Screening and Diagnosis

Most breast-cancer-related tests fall into one or more of the following categories

Screening tests : Screening tests (such as yearly mammograms) are given routinely to people who appear to be healthy and are not suspected of having breast cancer. Their purpose is to find breast cancer early, before any symptoms can develop and the cancer usually is easier to treat
Diagnostic tests : Diagnostic tests (such as biopsy) are given to people who are suspected of having breast cancer, either because of symptoms they may be experiencing or a screening test result. These tests are used to determine whether or not breast cancer is present and, if so, whether or not it has travelled outside the breast. Diagnostic tests also are used to gather more information about the cancer to guide decisions about treatment.
Monitoring tests : Once breast cancer is diagnosed, many tests are used during and after treatment to monitor how well therapies are working. Monitoring tests also may be used to check for any signs of recurrence.

Here are the tests you may have at different points in the process of screening, diagnosis, and treatment. The tests are covered in alphabetical order.

Ultrasonography

Ultrasound is an imaging test that sends high-frequency sound waves through your breast and converts them into images on a viewing screen. The ultrasound technician places a sound-emitting probe on the breast to conduct the test. There is no radiation involved.

Ultrasound is not used on its own as a screening test for breast cancer. Rather, it is used to complement other screening tests. If an abnormality is seen on mammography or felt by physical exam, ultrasound is the best way to find out if the abnormality is solid (such as a benign fibroadenoma or cancer) or fluid-filled (such as a benign cyst). It cannot determine whether a solid lump is cancerous, nor can it detect calcifications.

If you’re under age 30, ultrasound is recommended before mammography to evaluate a palpable breast lump (a breast lump that can be felt through the skin). Mammograms can be difficult to interpret in young women because their breasts tend to be dense and full of milk glands. (Older women’s breasts tend to be more fatty and are easier to evaluate.) In mammograms, this glandular tissue looks dense and white — much like a cancerous tumour. Some doctors say that locating an abnormality in the midst of dense gland tissue can be like finding a polar bear in a snowstorm. Most breast lumps in young women are benign cysts, or clumps of normal glandular tissue.

Ultrasound is also used to guide biopsy needles precisely to suspicious areas in the breast.

Portable ultrasound is used during surgery to localise small impalpable tumours or to guide catheters into central vascular system during chemoport insertions or PICC line insertion

Biopsy

Imaging studies such as ultrasonography , digital mammography and MRI, often along with clinical examination of the breast, can lead doctors to suspect that a person has breast cancer. However, the only way to know for sure is to take a sample of tissue from the suspicious area and examine it under a microscope.

A biopsy is a small procedure done to remove tissue partially or completely from an area of concern in the body. If your doctor feels anything suspicious in your breast, or sees something suspicious on an imaging study, he or she will order a biopsy. The tissue sample is examined by a pathologist (a doctor who specializes in diagnosing disease) to see whether or not cancer cells are present. If cancer is present, the pathologist can then look at the cancer’s characteristics. The biopsy will result in a report that lays out all of the pathologist’s findings.

Biopsy is usually a simple procedure. In India, about 40% of women who have biopsies turn out to have cancer.

Biopsy techniques

Different techniques can be used to perform biopsy, and it’s likely that your surgeon will try to use the least invasive procedure possible — the one that involves the smallest incision and the least amount of scarring. However, the choice of procedure really depends on your individual situation. Biopsy can be done by placing a needle through the skin into the breast to remove the tissue sample. Or, it can involve a minor surgical procedure, in which the surgeon cuts through the skin to remove some or all of the suspicious tissue.

Fine needle aspiration biopsy

Fine needle aspiration (FNA) is the least invasive method of biopsy and it usually leaves no scar. You will be lying down for this procedure. First, an injection of local anesthesia is given to numb the breast. The surgeon or radiologist uses a thin needle with a hollow center to remove a sample of cells from the suspicious area. In most cases, he or she can feel the lump and guide the needle to the right place.

In cases where the lump cannot be felt, the surgeon or radiologist may need to use imaging studies to guide the needle to the right location. This is called ultrasound-guided biopsy when ultrasound is used, or stereotactic needle biopsy when mammogram is used. With ultrasound-guided biopsy, the doctor will watch the needle on the ultrasound monitor to guide it to the area of concern. With stereotactic mammography, mammograms are taken from different angles to pinpoint the location of the breast mass. The doctor then inserts the hollow needle to remove the cell sample.

