Diagnosis and Stages of Breast Cancer

The initial step is a complete history and physical exam. This includes reviewing your personal and family medical history as well as determining current overall health concerns. A breast specialist will also perform a clinical breast examination. Diagnostic breast imaging may also be performed to further evaluate a finding on your breast exam.

Watch a video on breast imaging.

We offer you the important benefit of having your breast images reviewed by breast imaging specialists who devote their time exclusively to breast imaging, including mammography, breast ultrasound and breast MRI. The high volume of exams that these specialists read enables them to be skilled at identifying the subtle changes in breast tissue which may indicate cancer.

Our experts utilize the most advanced technology to review imaging studies, including digital 3-D mammography which captures images of the breast that can be seen on a computer screen, and computer-aided detection (CAD) software which can search digitized mammographic images for abnormal areas of the breast that require further analysis.

Access information about digital 3-D mammography.

Your diagnostic tests may include one or more of the following procedures:

• Mammogram - X-ray images of the breast. At all four sites (BWH, BWFH, DFCI, and SSH) we use digital mammograms, which provide a clear two-dimensional image highlighting unusual structures such as calcifications or masses which may need further evaluation.
• Tomosynthesis - 3D digital imaging that uses compression and X-rays. The procedure feels similar to a mammogram, but takes extra images to allow doctors to examine each layer of the breast. Tomosynthesis may increase doctors' ability to find some cancers while also lowering the risk of false positive evaluations; however, it may also expose a person to additional radiation. Only research will determine which patients benefit most from tomosynthesis.
• MRI (magnetic resonance imaging) - Contrast enhanced breast imaging is used in special situations, often for individuals who have a genetic predisposition to breast cancer and/or have unclear mammograms. Access Frequently Asked Questions (FAQs) about breast cancer screening with MRI.
• Ultrasound - Imaging that can capture the size and structure of a potential tumor. Ultrasound can be used as an adjunct to screening, but more commonly, it is used in conjunction with mammography. For example, ultrasound can further characterize an abnormality seen on a mammogram, or help guide the needle during a breast biopsy.
• Ductogram - X-ray examination that uses mammography and contrast material to obtain pictures, called galactograms, of the inside of the breast's milk ducts. Women with nipple discharge can be evaluated with this technique to identify the cause of the discharge.

In some cases, more extensive imaging may be necessary to determine whether breast cancer has spread beyond the breast. When this is the case, CT scans and/or bone scans may be used. In select cases, a PET scan may also be necessary.

If an imaging test reveals an abnormal finding that cannot be resolved through other imaging techniques, your doctor will likely recommend a biopsy. A biopsy involves the removal of a small sample of tissue through one of several techniques, depending on the location and quality of the tissue to be examined. Radiologists, pathologists and sometimes surgeons are involved in the biopsy process.

Types of biopsies include:

• Fine needle aspiration - This nearly painless procedure involves the insertion of a very thin needle into the suspicious area of the breast. The clinician uses the needle to "aspirate" fluid and cells to be examined by a pathologist.
• Core needle biopsy - When a slightly larger tissue sample is required for a definitive diagnosis, a clinician will use a hollow needle to withdraw a thin cylinder of tissue from the suspicious area. This type of biopsy requires local anesthesia.
• Image-guided core needle biopsy - In cases in which locating a suspicious area through touch is impossible, radiologists use ultrasound, stereotactic (mammographic) imaging or MRI to guide the removal of tissue using a hollow needle. Stereotactic biopsy finds the exact location of a breast lump or suspicious area by using a computer and mammogram images to determine the three-dimensional lesion location within the breast. A sample of tissue is removed with a needle that is guided to the appropriate area using the 3D coordinates. A titanium clip is typically placed during a core needle biopsy to ensure that the area of interest can be identified after biopsy in the event that additional tissue must be removed.
• Surgical biopsy - In relatively few cases, standard imaging and biopsy techniques may not provide enough information to either diagnose or rule out breast cancer. When that happens, radiologists and surgeons work together to remove all or part of a suspicious mass. If the lump can't be felt, a wire or radioactive seed is inserted to guide your surgeon to the right location. While a surgical biopsy does require sedation, it does not require an overnight hospital stay.

Once a biopsy is completed, tissue samples are examined by pathologists who specialize exclusively in breast cancer. Pathologists' findings are critical to determining the best treatment for your cancer. At Dana-Farber Brigham Cancer Center, pathologists are key members of your medical team, providing consultation to clinicians and, at times, working side-by-side with surgeons. Our pathologists not only evaluate tissues to characterize your cancer, but they also investigate any unusual or unexpected findings in the breast tissue.

Watch this video on breast biopsy.