Diagnosis and Staging of Breast Cancer
Whenever a patient presents with breast-related symptoms, she is always worried about whether it is cancer. Often when I examine the patients, many of them ask me, "Doctor, is it something serious? Please tell me whether it is cancer or not?"
I’d like to share with you what I often explain to my patients who ask me this question.
The diagnosis of breast cancer is always done by “Triple assessment“. What does that mean? It means that the process of diagnosis involves three steps.
Step No 1: Clinical assessment, which includes a thorough history taking about the breast problem with which the lady has presented and a proper examination of breasts, armpits and neck.
Step No. 2: During the clinical examination, if the doctor notices any abnormalities in either breast, further radiological investigation is advised appropriate to the patient’s age. These investigations include mammography, ultrasound scan, and MRI of both breasts. In women younger than 40 years commonly ultrasound of the breasts is the first investigation and mammography is generally the first choice in older women. However, on many occasions, the doctor may advise more than one investigation. In many women who have dense breasts, all three may be needed to appropriately visualise the extent of abnormality within the breasts, and they complement each other. Sometimes it is very difficult for the doctors to explain why all these investigations are needed in one patient.
Step No. 3: The third and the most important step is pathological assessment of the abnormal finding in the breast. It is called a ‘biopsy’. The most ideal way to do this is under image guidance. It increases the accuracy of the biopsy procedure and prevents repeat biopsy procedures. The simplest and most economical way of doing this is to perform this biopsy under USG guidance. However, occasionally some abnormalities are not visualised on USG. In such a situation, biopsies are performed under mammography (also called as stereotactic biopsy) or under MRI guidance. There is another technique of doing pathological assessment which is called as FNAC or fine needle aspiration cytology. However, it has some limitations and it has been replaced by a needle biopsy.
FNAC is usually used for assessment of nodes in the armpit. It is also carried out under the guidance of USG scan.
Once the diagnosis of breast cancer is made, it is important to assess the clinical stage of the disease because the management planning depends on stage of the disease. Staging process includes investigations to assess whether the disease has spread to any other part of the body like lungs, liver, bones or brain. Appropriate investigations are advised depending on patient’s symptoms which may indicate spread of the disease. The likelihood of spread of the disease to other parts of the body is very minimal in patients with early stage disease hence only x ray chest and ultrasound scan of abdomen suffice. For locally advanced disease or for patients who have any suspicious findings on above investigations, a whole body PET-CT scan is indicated.
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