Breast Cancer Diagnosis
“I feel a breast lump. What next?”
“Is it cancer?”
“What is breast biopsy?”
First appointment with the doctor
If you notice a lump or any change in your breast, you need a proper assessment to find out what is causing it.
When a woman comes to our clinic with a breast lump or another change, our first job is to settle her anxiety. Most breast changes are not cancer. We then carry out a triple assessment, which is the internationally accepted standard for evaluating a breast problem.
Triple assessment has three parts
(1) Clinical examination. Dr Rajinder Kaur Saggu takes a detailed history, reviews your risk factors, and examines both breasts and both armpits.
(2) Imaging. A breast radiologist performs an ultrasound, a mammogram, or both. Ultrasound is usually the first choice under 40. From 40 onwards a mammogram is generally added, though the right combination depends on your age, your breast density and what is found on examination.
(3) Needle sampling. If either scan shows something that needs sampling, an image-guided core needle biopsy is performed.
All three parts are read together. It is the combination that gives a reliable answer, which is why we do not rely on any single test on its own.
“Do I need any other tests?”
Sometimes. Depending on what the first round shows, you may need a breast MRI or further imaging. MRI is not routine. It is used for specific reasons, such as dense breasts with an unclear finding, suspected disease in more than one area, lobular cancers, or planning after chemotherapy.
Genetic testing
Testing for inherited gene changes such as BRCA1 and BRCA2 is offered far more widely than it once was, and it is no longer reserved for women with a strong family history. Whether it is recommended depends on your age at diagnosis, the type of cancer and your family history. The result can change both your surgical options and your drug treatment, so it is worth doing early where it is indicated. We will discuss whether testing is right for you and arrange genetic counselling.
You are welcome to bring your partner, a friend or a relative to your appointment.
What is Breast Biopsy?
A breast biopsy means taking a sample of breast tissue or cells so that a pathologist can examine it under a microscope.
A biopsy is the only way to know for certain whether a breast change is cancer. Imaging can raise or lower the suspicion, but it cannot give a definite answer on its own.
Most breast biopsies are done as day procedures in the clinic or on an OPD basis, so you go home the same day. Local anaesthetic is used. You stay awake, but the breast is numb and the procedure is not painful.
Try not to panic while you wait
A large proportion of breast biopsies turn out to be benign. And if cancer is found, it is treatable. Breast cancers found early have a high chance of cure with standard treatment.
Types of Breast Biopsy
Core needle biopsy is the standard test for diagnosing a breast lump. The other methods below have specific, narrower uses.
Core needle biopsy
This is the procedure we use in almost all cases. A hollow needle removes several thin cylinders of tissue, called cores, each about the size of a grain of rice.
It is an OPD procedure done under local anaesthetic. A small injection numbs the area, the needle is passed into the lesion, and a few cores are taken and sent to the pathologist.
A core biopsy does more than confirm whether cancer is present. It tells us the type and the grade, and it gives us enough tissue for the receptor tests that decide your treatment. On every breast cancer sample we assess ER (oestrogen receptor), PR (progesterone receptor), HER2 and Ki-67.
The HER2 result is now reported in more detail than it used to be. Cancers that would once have been called simply HER2 negative may be reported as HER2-low, and that matters, because newer drugs work in that group. If your report mentions HER2-low, ask us what it means for your treatment.
When the biopsy is guided by ultrasound it is called an ultrasound-guided core biopsy. When it is guided by mammogram it is called a stereotactic biopsy, and MRI guidance is also possible. A radiologist usually performs it, though a surgeon can as well.
“Core needle biopsy is a common, well-tolerated procedure. Most patients find it far easier than they expected.”
Vacuum assisted breast biopsy (VABB)
A hollow probe is placed through a small cut using image guidance. Tissue is drawn into the probe and a rotating blade cuts the samples. VABB removes more tissue than a standard core biopsy, which makes it useful for calcifications, for small lesions, and where a core biopsy result does not fit the imaging.
Fine needle aspiration (FNA)
A thin needle draws out fluid and cells. FNA takes only a few minutes, but it has an important limitation. It gives cells rather than tissue, so it often cannot tell whether a cancer is invasive or in situ, and it does not reliably provide receptor results.
