What are the symptoms of breast cancer?

Breast lumps

In most women, breast cancer is first noticed as a painless lump in the breast. You should visit your doctor straight away if you notice a lump or are aware of any new change in your breast. Although most breast lumps are benign (not cancerous), they still need to be checked carefully to rule out the possibility of cancer. Also, if it is a cancer, the earlier the treatment is given, the more likely it is to be successful.

Other breast changes

Other, less common signs of breast cancer may include:

• a change in the size or shape of a breast
• dimpling of the skin of the breast
• a thickening in the breast tissue
• a nipple becoming inverted (turned in)
• a lump or thickening behind the nipple
• a rash (like eczema) affecting the nipple
• a bloodstained discharge from the nipple (this is very rare)
• a swelling or lump in the armpit.

Pain in the breast is usually not a symptom of breast cancer. In fact, many healthy women find that their breasts feel lumpy and tender before a period. And some types of non- cancerous breast lumps can be painful.

Non-cancerous breast lumps

Most breast lumps are not cancer (benign). Common causes of benign breast lumps are:

• Cysts – sacs of fluid that build up in the breast tissue. Breast cysts are quite common. Nearly 1 in 10 women will have a breast cyst at some time during her life.
• Fibroadenomas – solid tumours made up of fibrous and glandular tissue. They are more common in women in their 20s and 30s. Benign breast lumps are easily treated.

How breast cancer is diagnosed

Seeing your GP

If you notice a lump or other breast changes, you will probably begin by seeing your GP, who will examine your breasts. If your GP is not sure what the problem is, or thinks that cancer may be present, you will be referred to a specialist for advice or treatment. If your GP suspects that you might have a cancer you should be seen at the hospital within two weeks.

At the hospital

At the hospital, the specialist will ask you about your general health and any previous medical problems, before examining you. He or she will examine your breasts and feel for any enlarged lymph nodes under your arms and at the base of your neck. The specialist will arrange for any tests you may need, usually a mammogram or ultrasound scan, followed by a biopsy (tissue sample) to check for cancer cells.

Tests for breast cancer

The following tests may be used to diagnose breast cancer. You may have one, two or a combination of the tests. You also may have a chest x-ray to check your general health. It can help to have a friend or relative with you when you go for any tests or to get your results.

• Mammogram
• Ultrasound
• Biopsy such as a needle (core) biopsy, fine needle aspiration or excision biopsy
• Blood tests

Mammogram

A mammogram is a low-dose x-ray of the breast tissue. Mammograms can detect changes in the breast tissue before they develop into a lump large enough to be felt.

You will need to take off the clothes from the top part of your body, including your bra. The radiographer will then position you so that the breast is against the x-ray machine and gently but firmly compressed with a flat, clear, plastic plate. Two mammograms (from different angles) are taken of each breast.

Mammograms are usually only used for women over the age of 35. In younger women the breast tissue is more dense, which makes it difficult to detect any changes on the mammogram. Many women find having a mammogram uncomfortable or even painful, but this is normally just for a short time.

Ultrasound

An ultrasound uses sound waves to build up a picture of the breast tissue. Ultrasound can often tell whether a lump is solid (made of cells) or a fluid-filled cyst. It can also often tell whether a solid lump is likely to be benign or malignant.

You will be asked to take off your clothes from the upper part of your body and lie down on a couch. An ultrasound specialist will then put gel onto your breast and gently rub a small microphone-like device over the affected area. This shows a picture of the internal tissue of the breast on a screen. Ultrasound is painless and only takes a few minutes.

A special type of ultrasound, colour Doppler ultrasound, can show the blood supply to the lump. The blood supply shows up as patches of red or blue colour on the scan, and the pattern of the blood flow can help tell the difference between a cancer and a benign lump.

Biopsy

There are several ways of taking a breast biopsy. Doctors may use a needle, sometimes with

What is a biopsy?

A biopsy means taking a small sample of tissue from the body for examination under a microscope. The results of the biopsy can tell doctors whether or not the tissue is cancerous. The tests done on the tissue from the biopsy also give doctors important information about a cancer and how it should be treated.

ultrasound or x-ray to guide the needle to the right area, or perform a small operation to collect the tissue sample.

