Results and Further Testing: What to expect

steps of treatment
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After the mammogram detects an issue, you will go through steps to determine if it is breast cancer and if so, to what extent.

There are two basic procedures for diagnosing breast cancer:
 
  1. Imaging
  2. Biopsy
 
Imaging
It is the basic step to diagnose breast cancer and to estimate the extent of spread as well as stage of cancer in the patient.
 
Imaging is done by using three methods:
  1. Ultrasonography
  2. Mammography
  3. Breast magnetic resonance imaging (MRI).
 
Biopsy:
Another method for breast cancer diagnosis is biopsy. This method is helpful to know if any abnormal tissue or lump is present in your breast. In this process a pathologist, surgeon or a radiologists removes a small portion of suspicious tissue from the breast. This sample of tissues is examined under the microscope for estimating the presence of cancer cells.
 
Biopsy can be performed in three ways:
  1. Stereotactic Core Biopsy: This procedure is less invasive method to get the samples for diagnosis. It this procedure your breast is compressed and the tissues are removed with a biopsy needle. It is similar to the mammogram. This biopsy does not cause any significant scarring and can heal in very short time period.
  2. Fine Needle Aspiration (FNA) Biopsy: In this procedure a sample of women’s breast lump is taken, this procedure may produce a small mark n the location. FNA often helps to get the results of the lump diagnosis within two three days.
  3. Needle (Wire) Localization Biopsy: This process involves the use of wire and needle in order to locate the abnormal lump in the breast. When your mammogram shows abnormality, needle localization can be helpful. This is an outpatient type of biopsy, which is performed in two steps in one day.
These are the types of breast cancer diagnosis that are generally used to detect the presence of cancer in the patient’s breast. (1)
  
 
The NIH describes the biopsy as follows:
 

Biopsy : The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer. If a lump in the breast is found, a biopsy may be done.

There are four types of biopsy used to check for breast cancer:

  • Excisional biopsy : The removal of an entire lump of tissue.
  • Incisional biopsy : The removal of part of a lump or a sample of tissue.
  • Core biopsy : The removal of tissue using a wide needle.
  • Fine-needle aspiration (FNA) biopsy : The removal of tissue or fluid, using a thin needle.(2)
 
I personally had an ultrasound (of both breasts), then biopsies (of both breasts – a blip in my left breast was checked as a precaution). This was performed before surgery.  Cancer was found in two locations in my right breast from the initial biopsies, therefore a biopsy was also performed on the sentinel lymph node nearest my cancerous breast, which was removed during surgery for testing.  
 
I had two locations in my breast that needed biopsies. One was a lump in the duct, and in another area I had a cyst filled with fluid, where a sampling of the fluid needed to be drawn for testing. 
 
Determining the Stage of Your Breast Cancer
 

Staging breast cancer

Once your doctor has diagnosed your breast cancer, he or she works to establish the extent (stage) of your cancer. Your cancer’s stage helps determine your prognosis and the best treatment options.

Complete information about your cancer’s stage may not be available until after you undergo breast cancer surgery.

Tests and procedures used to stage breast cancer may include:

  • Blood tests, such as a complete blood count
  • Mammogram of the other breast to look for signs of cancer
  • Breast MRI
  • Bone scan
  • Computerized tomography (CT) scan
    Positron emission tomography (PET) scan

Not all women will need all of these tests and procedures. Your doctor selects the appropriate tests based on your specific circumstances and taking into account new symptoms you may be experiencing.

Breast cancer stages range from 0 to IV with 0 indicating cancer that is noninvasive or contained within the milk ducts. Stage IV breast cancer, also called metastatic breast cancer, indicates cancer that has spread to other areas of the body.

Breast cancer staging also takes into account your cancer’s grade; the presence of tumor markers, such as receptors for estrogen, progesterone and HER2; and proliferation factors.(3)

 
 
Testing: Examining the biopsies and cancer cells to determine what type of surgery and treatment is needed
 

If cancer is found, tests are done to study the cancer cells.

Decisions about the best treatment are based on the results of these tests. The tests give information about:

  • how quickly the cancer may grow.
  • how likely it is that the cancer will spread through the body.
  • how well certain treatments might work.
  • how likely the cancer is to recur (come back).

Tests include the following:

  • Estrogen and progesterone receptor test : A test to measure the amount of estrogen and progesterone (hormones) receptors in cancer tissue. If there are more estrogen and progesterone receptors than normal, the cancer is called estrogen and/or progesterone receptor positive. This type of breast cancer may grow more quickly. The test results show whether treatment to block estrogen and progesterone may stop the cancer from growing.
  • Human epidermal growth factor type 2 receptor (HER2/neu) test : A laboratory test to measure how many HER2/neu genes there are and how much HER2/neu protein is made in a sample of tissue. If there are more HER2/neu genes or higher levels of HER2/neu protein than normal, the cancer is called HER2/neu positive. This type of breast cancer may grow more quickly and is more likely to spread to other parts of the body. The cancer may be treated with drugs that target the HER2/neu protein, such as trastuzumab and pertuzumab.
  • Multigene tests: Tests in which samples of tissue are studied to look at the activity of many genes at the same time. These tests may help predict whether cancer will spread to other parts of the body or recur (come back).

