nurses-many will have specialized training in breast cancer treatment in such areas as post-operative care, chemotherapy or radiation therapy.
Social worker-can help you deal with social and economic aspects of treatment, such as finding a support group or solving insurance issues.
Physical therapist-helps you with post-surgical rehabilitation using exercise, heat, massage and other treatments.
Radiation tech-works under the radiation oncologist to deliver radiation treatment.
Residents and fellows-doctors in training in medicine, surgery, radiation and other fields.

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Your personal support team

Last but certainly not least, in the event you are diagnosed with breast cancer, you'll need a network of people to support you. These are the people in your life who you can really count on to remain positive, to be supportive, to stay levelheaded and to be there for you through thick and thin.

Advocate-one of the best things you can do is seek support from a group or individual who has survived breast cancer. After all, who better to understand your thoughts and worries, to guide you toward the right resources and to help inform your decision-making processes?

Buddy-whether it's your spouse, best friend, relative or friendly neighbor, bring someone with you to appointments and exams who's not only close to you but clear-thinking and dependable. They'll be like the rudder on your ship if the seas get choppy. They'll be the one to ask questions, remember information and write down instructions if you feel too emotional.

Family and friends-ultimately those closest to you form the backbone of support needed to face and overcome challenges. Seek out those who build your positive attitude and self-esteem but who are also genuine and honest. It's what real friends are for.

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Breast Cancer Staging

The breast cancer staging system is essentially a summary of all your diagnostic information. It ranks your cancer and expresses the degree to which it has advanced. However, to understand the staging system, it first helps to know the different types of breast cancer.

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Types of beast cancer

Breast cancer types are named according to where in the breast they develop and whether or not they are invasive. Don't be too alarmed if you're told your cancer is invasive. Most cancers are, so that's the usual kind.

In situ (non-invasive) breast cancers

Lobular Carcinoma In Situ (LCIS)-although not a true cancer, LCIS is sometimes classified as non-invasive breast cancer. It begins in the lobules (milk-producing glands), but does not grow through their wall. Most breast cancer specialists think that LCIS does not become invasive very often, but women with this condition do have a higher risk of eventually developing invasive breast cancer. So women with LCIS should have regular mammograms.

Ductal Carcinoma In Situ (DCIS)-this is the most common type of non-invasive breast cancer. Cancer cells are inside the milk ducts, but haven't spread through their walls into surrounding tissue. About 20% of new breast cancer cases are DCIS. Nearly all women diagnosed at this early stage of breast cancer can be cured and regular mammograms are the best way to find DCIS early.

Invasive breast cancers

Invasive Lobular Carcinoma (ILC)-starts in the lobules, but can spread to other parts of the body. About 10% of invasive breast cancers are ILCs.

Invasive Ductal Carcinoma (IDC)-is the most common type of breast cancer. It starts in the ducts, breaks through the duct walls, and then invades the fatty tissue of the breast. At this point, it may spread (metastasize) to other parts of the body through the lymph system and bloodstream. About 80% of invasive breast cancers are IDC.

Rare forms of breast cancer

Inflammatory breast cancer (IBC) is an uncommon type of invasive breast cancer accounts for about 1% to 3% of all breast cancers. Usually there is no single lump or tumor. Instead, IBC makes the skin of the breast look red and feel warm and gives it a thick, pitted appearance like an orange peel.

Mixed tumors contain a variety of cell types, such as IDC combined with ILC. In this case, the tumor is treated as if it were an IDC (invasive ductal cancer).

Medullary cancer is a special type of infiltrating breast cancer with a well-defined, distinct boundary between tumor tissue and normal tissue. It also includes large cancer cells and immune system cells at the tumor edges.

Metaplastic carcinoma is a very rare kind of invasive ductal cancer. These tumors have cells not normally found in the breast, such as cells that make bone or look like skin cells.

Mucinous carcinoma is also known as colloid carcinoma and is a rare type of invasive breast cancer formed by mucus-producing cancer cells.

Paget disease of the nipple starts in the breast ducts, spreads to the skin of the nipple and then to the areola (the dark circle around the nipple). This skin often appears crusted, scaly and red-with areas of bleeding or oozing.

Tubular carcinoma is another special type of IDC. It's named tubular because that's how the cells look under a microscope.

Papillary carcinoma is a cancer with cells arranged in small, finger-like shapes. These cancers are usually treated as a subtype of DCIS.

Adenoid cystic carcinoma has both glandular and cylinder-like features when seen under a microscope. These cancers rarely spread to the lymph nodes and so tend to be curable.

Phyllodes tumor is a very rare breast tumor that develops in the connective tissue of the breast, rather than in the ducts or lobules. It's usually benign.

Angiosarcoma is a form of cancer that starts from cells that line blood vessels. It rarely occurs in the breasts, but when it does, it is usually a complication of radiation that shows up five to ten years after radiation treatment.

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Understanding the staging system

It's important to remember that each cancer is unique, just like each woman is. This makes the potential combination of treatment options vast. To summarize, however, cancer specialists rely on staging-a system that categorizes cancer into well-defined groups. The stage of your tumor, though not the only factor, is a critical one in deciding the treatment best for you.

The TNM System

In simplified form, staging is based on three major factors:

T-Tumor Size is determined when the tumor is removed and sent to the pathologist.
N-Lymph Nodes are checked for evidence of tumor spread at the time of surgery in a procedure called axillary lymph node dissection.
M-Metastasis determines the degree to which the cancer has spread to other organs and is assessed with bone scans, X-rays, CAT scans and blood tests.

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The five stages of breast cancer

Stage 0

This is the earliest form of breast cancer. It's usually DCIS and so cancer cells are still within the duct and haven't invaded surrounding breast tissue. LCIS is sometimes classified as stage 0 breast cancer, but most oncologists believe it's not a true breast cancer. Paget disease of the nipple-without an underlying tumor-is also stage 0. In all cases, the cancer has not spread to lymph nodes or distant sites.

Stage I

The tumor is 2 cm (3/4-inch) or less across and has not spread to lymph nodes or distant sites.

Stage II

The tumor is 2-5 cm (3/4 to 2-inches) across and the may or may not have spread to a few axillary lymph nodes or internal mammary lymph nodes. In either case, the cancer hasn't spread to distant sites.

Stage III

The cancer still hasn't spread to distant sites. But the tumor is either: larger than 5 cm; has spread to many axillary lymph nodes; has enlarged the internal mammary lymph nodes; has spread into the lymph nodes under or above the collarbone; or has grown into the chest wall or skin. Inflammatory breast cancer also is classified as stage III, unless it has spread to distant lymph nodes or organs.

Stage IV

The cancer can be any size and may or may not have spread to nearby lymph nodes. However, it has spread to distant organs (usually the bones, liver, brain or lungs) or to lymph nodes located far away from the breast.

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