Initial investigations
The tests you will need depend on your symptoms and medical history.
It is recommended that doctors use an approach called the “triple test” to further investigate and establish the cause of your symptoms.
Many women with breast changes won’t need all of these tests.
The triple test involves:
- taking a history of your symptoms and your family history and doing clinical breast examination (including both breasts, nipples, armpits and up to the collarbone).
- doing imaging tests, such as;
- a mammogram which examines the breasts using low-dose X-rays; if you have very dense breasts, you might have a form of breast imaging called tomosynthesis
- an ultrasound which examine the breasts and/or armpit area using high-frequency sound waves or
- a magnetic resonance imaging (MRI) scan
- taking a biopsy to remove cells or tissue for examination. If the clinical examination or imaging tests show an abnormal area, you will need a biopsy. This might involve another mammogram, ultrasound or MRI to show where the abnormal area is. You might have one or more of the following types of biopsy:
- Core biopsy – a needle is used to remove a small piece of tissue from the abnormal area, usually under local anaesthetic.
- Fine needle aspiration – a thin needle is used to remove cells from the abnormal area. An ultrasound or a mammogram may be used to show where the abnormal area is.
- Vacuum-assisted stereotactic core biopsy – a needle attached to a suction-type instrument is inserted into a small cut in the breast. A larger amount of tissue is removed with a vacuum biopsy than with fine needle aspiration, which can make it more accurate. A mammogram, an ultrasound or an MRI scan may be used to show where the abnormal area is.
- Surgical (or open) biopsy – during surgery, a lump is removed. You may have a surgical biopsy if the other tests do not give a definite answer about your diagnosis.
Most women show no signs of cancer on any of the tests. However, if there are possible signs of cancer on one or more of the tests, your GP might refer you to a surgeon for further tests or treatment.
- Tests if breast cancer has spread [1][2]
Once the doctor has diagnosed breast cancer, it is important to investigate if the cancer has spread beyond the breast. This is called staging the cancer. The stage of the cancer will help to guide your treating team on the most suitable treatment for you.
X-rays
X-rays are used to look for changes in the bones or chest that may be from cancer. They are quick and easy to do, but might not show early signs of cancer.
Bone scans
A bone scan involves a small amount of radioactive substance (called a radiopharmaceutical or radionuclide) being injected into a vein, usually in your arm. This travels to the bones within 1 to 3 hours, then scanning can start.
During the scan, you will need to lie still on a scanning table while a scanner moves over your body. The scan can take up to 1 hour.
A bone scan can find areas in the bones where cells are growing more quickly (called ‘hot spots’). These can indicate cancer or another medical condition, such as arthritis, an infection or an injury. You might need other tests to confirm the diagnosis.
Blood tests
Your doctor might refer you for blood tests to determine:
- how well your liver is working
- how healthy your bone marrow is
- whether the levels of calcium in your blood are higher than normal.
Abnormal blood tests results may suggest metastatic breast cancer.
Ultrasound
Your doctor might refer you for an ultrasound, which looks for changes in areas of your body – such as in your liver – that might indicate the cancer has spread.
This only takes a few minutes and is painless. You will likely need to fast for at least 4 hours before an ultrasound of the abdomen.
Computed tomography (CT) scan
A CT scan may be used to look for cancer in different parts of the body.
During a CT scan, you will need to lie on your back on a moving table, which passes through a doughnut-shaped machine that takes pictures of the inside of your body. The scan is painless and takes 10 to 20 minutes.
If you are worried about feeling claustrophobic inside the scanner, you can ask for a sedative.
Sometimes a small amount of dye is injected through a vein in the arm or hand before the scan. This makes it easier to see changes in the body that may be due to cancer. You might need to drink an oral contrast before the scan. This helps doctors separate the bowel from other organs nearby.
MRI scan
An MRI scan might be used to check for signs of cancer in the brain, spinal cord or spine, or liver.
During an MRI scan, you will need to lie inside a tunnel-like machine while it takes pictures of the inside of your body. The test takes about 30 minutes and is painless.