There are many types of multigene tests.

The following multigene tests have been studied in clinical trials:

  • Oncotype DX : This test helps predict whether early-stage breast cancer that is estrogen receptor positive and node negative will spread to other parts of the body. If the risk that the cancer will spread is high, chemotherapy may be given to lower the risk.
  • MammaPrint : This test helps predict whether early-stage breast cancer will spread to other parts of the body. If the risk that the cancer will spread is high, chemotherapy may be given to lower the risk.

Based on these tests, breast cancer is described as one of the following types:

  • Hormone receptor positive (estrogen and/or progesterone receptor positive) or hormone receptor negative (estrogen and/or progesterone receptor negative).
  • HER2/neu positive or HER2/neu negative.
  • Triple negative (estrogen receptor, progesterone receptor, and HER2/neu negative).

This information helps the doctor decide which treatments will work best for your cancer.

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) and treatment options depend on the following:

  • The stage of the cancer (the size of the tumor and whether it is in the breast only or has spread to lymph nodes or other places in the body).
  • The type of breast cancer.
  • Estrogen receptor and progesterone receptor levels in the tumor tissue.
  • Human epidermal growth factor type 2 receptor (HER2/neu) levels in the tumor tissue.
  • Whether the tumor tissue is triple negative (cells that do not have estrogen receptors, progesterone receptors, or high levels of HER2/neu).
  • How fast the tumor is growing.
  • How likely the tumor is to recur (come back).
  • A woman’s age, general health, and menopausal status (whether a woman is still having menstrual periods).
  • Whether the cancer has just been diagnosed or has recurred (come back).(4)

I was diagnosed with 2 tumors, Stage 1; HER2-positive; aggressive type.

 
 

TIP: General Breast Cancer Treatment Steps in a Nutshell

  1. Family physician physical exam
  2. Mammogram
  3. Ultrasound
  4. Biopsy
  5. Surgery
  6. Port-a-cath surgical insertion if needed
  7. Pre-Chemotherapy testing
  8. Chemotherapy
  9. Pre-Radiation testing if needed
  10. Radiation
  11. Continuation with non-chemo drugs if needed
  12. Hormone treatment if needed
  13. Ongoing management and testing

TIP: Cancer Treatment Team

 If cancer is detected, you will have a team of doctors and other specialists assigned to you or available to you, and you will be offered other forms of help and resources. The list below is a good example, some are dependent on the patient’s needs and the care facility.

  • Primary care doctor
  • Medical oncologist
  • Surgical oncologist
  • Nurses
  • Radiologists/technicians
  • In-hospital Pharmacist
  • In-hospital Dietitian
  • Psychologists/social workers
  • Physical therapists
  • Rehabilitation specialists
  • Spiritual support providers
  • Palliative care providers
  • Plastic surgeon
  • Social workers (5)
  • Patient navigator (6)

TIP: Biopsy Markers

At the time of my biopsies the doctor had inserted markers to show where the tumors were. They are placed to show location, but also for referring back to the areas for more tumor growth. See the Helpful Links, below for more details. But, generally, they are inserted at the same time the biopsy is taken. The tissue is taken and the marker inserted via a needle. You cannot feel it.

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Helpful Links

https://www.cancer.org/cancer/breast-cancer/screening-tests-and-early-detection/breast-biopsy.html

(2) https://www.cancer.gov/types/breast/patient/breast-treatment-pdq#section/_148 (very good, detailed information here)

(3) https://www.mayoclinic.org/diseases-conditions/breast-cancer/diagnosis-treatment/drc-20352475

https://www.cancer.org/cancer/breast-cancer/screening-tests-and-early-detection/tests-to-find-out-if-breast-cancer-has-spread.html

https://ww5.komen.org/BreastCancer/LumpectomyTheSurgicalProcedure.html

(includes explanation of biopsy markers or “clips”.)

(1) http://www.cancer8.com/breast-cancer/breast-cancer-diagnosis.html

(4) https://www.cancer.gov/types/breast/patient/breast-treatment-pdq#section/_148

 

TIPS Sources

(5) https://blog.dana-farber.org/insight/2016/03/how-can-social-workers-help-cancer-patients/
 

(6) https://www.cancer.org/latest-news/navigators-help-cancer-patients-manage-their-care.html

 

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