Diagnosing and staging breast cancer
Every person with breast cancer is different, and every tumor is different. The more we can learn about your specific tumor, the better we can customize your treatment plan to you.
At Fred Hutchinson Cancer Center, we do extensive testing to diagnose and stage your disease precisely and accurately. Identifying features of your disease is important. It helps your physicians choose the treatments that will work best.
Getting a diagnosis
Getting a breast cancer diagnosis usually starts in one of two ways. One is that your screening mammogram shows something that isn’t normal. The other is that you notice signs or symptoms and decide to see a physician. Then, you will often have an exam, imaging tests and a biopsy.
Many of our breast cancer patients are first diagnosed right here at Fred Hutch. Our breast health experts look at your signs and symptoms, and they do screenings, imaging tests and biopsies. Fred Hutch breast imaging specialists study your imaging tests and give the results. Our pathologists test your tissue samples to get details about your specific cancer. Together, these details create a complex picture that will help guide decisions about your treatment. For example, some medicines may work well against some types of breast cancers but not others.
We have many patients with breast cancer who come to Fred Hutch after they have been diagnosed somewhere else. Before your first visit with Fred Hutch physicians, we will go over the results of your scans and tests so far. Our breast imaging specialists look at your mammograms and any other scans. Our pathologists look at the pathology slides and the report from your biopsy. We may also run more tests on your tissue samples. We do this in order to be sure about your diagnosis and to plan treatment that matches your needs.
Imaging tests and biopsies
We offer a full range of imaging tests and biopsy methods to get the details we need to know your diagnosis, stage your disease and plan your care.
Imaging tests for breast cancer
Fred Hutch is recognized as a Breast Imaging Center of Excellence by the American College of Radiology.
Our technologists and radiologists specialize in breast imaging only. They will do your imaging tests and give the results. To help find and diagnose breast cancer, we use mammography, ultrasound and breast MRI (magnetic resonance imaging).
Your team uses the same types of imaging to figure out the stage of your disease. For staging, you may also need more imaging, like a chest X-ray, CT (computed tomography) scan, PET (positron emission tomography) scan or bone scan.
Fred Hutch physicians use 3D mammography to check breast problems or symptoms. We also use it to follow up if a screening showed something abnormal. Typically, we take more views of one or both breasts to get more details.
Our radiologists specialize in mammography. Studies show that specialists like ours can read the images more accurately than physicians with less experience.
If your mammogram shows anything that isn’t normal, it might help to get a breast ultrasound. This can help your care team check lumps that are hard to see on a mammogram.
Sound waves bounce off solids and fluids differently. So an ultrasound can often help us tell if a lump is a solid mass or a benign cyst (a sac of fluid that is not cancer).
MRI can help us see breast cancers that are harder to see on a mammogram. This makes MRI an important test for some people. We use it to diagnose and plan treatment.
Fred Hutch radiologists are experts at knowing if this test will help you. We have the training and knowledge to get high-quality breast MRI images.
Biopsies for breast cancer
To know for sure if you have breast cancer, you will need a biopsy. Biopsies show if there are cancer cells in a small tissue sample or in a tumor that was taken out by surgeons.
In most cases, Fred Hutch breast health specialists get a sample of tissue using a small needle (core biopsy) under precise image guidance. This can mean using ultrasound, mammography (stereotactic biopsy) and MRI imaging. If core biopsies do not give your care team clear results, you might need a surgical biopsy.
After diagnosis, most people will need surgery to take out their breast tumor. We may do more tests on the tumor as well as nearby lymph nodes to see if cancer has spread there (sentinel lymph node biopsy).
Fred Hutch pathologists will study and test your tissue samples to learn about your specific disease. This matters so your team can choose the treatments that will work best for you.
Staging breast cancer
Staging means finding out how far cancer has spread in your breast or other parts of your body. Accurate staging helps your physicians decide which therapies to use to treat your disease. There are two main systems for staging breast cancer: TNM staging and overall stage grouping.