Core needle biopsy

Core needle biopsy uses a larger hollow needle than fine needle aspiration does. If you have this type of biopsy, you’ll be lying down. After numbing the breast with local anesthesia, the surgeon or radiologist uses the hollow needle to remove several cylinder-shaped samples of tissue from the suspicious area. In most cases, the needle is inserted about 3 to 6 times so that the doctor can get enough samples. Usually core needle biopsy does not leave a scar.

If the lesion cannot be felt through the skin, the surgeon or radiologist can use an image-guided technique such as ultrasound-guided biopsy or stereotactic needle biopsy. A small metal clip may be inserted into the breast to mark the site of biopsy in case the tissue proves to be cancerous and additional surgery is required. This clip is left inside the breast and is not harmful to the body. If the biopsy leads to more surgery, the clip will be removed at that time.

In addition to offering quick results without significant discomfort and scarring, both fine needle aspiration and core needle biopsy give you the opportunity to discuss treatment options with your doctor before having any surgery. In some cases, needle biopsy can be performed right in the doctor’s office, unless your doctor needs the help of imaging equipment to guide the biopsy. However, needle biopsy has a higher risk of a “false negative” result — a result suggesting that cancer is not present when it really is. This is likely because needle biopsy removes a smaller amount of tissue than surgical biopsy does and may not pick up the cancer cells. Your doctor may recommend a surgical biopsy in follow up to, or instead of, a needle biopsy. Together you can decide what is best for your situation.

The advantages of core biopsy are as follows:

A good representative core biopsy is usually adequate to give a definitive diagnosis. Repeat biopsies and further excision biopsies for diagnosis can be avoided. We had five patients (1.07%) who had a non-diagnostic core biopsy, requiring further excision biopsy for diagnosis.
A large majority of benign lesions can be followed-up without the need for surgical excision with a benign pathology report on core biopsy. We were able to defer excisions for 60% of patients with a clear rad path concordance for benign lesions.
If the lesion is malignant it is possible to differentiate invasive from in situ malignancy and lobular from ductal carcinoma on a core biopsy.
It is possible to do ER and PR studies and Her2 neu studies on core biopsy samples for proper pre-operative treatment planning.
In a neoadjuvant setting core biopsy tissue might be the only tissue available for prognostic marker and predictive marker studies, as the tumor might respond completely with chemotherapy.
Tumor banking, particularly in the neoadjuvant setting is usual for molecular studies.

The availability of automated guns has made the procedure extremely easy with image guidance. There is no role for routine testing of coagulation parameters before a core biopsy unless patient is on warfarin. Patients on aspirin or clopidogrel may bruise a bit more than usual. Patients should be warned about it, but we have not had to withhold aspirin or clopidogrel for a needle core biopsy. There is no role for routine antibiotics post-procedure.

The possible risks after core biopsy include:

Hematoma

US guidance with colour Doppler can usually identify vasculature and this can be avoided. However, if bleeding occurs it usually stops with pressure post-procedure for 5 min. Ice compresses can be used later by patient for comfort. The presence of a large hematoma can alter the tactile discrimination for the operating surgeon at the time of surgery to ascertain the gross surgical margins in breast conservation surgery. Two of our patients had a significant hematoma following core biopsy. This however, did not affect clinical management as both patients underwent a mastectomy.

Pneumothorax

This can be avoided by the needle staying parallel to the chest wall. It must be remembered that the automated gun has a needle trajectory (throw) of about 2 cm. With some automated guns, this throw can be reduced to 1.5 cm. It is important to keep the entire length of the needle in the breast in vision without angulation toward the chest wall and staying parallel to the chest wall to avoid pneumothorax. When the lesion is close to the chest wall, a generous quantity of local anesthetic can be injected (5-10 ml) behind the lesion between the muscle and the lesion. This lifts the lesion away from the muscle and avoids pain and pneumothorax. None of our patients developed a pneumothorax post-procedure.

Infection

Infection following a core biopsy is rare and there no role for routine antibiotics. There was no core biopsy associated infections in our study.