For that reason FNA is no longer used as the main test for diagnosing a breast lump. It still has a clear role in draining a cyst and in confirming whether a suspicious lymph node in the armpit is involved.
Excisional biopsy
When the whole lump or suspicious area is removed surgically, this is an excisional or open biopsy. It is rarely needed for diagnosis today, because needle biopsy answers the question in most cases without an operation. It is still used when needle results are inconclusive or do not match the imaging.
Incisional biopsy
If the mass is very large, only part of it may be removed to make the diagnosis. This is now uncommon.
What is Biopsy Report?
The biopsy report is usually ready in two to five working days. I go through it in detail, then sit down with you and your family and explain it line by line.
Your report will describe the type of cancer, its grade, and the receptor results. Together these tell us the biology of your particular cancer, and biology drives the treatment plan just as much as the size or the stage does. Two cancers of the same size can need quite different treatment.
If the report confirms cancer, I will tell you directly and clearly. What I want you to hold on to is this. Breast cancer treatment today is far ahead of where it was even ten years ago. We are in this together, and I will guide you through every step of the journey.
Every case is discussed in our multidisciplinary meeting, where surgeons, radiologists, pathologists, medical oncologists and radiation oncologists review it together. The plan we bring back to you is one the whole team has agreed on, built around your cancer and your circumstances.
What is Staging Test?
Once breast cancer is confirmed, the next question is how far it has spread. The less it has spread, the earlier the stage, and earlier stages have better outcomes.
Most women with early breast cancer do not need whole-body scans
This surprises many patients, so it is worth stating plainly. If your cancer is early and you have no symptoms suggesting spread, staging scans of the rest of the body are not recommended. They very rarely find anything, and they frequently pick up harmless findings that cause worry and lead to more unnecessary tests.
National and international guidelines are clear on this. Not ordering a scan is a considered clinical decision, not a shortcut.
Staging investigations are appropriate when the cancer is locally advanced, when lymph nodes are clearly involved, or when you have symptoms or blood results that need explaining.
When staging tests are needed, they may include:
- Ultrasound of the abdomen
- Chest X-ray or CT scan of the chest
- Bone scan
- CT scan
- PET-CT scan
Breast MRI is a separate matter. It assesses the breast itself rather than the rest of the body, and it is ordered for specific reasons during planning.
We will choose the tests that are genuinely useful in your situation, and explain why each one is being done.
Stages of Breast Cancer
Staging describes how much cancer there is and where it is at the time of diagnosis. It guides treatment and gives a sense of the likely outcome.
Staging today has two parts
Anatomical stage describes the physical extent of the cancer: the size of the tumour, whether lymph nodes are involved, and whether it has spread elsewhere. This is the traditional staging most people have heard of.
Prognostic stage adds the biology: the grade of the cancer, its ER, PR and HER2 status, and in some cases the result of a genomic test. This has been part of the international staging system since 2018.
This matters because biology can move a cancer’s stage. A small, low-grade, hormone-receptor-positive cancer may be given a better prognostic stage than its size alone would suggest. If the stage you are told does not match what you have read online, this is usually the reason.
The anatomical stages
Stage 0. DCIS, or ductal carcinoma in situ. Abnormal cells are confined within the breast ducts and have not invaded the surrounding tissue. LCIS, lobular carcinoma in situ, is no longer classified as a cancer. It is a marker of increased future risk rather than a cancer itself.
Stage I. The cancer has invaded beyond the duct or lobule wall but is 2 cm or smaller, with no lymph node involvement or only very small deposits in the nodes.
Stage II. Tumours larger than 2 cm without node involvement, or tumours up to 5 cm with cancer in one to three armpit lymph nodes.
Stage III. Locally advanced disease. Cancer in four or more armpit nodes, or in the nodes near the collarbone or behind the breastbone, or tumours over 5 cm with node involvement, or tumours that have grown into the chest wall or skin. Inflammatory breast cancer is also staged here.
Stage IV. The cancer has spread beyond the breast and nearby nodes to other organs, most often bone, liver, lung or brain. Stage IV breast cancer is treatable, and with today’s drugs many women live well with it for years.