If you’re worried about feeling claustrophobic inside the machine, you can request a sedative. The machine can also be noisy. Listening to music during the scan or having a friend or family member in the room can help.
Sometimes a small amount of contrast agent is injected through a vein in the arm or hand during the scan. This helps to see changes in the body that may be due to cancer.
Positron emission tomography (PET) scan
A PET scan can show areas in the body where cells are more active than usual, such as fast-growing cancer cells. The scan is painless and takes 15 minutes to 2 hours.
Before the scan, a small amount of a radioactive material is injected into a vein, usually in the arm. You will then need to lie on your back on the scanning table. The table moves through a scanner ‘ring’, which takes pictures of the inside of the body.
Breast biopsy
In the setting of breast cancer that has spread, a breast biopsy is usually only done if there is evidence of a lesion in the breast, and metastatic breast cancer is the first diagnosis of cancer. This helps to confirm the diagnosis and find out what receptors are on the breast cancer cells so that doctors can work out the best treatment.
If you have had breast cancer before, a repeat biopsy will help determine whether receptors have changed since the original cancer.
The pathology report
After a biopsy, the cells or tissue sample are sent to a pathologist. The pathologist will examine the sample and detail the results in a pathology report.
If breast cancer is present, the results will include information about:
- the type, stage and grade of breast cancer
- the cancer’s size and location – this affects what treatments are recommended, including the type of surgery
- whether the breast cancer is positive or negative for hormone receptors – this affects whether hormonal therapies are recommended
- whether there are HER-2 receptors on the breast cancer – this affects whether targeted therapies are recommended
- whether there are cancer cells in the lymph nodes – this information is usually available after surgery to the armpit and might affect whether chemotherapy is recommended
- the surgical margin – during breast conserving surgery, the surgeon removes the breast cancer and an area of healthy looking tissue around the cancer; if the surgical margin is clear of cancer cells, it’s likely that all the cancer has been removed, otherwise, you might need more surgery.
The information on the pathology report will help your medical team plan your treatment. You might like to keep a copy of your pathology report to refer to later.
Waiting for test results
Waiting for test results can be worrying, especially as it’s often not immediately clear whether symptoms are due to cancer or other medical conditions.
Current evidence suggests that even if your diagnosis takes a few weeks or months, this will not affect the length or quality of your life or how you respond to treatment.
See more information about living with cancer and finding support.
Triple test
Personal history and clinical breast examination
The doctor will ask about the woman’s personal and family history of breast cancer and about any symptoms.
The doctor will perform a clinical breast examination. This involves a thorough physical examination of the whole breast area, including both breasts, nipples, armpits and up to the collarbone.
Imaging tests
Imaging tests for breast cancer may involve:
- mammogram: a way of examining the breasts using low-dose X-rays
- ultrasound: a way of examining the breasts and/or armpit area using high-frequency sound waves
The tests used will depend on the woman’s age. For women aged 35 years or older, both a mammogram and an ultrasound will be used. For women younger than 35 years, an ultrasound is used first and a mammogram may also be used if more information is needed.
Biopsy
If the clinical examination or imaging tests show an abnormal area, a woman will have a biopsy so that cells or tissue from the area can be examined for signs of cancer.
There are two types of biopsy. A woman may have one or more of these.
- Core biopsy: a needle is used to remove a small piece of tissue from the abnormal area. This test is usually done under local anaesthetic. A mammogram or ultrasound may be used to show where the abnormal area is.
- Fine needle aspiration (FNA): a thin needle is used to remove cells from the abnormal area. An ultrasound or mammogram may be used to show where the abnormal area is.
After any type of biopsy, the cells or tissue are sent to a pathologist. The pathologist examines the cells or tissue to find out whether the breast change is due to breast cancer.
If more information is required, the biopsy may be repeated or the woman may have an excision/surgical biopsy. In this test a surgeon removes some (or all) of the abnormal tissue. This test is usually done under general anaesthetic. If the abnormal area can’t be felt easily, a small wire may be inserted into the breast before the surgical biopsy (under local anaesthetic) to show the surgeon where the abnormal area is.