Needle track seedling of tumor

Needle track seedling is a potential risk, but studies have not shown any increase in the incidence of local recurrence because of needle track seedling. However, the site of the skin nick and the needle track can be kept well within the surgical incision, so it can be included in the excision. Targeting accurately and minimizing the number of passes will also reduce the risk of needle track seedling. Core tack seedling was not reported in this study following excision.

False negative result

It is possible to miss the lesion due to technical difficulties. Deep seated lesions, poor needle or lesion visualization or a dense or fibrotic breast tissue may make the procedure difficult and therefore have a discordant result. When there is histological and radiologic discordance (i.e.,) when mammogram or ultrasound is suspicious of malignancy, but core biopsy histopathology is benign or inconclusive, surgical excision must always be done. Accurate targeting of the lesion will minimize the chances of false negatives. Correlating radiological findings with pathology with appropriate recommendations for further biopsy/surgical excision or follow-up should be performed. We observed false negative results in around 18% of biopsies in our patients.

Vacuum-assisted breast biopsy ( VAB)

Vacuum-assisted breast biopsy, also known by the brand names Mammotome or MIBB (which stands for Minimally Invasive Breast Biopsy), is a newer way of performing breast biopsy. Unlike core needle biopsy, which involves several insertions of a needle through the skin, vacuum-assisted biopsy uses a special probe that only has to be inserted once. The procedure also is able to remove more tissue than core needle biopsy does.

For vacuum-assisted breast biopsy, you’ll lie face down on an exam table with special round openings in it, where you place your breasts. First, an injection of local anaesthesia is given to numb the breast. Guided by mammography (stereotactic-guided biopsy) or ultrasound, the surgeon or radiologist places the probe into the suspicious area of the breast. A vacuum then draws the tissue into the probe. A rotating cutting device removes a tissue sample and then carries it through the probe into a collection area. The surgeon or radiologist can then rotate the probe to take another sample from the suspicious lesion. This can be repeated 8 to 10 times so that the entire area of concern is thoroughly sampled.

In some cases, a small metal clip is placed into the biopsy site to mark the location, in case a future biopsy is needed. This clip is left inside the breast and causes no pain or harm. If the biopsy leads to more surgery, the clip will be removed at that time.

Vacuum-assisted biopsy is becoming more common, but it is still a relatively new procedure. If you are having this form of biopsy, make sure that the surgeon or radiologist is experienced at using the equipment.

Incisional biopsy

Incisional biopsy is more like regular surgery. After using local anesthesia to numb the breast and giving you an injection to make you drowsy, the surgeon uses a scalpel to cut through the skin to remove a piece of the tissue for examination.

As with needle biopsy, if the surgeon cannot feel the lump or suspicious area, he or she may need to use mammography or ultrasound to find the right spot. Your surgeon also may use a procedure called needle wire localization. Guided by either mammography or ultrasound, the surgeon inserts a small hollow needle through the breast skin into the abnormal area. A small wire is placed through the needle and into the area of concern. Then the needle is removed. The doctor can use the wire as a guide in finding the right spot for biopsy.

Your doctor may recommend incisional biopsy if a needle biopsy is inconclusive — that is, the results are unclear or not definite — or if the suspicious area is too large to sample easily with a needle. As with needle biopsy, there is some possibility that incisional biopsy can return a false negative result. However, you do get the results fairly quickly. Given that it is a surgical procedure, incisional biopsy is more invasive than needle biopsy, it leaves a scar, and it may require more time to recover.

Excisional biopsy

Excisional biopsy, the most involved form of biopsy, is surgery to remove the entire area of suspicious tissue from the breast. In addition to removing the suspected cancer, the surgeon generally will remove a small rim of normal tissue around it as well, called a margin.

As with incisional biopsy, if the surgeon cannot feel the lump or suspicious area, he or she may need to use mammography or ultrasound to find the right spot. Your surgeon also may use needle wire localization to mark the right area for biopsy.

Excisional biopsy is the surest way to establish a definite diagnosis without getting a false negative result. Also, having the entire lump removed may provide you with some peace of mind. However, excisional biopsy is more like regular surgery, and it will leave a scar and require more time to recover. Like incisional biopsy, excisional biopsy is performed with local anesthesia.

Before your biopsy

Biopsies are not medical emergencies and can be scheduled at your convenience. But for peace of mind, most people want their biopsies done “yesterday.”