Your Fred Hutch physicians will base your stage on a physical exam, imaging tests and biopsies. This is sometimes called clinical staging. We will do all the tests you need at Fred Hutch. Your team will help plan your appointments to make a schedule that works best for you.
Most people with breast cancer will have surgery to remove their tumor as well as some lymph nodes under their arm. Tests on the tumor and nodes can give your physicians more details about the type of cancer and the treatments you may need. It is normal to learn more about your stage after this surgery. This is called pathologic staging.
TNM stands for tumor, nodes and metastasis. Your TNM stage is:
- The letter T with a number from 0 to 4. A higher T number means the tumor is larger, has spread more widely into nearby tissues or both.
- The letter N with a number from 0 to 3. A higher N number means more spread of cancer cells to lymph nodes near the breast, such as in the armpit or under the collarbone.
- The letter M with a 0 or 1. M0 means physicians did not find cancer in lymph nodes away from your breast or in distant organs. M1 means distant spread was found.
After your physician finds your TNM stage, they will assign a stage using Roman numerals I (one), II (two), III (three) or IV (four).
- Stage 0: Noninvasive cancers (which are only in the milk ducts or glands).
- Stage I: The tumor is smaller than 1 inch across. It has not spread to lymph nodes under your arm or to other places outside your breast.
- Stage II: The tumor is 1 to 2 inches across, or cancer has spread to lymph nodes under your arm. Stage I or II cancers are considered early-stage cancers.
- Stage III: Cancer is in your breast, surrounding tissues and lymph nodes. Stage III cancers may be considered early-stage or advanced cancers.
- Stage IV: Cancer has spread to distant parts of your body or to lymph nodes outside your armpit. This is called metastatic cancer.
Types and features of breast cancer
There are many types of breast cancer. Knowing your type is important in planning the right treatment.
In this noninvasive type of breast cancer, cancer cells are only in the milk ducts. Surgery to remove the cancer is recommended to keep it from turning into invasive cancer. Surgery is also important to rule out the chance that some invasive cancer is already there. Radiation therapy and hormone therapy are also common parts of treatment.
This type can start in the milk ducts or the lobules (glands that make milk), and it can grow into surrounding breast tissue. The most common types of invasive breast cancer are:
- Invasive ductal carcinoma
- Invasive lobular carcinoma
Invasive breast cancer can spread beyond your breast. Breast cancer typically spreads to lymph nodes under the arm and to other nodes in the same region before it spreads to other parts of the body. Breast cancer that spreads to other organs, such as the lung, liver or bones, is called metastatic or stage IV (four) disease.
Along with the types listed above, there are other types of breast cancer. They include rare types like inflammatory breast cancer, metaplastic breast cancer, angiosarcoma and Paget disease of the nipple.
To select the right treatments for you, your care team needs to know if your cancer cells have hormone receptors. These are points where estrogen, progesterone or both can attach and make the cells grow. If your cancer cells have these, your cancer is hormone receptor-positive (HR+). It may respond to endocrine therapies (also called hormonal or anti-estrogen therapies).
Another key feature is if the cancer cells have more HER2 receptors than normal. HER2 stands for human epidermal growth factor type 2. If your cancer cells have more of these receptors than normal, the cancer is HER2-positive (HER2+). It may respond to certain targeted therapies, such as trastuzumab.
Triple-negative breast cancer is breast cancer that has normal HER2 receptors and doesn’t have receptors for estrogen or progesterone.
Based on the type and stage of your breast cancer, your SCCA care team may run more tests on your cancer cells. For example, we may do genetic testing to see how likely early-stage breast cancer is to spread or come back. If tests show that the risk is high, you may benefit from having chemotherapy along with endocrine therapy, rather than endocrine therapy alone.
There are many more examples. If tests show that you have genetic changes in the genes BRCA1 or BRCA2, you might benefit from a group of medicines called PARP inhibitors. At SCCA, we do any testing that can help us choose the treatments that are right for you.