Breast Cancer Basics -- From Screening to Diagnosis
What is breast cancer?
To understand what breast cancer is it is helpful to begin with some background on the basic anatomy of the breast. The female breast is made up of lobules, ducts, and stroma. Lobules are the milk producing glands; ducts are the tiny tubes that carry the milk from the lobules inside the breast to the nipple; and stroma is the fatty tissue and connective tissue that surrounds the ducts and the lobules, as well as the blood vessels and the lymphatic vessels in the breast.
Breast cancer is a malignant tumor that starts from the cells of the breast. Most breast cancers begin in the cells that line the ducts. This form of breast cancer is called ductal breast cancer. Some breast cancers begin in the cells that line the lobules. This is called lobular breast cancer. A small number of breast cancers begin in other breast tissue.
What are the signs and symptoms of breast cancer?
In its early stages breast cancer usually has no signs or symptoms. As a breast tumor grows, there may be several signs and symptoms, including the following:
- A lump in the breast or underarm that persists after your menstrual cycle. A lump is often the first apparent symptom of breast cancer. Breast cancer lumps are typically painless, although some may cause a prickly sensation. Breast cancer lumps are usually visible on a mammogram long before they can be seen or felt.
- Swelling in the armpit.
- Unusual pain or tenderness in the breast.
- A noticeable flattening or indentation on the breast.
- Any change in the size, contour, texture, or temperature of the breast.
- A reddish, pitted surface on the breast like the skin of an orange.
- A change in the nipple, such as an indrawn or dimpled look, an itching or burning sensation, or an ulceration.
- Scaling of the nipple.
- Unusual discharge from the nipple that may be clear, bloody, or another color.
- A marble-like area under the skin of the breast.
- An area that is distinctly different from any other area on either breast.
What screening tests are there for breast cancer?
Screening tests are used to find a disease, such as breast cancer, before there are any signs and symptoms of the disease. There are several screening tests for breast cancer:
- Mammogram: A mammogram is an x-ray of the breast. Screening mammograms are used to look for breast cancer in women who are asymptomatic, i.e., they are not experiencing any breast problems or abnormalities. Screening mammograms usually involve x-ray pictures taken from two different angles of each breast. During a mammogram, the breast is pressed between two plates to flatten and spread the breast tissue. This may be uncomfortable for a moment, but it is necessary to produce good images of the breast. Your mammogram films will be evaluated by a doctor specially trained in reading mammograms. Among the things the doctor will be looking for on your mammogram are microcalcifications. Microcalcifications are tiny specks of calcium in the breast. They may appear alone or in clusters. Microcalcifications seen on a mammogram can be a sign of early breast cancer. A mass is another important change that can be seen on mammograms. Masses can be many things, including cysts (non-cancerous, fluid-filled sacs) and non-cancerous solid tumors (such as fibroadenomas), but they can also be cancerous. The primary limitation of mammograms is that they cannot say whether an abnormal area -- such as a microcalcification or a mass -- is or is not cancer. To determine whether cancer is present, a small amount of tissue must be removed and looked at under a microscope. This procedure is called a biopsy and is discussed below in the section entitled "How is breast cancer diagnosed?".
- MRI: MRI scans use magnets and radio waves (instead of x-rays) to produce very detailed, cross-sectional images of the body. The most useful MRI exams for breast imaging use a contrast material (gadolinium) that is injected into a vein in the arm before or during the exam. This improves the ability of the MRI to clearly show breast tissue details. MRI is more sensitive in detecting breast cancers than mammograms.
- Clinical Breast Examination: A clinical breast exam (CBE) is an examination of your breasts by a health care professional, such as a doctor. During this examination, the doctor will first look at your breasts for abnormalities in size or shape, or changes in the skin of the breasts or nipple. Then, using the pads of the fingers, the examiner will gently feel (palpate) your breasts. Special attention should be given to the shape and texture of the breasts, location of any lumps, and whether such lumps are attached to the skin or to deeper tissues. The area under both arms should also be examined.
- Breast Self-Examination: The best time for you to examine your breasts is when they are not tender or swollen. To examine your breasts, you need to lie down and place your right arm behind your head. Then use the finger pads of your three middle fingers on your left hand to feel for lumps in the right breast. Use overlapping dime-sized circular motions of the finger pads to feel the breast tissue. Use three different levels of pressure to feel all the breast tissue. Light pressure is needed to feel the tissue closest to the skin; medium pressure to feel a little deeper; and firm pressure to feel the tissue closest to the chest and ribs. Move around the breast in an up and down pattern starting at an imaginary line drawn straight down your side from the underarm and moving across the breast to the middle of the chest bone (sternum or breastbone). Be sure to check the entire breast area going down until you feel only ribs and up to the neck or collar bone (clavicle). Repeat the exam on your left breast, using the finger pads of the right hand. Now, while standing in front of a mirror with your hands pressing firmly down on your hips, look at your breasts for any changes of size, shape, contour, or dimpling, or redness or scaliness of the nipple or breast skin. Finally, examine each underarm while sitting up or standing and with your arm only slightly raised so you can easily feel in this area. Raising your arm straight up will tighten the tissue in this area and make it harder to examine.
How is breast cancer diagnosed?
If something suspicious is found during a screening exam, or if you have any of the symptoms of breast cancer described above, your doctor should use one or more of the methods described below to find out if breast cancer is present.
- Ultrasound: Ultrasound uses sound waves to outline a part of the body. During ultrasound, a gel is applied to the skin and a small instrument called a transducer is placed on the skin. The transducer emits sound waves and picks up the echoes as they bounce the tissue in your body. These echoes are converted into black and white images that are displayed on a computer screen. This test is painless and does not expose you to radiation.
- Biopsy: During a biopsy, the doctor removes a sample of the tissue in the suspicious area of the breast and sends this tissue for microscopic analysis. A biopsy is the only way to tell if breast cancer is really present. There are several types of biopsies, including fine needle aspiration biopsy, core (large needle) biopsy, and surgical biopsy. In a fine needle aspiration (FNA) biopsy, the doctor uses a very thin, hollow needle attached to a syringe to withdraw (aspirate) a small amount of tissue from a suspicious area, which is then looked at under a microscope. The needle used for FNA biopsy is thinner than the ones used for blood tests. A core biopsy uses a larger needle to sample breast changes felt by the doctor or pinpointed by ultrasound or mammogram. The needle used in core biopsies is larger than that used in FNAB. It removes a small cylinder of tissue (about 1/16- to 1/8-inch in diameter and ½-inch long) from a breast abnormality. Depending on whether the abnormal area can be felt, about 3 to 5 cores are usually removed. Sometimes, surgery is needed to remove all or part of the lump for microscopic examination. This is referred to as a surgical biopsy or an open biopsy. Usually this is an excisional biopsy, where the surgeon removes the entire mass or abnormal area, as well as a surrounding margin of normal-appearing breast tissue (as opposed to an incisional biopsy, where only part of the mass is removed).
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