Medical guidelines say that about 90% of biopsies should be needle biopsies, the least invasive procedure. Still, research has shown that about 70% of breast biopsies are surgical biopsies. This means that many women who don’t have cancer are having unnecessary surgery. It also means that women who are diagnosed with breast cancer have to have a second operation to remove the cancer.

Before proceeding with a biopsy, be sure to ask your doctor to:

review the results of your mammogram and any other imaging studies with you
show you the area in question
explain the type of biopsy that’s recommended for you and explain why that type of biopsy is recommended; if surgical biopsy is recommended ask if needle biopsy can be done
discuss how and why the biopsy will be performed
answer any of your questions
arrange for you to sign required consent forms
tell you when and how you can get the biopsy results

A few days to a week after biopsy, your doctor should give you a pathology report that explains what was found in the tissue sample.

Myths of Biopsy

Biopsy increases tumour size- Any needle biopsy doesn’t cause any change in tumour size per se. You may get transient increase in its size after biopsy for some days . It’s usually because of internal bleeding at biopsy site causing haematoma or inflammatory response due to procedure

Biopsy causes Cancer spread – studies have not shown any evidence of needle track seedling or disintegration and dispersion of cancer cells into blood vessels causing distant spread of the disease.

Digital Mammography

Mammograms are probably the most important tool doctors have not only to screen for breast cancer, but also to diagnose, evaluate, and follow people who’ve had breast cancer. Safe and reasonably accurate, a mammogram is an X-ray photograph of the breast. The technique has been in use for more than 50 years.

Diagnostic mammograms are different from screening mammograms. Diagnostic mammograms focus on getting more information about a specific area (or areas) of concern — usually because of a suspicious screening mammogram or a suspicious lump. Diagnostic mammograms take more pictures than screening mammograms do. A mammography technician and a radiologist work together to get the images your doctor needs to address that concern.

Routine screening mammograms for women with an average risk of breast cancer should start at age 50 instead of age 40. For women at average risk, screening mammograms should be performed annually beginning at age 40 to check the breasts for any early signs of breast cancer. If you have a higher risk of breast cancer, you and your doctor may decide that you will be start screening mammograms at a younger age.

Finding breast cancers early with mammography has also meant that many more women being treated for breast cancer are able to keep their breasts. When caught early, localized cancers can be removed without resorting to breast removal (mastectomy).

The main risk of mammograms is that they aren’t perfect. Normal breast tissue can hide a breast cancer so that it doesn’t show up on the mammogram. This is called a false negative. And mammography can identify an abnormality that looks like a cancer, but turns out to be normal. This “false alarm” is called a false positive. Besides worrying about being diagnosed with breast cancer, a false positive means more tests and follow-up visits, which can be stressful. To make up for these limitations, more than mammography is often needed. Women also need to practice breast self-examination, get regular breast examinations by an experienced health care professional, and, in some cases, also get another form of breast imaging, such as breast MRI or ultrasound.

Important things to know about mammograms

They can save your life. Finding breast cancer early reduces your risk of dying from the disease by 25-30% or more. Women should begin having mammograms yearly at age 40, or earlier if they’re at high risk.
Don’t be afraid. Mammography is a fast procedure (about 20 minutes), and discomfort is minimal for most women. The procedure is safe: there’s only a very tiny amount of radiation exposure from a mammogram. To relieve the anxiety of waiting for results, go to a center that will give you results before you leave.
Get the best quality you can. If you have dense breasts or are under age 50, try to get a digital mammogram. A digital mammogram is recorded onto a computer so that doctors can enlarge certain sections to look at them more closely.

Myths about mammography

Mammography causes cancer – Some women wonder about the risks of radiation exposure due to repeated mammography. Modern-day mammography only involves a tiny amount of radiation — even less than a standard chest X-ray. Annual mammogram for a lifetime doesn’t cause exposure to radiation which can cause cancer.

Mammography prevents Cancer – Mammograms don’t prevent breast cancer, but they can save lives by finding breast cancer as early as possible.

Mammography is unsafe during pregnancy -it’s generally thought to be safe to have a mammogram during pregnancy. The amount of radiation needed for a mammogram is small, and the radiation is focused on the breasts, so that most of it doesn’t reach other parts of the body. The “scatter” that might reach the embryo would be extremely small and would not represent an increased risk for birth defects or miscarriage to embryo

Mammography technique

There are two main types of mammography: film-screen mammography and digital mammography, also called full-field digital mammography or FFDM. The technique for performing them is the same. What differs is whether the images take the form of photographic films or of digital files recorded directly onto a computer.

When you have a mammogram, a skilled technologist positions and compresses your breast between two clear plates. The plates are attached to a highly specialized camera, which takes two pictures of the breast from two directions. Then the technologist repeats the technique on the opposite breast. For some women, more than two pictures may be needed to include as much tissue as possible.

Mammography can be painful for some women, but for most it is mildly uncomfortable, and the sensation lasts for just a few seconds. Compressing the breast is necessary to flatten and reduce the thickness of the breast. The X-ray beam should penetrate as few layers of overlapping tissues as possible. From start to finish, the entire procedure takes about 20 minutes. A diagnostic mammogram generally takes more time than a screening mammogram because it takes more pictures from more angles.

Mammography involves minimal radiation exposure. In fact, the amount of radiation exposure from modern-day mammography machines is much lower than it was in past decades. The American Cancer Society notes that the dose of radiation received during a screening mammogram is about the same amount of radiation a person gets from their natural surroundings (background radiation) in an average 3-month period.

If you’ve had breast surgery for another reason, such as a benign biopsy or surgery to reduce the size of your breasts, the radiologist will want to know where those scars are in case the scar tissue has to be distinguished from another kind of breast abnormality. If you’ve had breast cancer surgery, small metal balls will be taped on your skin to mark your scar. Your scar defines the site with the highest risk of recurrence.

At least one radiologist reads the mammogram. A radiologist is a doctor who specializes in analyzing imaging studies of the body to diagnose disease or other problems. Having two radiologists read your mammogram reduces the chance of missing a problem by about 10-15%. Some centers routinely have your mammogram read twice, but this is expensive, and most insurance companies won’t pay for it. You can also get a “second opinion” on your mammogram by having the images analyzed by a computer. This is called computer-aided detection (CAD). Special computer software reviews the images and marks any areas of suspicion. The radiologist then examines each area and decides if it needs further evaluation.

Types of mammography: Film-screen vs. digital

If you’ve had a film-screen mammogram, the images will be in black and white on large sheets of film. With digital mammography, the images are recorded directly into a computer. The image can then be viewed on a computer screen and specific areas can be enlarged or highlighted. If there is a suspicious area, your doctors can use the computer to take a closer look. The images also can be transmitted electronically from one location to another.

Many studies have shown that film-screen and digital mammography are equally accurate in screening for breast cancer. One 2005 study of nearly 50,000 women, the Digital Mammographic Imaging Screening Trial (DMIST), found that digital mammography was a better screening tool than film-screen mammography only for women who either:

If you fall into any one of these three categories, talk to your doctor about having digital mammography. If you’re not sure whether or not you have dense breast tissue, your doctor can help — usually by looking at previous mammograms you may have had.

The other advantages of digital mammography versus film-screen are that (1) digital images can be manipulated for better views and they can be stored more easily, and (2) digital mammograms deliver about three-fourths of the radiation that film-screen mammograms do (although film-screen mammograms deliver a safe and very small amount of radiation). The disadvantages of digital mammography are that it is more expensive and not as widely available as film-screen mammography.

In the future, it’s expected that digital mammography will become more common. In the meantime, you can speak with your doctor about which type of mammography is best for your individual situation. If your doctor recommends digital mammography, or you want to have it, you can work together to determine where it is available in your area. You also may need to confirm that your insurance plan will cover this type of screening.

Mammography Findings-

Most screening mammograms include two views of each breast taken from different angles. Diagnostic mammograms involve taking more views than screening mammograms. Even if you have a lump in only one breast, pictures will be taken of both breasts. This is so the breasts can be compared and so that the other breast can be checked for abnormalities. If you’ve had a mammogram before, the radiologist should compare your old mammogram to the new one to look for changes.

There are soecific features of lesions seen on mammograph which points toward the possibility of cancer like- dense shadow, irregular shape, sometimes with microcalcifications, sun ray appearance ( Stellate ) of the mass etc.

While they’re looking for possible cancer, your doctors may also come across masses or structures in the breast that deserve further investigation, including:

Calcifications : Calcifications are tiny flecks of calcium — like grains of salt — in the soft tissue of the breast that can sometimes indicate the presence of an early breast cancer. Calcifications usually can’t be felt, but they appear on a mammogram. Depending on how they’re clustered and their shape, size, and number, your doctor may want to do further tests.
Big calcifications — “macrocalcifications” — are usually not associated with cancer. Groups of small calcifications huddled together, called “clusters of microcalcifications,” are associated with extra breast cell activity. Most of the time this is non-cancerous extra cell growth, but sometimes clusters of microcalcifications can occur in areas of early cancer.
Cysts : Unlike cancerous tumors, which are solid, cysts are fluid-filled masses in the breast. Cysts are very common and are rarely associated with cancer. A follow-up ultrasound is the best way to tell a cyst from a cancer, because sound waves pass right through a liquid-filled cyst. Solid lumps, on the other hand, bounce the waves right back to the film.
Fibroadenomas : Fibroadenomas are movable, solid, rounded lumps made up of normal breast cells. While not cancerous, these lumps may grow. And any solid lump that’s getting bigger is usually removed to make sure that it’s not a cancer. Fibroadenomas are the most common kind of breast mass, especially in young women.

Mammography Results

Radiologists use the Breast Imaging Reporting and Database System, or BI-RADS, to report the findings of mammograms. Talk to your doctor about what category your result falls into and what follow-up plan he or she recommends.

Breast Imaging Reporting and Database System (BI-RADS)

Category	Assessment	Follow-up
0	Need additional imaging evaluation: means that more studies are necessary to gather more information.	Additional imaging needed before a category can be assigned.
1	Additional imaging needed before a category can be assigned.	Additional imaging needed before a category can be assigned.
2	Additional imaging needed before a category can be assigned.	Continue annual screening mammography (for women over age 40).
3	Probably benign: means that there is a finding that is most likely benign, but should be followed in a shorter period of time to see if the area of concern changes.	Probably benign: means that there is a finding that is most likely benign, but should be followed in a shorter period of time to see if the area of concern changes.
4	Suspicious abnormality: means that there are suspicious findings that could turn out to be cancer.	Suspicious abnormality: means that there are suspicious findings that could turn out to be cancer.
5	Highly suggestive of malignancy (cancer): means that there are findings that look like and probably are cancer.	Highly suggestive of malignancy (cancer): means that there are findings that look like and probably are cancer.
6	Highly suggestive of malignancy (cancer): means that there are findings that look like and probably are cancer.	Biopsy confirms presence of cancer before treatment begins.

Mammogram reports also include an assessment of your breasts’ density. Dense breasts have less fatty tissue and more non-fatty tissue compared to breasts that aren’t dense. Dense breasts:

BI-RADS classifies breast density into four groups:

Mostly fatty: The breasts are made up of mostly fat and contain little fibrous and glandular tissue. This means the mammogram would likely show anything that was abnormal.
Scattered density: The breasts have quite a bit of fat, but there are a few areas of fibrous and glandular tissue.
Consistent density: The breasts have many areas of fibrous and glandular tissue that are evenly distributed through the breasts. This can make it hard to see small masses in the breast.
Extremely dense: The breasts have a lot of fibrous and glandular tissue. This may make it hard to see a cancer on a mammogram because the cancer can blend in with the normal tissue.

Dos and Don’ts before mammography –

Don’t wear underarm deodorant or antiperspirant.

Deodorant can look like calcifications

Many deodorants contain metallic substances — aluminum is a common culprit — and on a mammogram, their dense particles can look just like calcifications. Calcifications are small deposits of calcium that show up as bright white specks or dots or like tiny grains of sand on the soft tissue background of the breasts because the calcium absorbs the X-rays from mammograms.

Calcifications are a sign of some underlying process that is happening in the breast tissue. Usually that process isn’t worrisome. Tissue injury or infection, cysts or other benign (non-cancerous) growths, and even simple aging are common causes of calcifications.

But sometimes calcifications can be a sign of an early cancer developing inside a breast duct. When abnormal cells grow unchecked inside the duct, the cells might get so crowded that some of them die and the body can’t clear them away. If this happens, those cells can harden (or petrify), and areas of calcification form. That’s why physicians take calcifications so seriously.

Don’t apply any cream/lotion or powder on breasts

Breast tissue is compressed under plates during mammography scanning.

One of the purposes of compression [during mammography] is to get as much of the breast tissue on the plate as possible. It’s harder for the technologist to get clear images if the skin is slippery, because there can be some blurring due to movement.

Avoid caffeine on the day of Mammography

Don’t drink coffee, tea, Chocolate or caffeinated soft drinks 3-4 days before a mammogram appointment. Caffeine can make breasts tender and lumpy, which may lead to discomfort during a mammogram.

Wear easy clothes

Avoid single piece clothes on the day of Mammography appointment

You might find it easier to wear a skirt or pants, so that you’ll only need to remove your top and bra for the mammogram.

Wear a snug breast support ( bra of proper size) after scan. It gives ou comfort after compression.

Analgesics

You can have a single dose mild pain killer ( aspirin / paracetamol ) 20-30 min before the scanning . It gives you comfort during and after compressions.

Digital Tomosynthesis

Digital tomosynthesis of the breast is different from a standard mammogram in the same way a ball is different from a a circle. One is 3-dimensional, the other is flat.

Mammography usually takes two X-rays of each breast from different angles: top to bottom and side to side. The breast is pulled away from the body, compressed, and held between two glass plates to ensure that the whole breast is viewed. Regular mammography records the pictures on film, and digital mammography records the pictures on the computer. The images are then read by a radiologist. Breast cancer, which is denser than most healthy nearby breast tissue, appears as irregular white areas — sometimes called shadows.

Mammograms are very good, but they have some significant limitations

The compression of the breast that’s required during a mammogram can be uncomfortable. Some women hate it, and it could deter them from getting the test.
The compression also causes overlapping of the breast tissue. A breast cancer can be hidden in the overlapping tissue and not show up on the mammogram.
Mammograms take only one picture, across the entire breast, in two directions: top to bottom and side to side. It’s like standing on the edge of a forest, looking for a bird somewhere inside. To find the bird, it would be better to take 10 steps at a time through the forest and look all around you with each move.

ABV scan MR mammography

There are very selective indications for the use of MRI breast. They are-

Diagnosed cancer underarms without evident primary focus in breast by clinical examination and conventional imaging
Very dense breast
Discordant findings on various modalities of breast examination like – clinical findings, USG, Digital mammography etc.
To evaluate the response to Neoadjuvant chemotherapy before Breast conservation surgery and oncoplasty
Screening for ‘high risk Women’

MRI breast is not recommended for routine screening for all women.

All high-risk women i.e those with a greater than 20% lifetime risk of breast cancer should have a breast MRI and a mammogram every year. For most women, these combined screenings should start at age 30 and continue as long as the woman is in good health. According to ACS guidelines, high-risk women include those who:

have a known BRCA1 or BRCA2 gene mutation
have a first-degree relative (mother, father, brother, sister, or child) with a BRCA1 or BRCA2 gene mutation and have not had genetic testing themselves
find out they have a lifetime risk of breast cancer of 20-25% or greater, according to risk assessment tools that are based mainly on family history
had radiation therapy to the chest for another type of cancer, such as Hodgkin’s disease, when they were between the ages of 10 and 30 years
have a genetic disease such as Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or have one of these syndromes in first-degree relatives

It is recommended that women at moderately increased risk of breast cancer i.e those with a 15-20% lifetime risk should talk with their doctors about the possibility of adding breast MRI screening to their yearly mammogram. This includes women who:

find out they have a lifetime risk of breast cancer of 15-20%, according to risk assessment tools based mainly on family history
have a personal history of breast cancer, ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS), or abnormal breast cell changes such as atypical ductal hyperplasia or atypical lobular hyperplasia
have extremely dense breasts or unevenly dense breasts when viewed by mammograms

Why breast MRI is not recommended for screening all women

Breast MRI is not recommended as a screening tool for women who are at average risk of developing breast cancer. Yes, breast MRI has been found to be more sensitive in detecting cancers than mammograms, which does seem like an advantage. However, a major disadvantage is that breast MRI screening results in more false positives — in other words, the test finds something that initially looks suspicious but turns out not to be cancer. If breast MRI were adopted as a screening tool for everyone, many women would end up having unnecessary biopsies and other tests, not to mention the anxiety and distress. That is why current recommendations reserve breast MRI screening for high-risk women only.
MRI is also more expensive than mammography, and dedicated breast MRI screening equipment is not widely available.

MRI mammography should be carried out at a specialised centre where the breast coil is available to screen and should be read by well-trained radiologist

PET CT scan

PET scans, short for Positron Emission Tomography, can detect areas of cancer by obtaining images of the body’s cells as they work. First, you are injected with a substance made up of sugar and a small amount of radioactive material. Cancer cells tend to be more active than normal cells, and they absorb more of the radioactive sugar as a result. A special camera then scans the body to pick up any “highlighted” areas on a computer screen. This helps radiologists identify areas where cells are suspiciously active, which can indicate cancer. Once doctors know where to look, further evaluation can be done with other techniques. One example is a combined PET and CT Scan(known as PET/CT), available in some centers.

PET scans are not used to screen women for breast cancer. The test has only a limited ability to detect small tumors. PET scans can be useful for evaluating people after breast cancer has already been diagnosed, in a number of different ways:

PET scans are available in only very few centers, and they are an expensive, sophisticated test that requires special expertise. Generally, they are used only if your doctor has reason to believe that the cancer may have spread beyond the breast. They also may be used if your doctor suspects recurrence of a previous breast cancer. PET scans can be helpful if other tests can’t tell for sure whether the cancer has spread beyond the breast or to other areas of the body.

Bone scan

A bone scan, also called bone scintigraphy, is an imaging test used to determine whether breast cancer has travelled to the bones. Your doctor may order a bone scan:

Bone scans begin with an injection of radioactive material into your arm, which will be taken up by the body’s bone-making cells over the next few hours. These bone-making cells are found mostly in areas damaged by disease, where they are busily trying to make new bone to patch the holes. After waiting 2 to 4 hours for the radioactive substance to be absorbed, the doctor uses a special camera to scan the body. Areas of extra bone activity (common in both cancer and arthritis) will show up on the scan because the radioactive substance collects in areas of new bone formation. These areas appear as dark patches on the film. Any part of the bone can be affected by cancer.

Except for the needle stick to give the injection, a bone scan is painless, although it may require you to lie still for up to an hour while the scanning is done. The test involves very little radiation exposure and poses no greater risk than a standard X-ray.

Many changes that show up on a bone scan are not cancer. With arthritis, the radioactive material tends to show up on the bone surfaces of joints, not inside the bone. But it can be hard to tell the difference between arthritis and cancer — especially in the spine. That’s because the spine is made up of so many little bones and joints. Changes in the spine may require additional evaluation.

Talk to your doctor about whether he or she recommends bone scans for your particular situation. You will not need bone scans if you’ve been diagnosed with a non-invasive form of breast cancer, such as ductal carcinoma in situ (DCIS). Typically there is no need to have yearly follow-up bone scans if you aren’t experiencing any unusual symptoms, such as persistent pain. The exam is expensive and time-consuming, and studies have shown that it won’t improve your quality of life or length of survival. Yet if you’re experiencing persistent back or leg pain, a repeat bone scan that shows no change from the baseline study is usually reassuring. Back pain is a common problem, but if you’ve had breast cancer it can cause a great deal of anxiety.

After your bone scan, you may return to your usual activities. This includes driving.

You should not feel any side effects from the tracer or the test itself. But your doctor may ask you to drink lots of water for the next 1 to 2 days. This flushes out any tracer that may be left in your body. Typically, all of the radioactive material is gone after 2 days.

Keep in mind that a bone scan is a different test than a bone density study (such as DEXA), which evaluates bone strength and your risk of osteoporosis (thinning of the bones).

DEXA scan

Blood Marker tests

Routine Examination- for fitness before surgery/chemotherapy/radiotherapy

Your doctor may prescribe few more general investigation to examine your overall fitness for surgery /chemotherapy/radiotherapy like

Blood investigations– Complete blood count, Liver function tests, Renal function tests, Thyroid Function test, Blood Sugars Levels , Coagulation Profile.

Others -Chest X ray, ECG, 2d Echo, Pulmonary function tests.

You may be guided to have opinion and fitness from cardiologist/ diabetologist /endocrinologist / pulmonologist if you have the respective comorbidities

Screening and Diagnosis

Digital Mammography

Digital Tomosynthesis

ABV scan MR mammography

PET CT scan

Bone scan

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Breast Cancer Statistics

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