Needle (core) biopsy

A doctor uses a needle to take a small piece of tissue from the lump or abnormal area. Needle biopsies are often done using ultrasound to guide the doctor to the lump. Local anaesthetic is injected into the area first to numb it. You may feel a little soreness or a sensation of pressure, but this should last only for a short time. Several biopsies are usually taken at the same time. The samples are then sent to a laboratory to be looked at by a specialist (pathologist) under a microscope. Depending on the number of biopsies taken, the breast tissue may be quite bruised and sore afterwards. This may take a few weeks to completely disappear.

Fine needle aspiration

A fine needle aspiration (FNA) is a quick, simple procedure done in the outpatient clinic. Using a fine needle and syringe, the doctor takes a sample of cells from the lump and sends it to the laboratory to see if any cancer cells are present. The breast is sensitive, so the test may be quite uncomfortable and the breast may be bruised and sore for a week or so afterwards. A local anaesthetic may be used to numb the area, particularly if an FNA is being taken from a lymph node in the armpit or in the neck.

Sometimes (especially if the lump is small) a needle aspiration may be carried out in the x- ray department so that the doctor can use x-ray or ultrasound guidance to make sure that the needle takes cells from the abnormal area of the breast.

Excision biopsy

Sometimes the whole lump is removed (excision biopsy) under a general or local anaesthetic and sent to a laboratory for examination under a microscope. This may mean an overnight stay in hospital, but it is done as day surgery in some hospitals.

If a lump is too small to be felt but has shown up on a mammogram or ultrasound, the radiologist may need to mark the area for the surgeon before the excision biopsy. This is done by inserting a very small wire (a guide wire) under local anaesthetic, using x-ray or ultrasound guidance. The procedure is known as wire localisation.

Blood tests

Samples of your blood will be taken to check your general health, the number of cells in your blood (blood count) and to see how well your kidneys and liver are working. Your blood may also be tested to see whether it contains particular chemicals (tumour markers), which are sometimes produced by breast cancer cells.

Waiting for your test results

It will probably take several days for the results of your tests to be ready and a follow-up appointment will be arranged for you before you go home. Obviously, this waiting period is an anxious time, and it may help you to talk things over with a close friend, a relative, the hospital specialist nurse or a support organisation. .

Staging and grading of breast cancer

The stage of a cancer describes its size and whether it has spread beyond where it started in the body. Doctors use the results of tests and findings from surgery to decide the stage of a woman's breast cancer.

Knowing the extent of the cancer and how quickly it is likely to grow (the grade) helps the doctors to decide on the most appropriate treatment and also gives a rough idea of the outlook.

Staging

Ductal carcinoma in situ (DCIS) is sometimes described as stage 0. DCIS is almost always completely curable with treatment.

The following stages of breast cancer are known as invasive breast cancer:

Stage 1 The tumour measures less than 2cm/1in. The lymph nodes in the armpit are not affected and there are no signs that the cancer has spread elsewhere in the body.

Stage 2 The tumour measures between 2 and 5cm/1–2in, or the lymph nodes in the armpit are affected, or both. However, there are no signs that the cancer has spread further.

Stage 3 The tumour is larger than 5cm/2in and may be attached to surrounding structures such as the muscle or skin. The lymph nodes are usually affected, but there are no signs that the cancer has spread beyond the breast or the lymph glands in the armpit.

Stage 4 The tumour is of any size, but the lymph nodes are usually affected and the cancer has spread to other parts of the body. This is secondary or metastatic breast cancer. Breast cancer that has come back after initial treatment is known as recurrent breast cancer.

This section deals with stages 1–3 breast cancer. Stage 4 is covered in our secondary breast cancer section.

TNM staging system

Another staging system known as the TNM system is commonly used. This can give more precise information about the extent of the cancer.

• T describes the size of the tumour (cancer)
• N describes whether the cancer has spread to the lymph nodes (sometimes called glands)
• M describes whether the cancer has spread to another part of the body, such as the bone, liver or the lungs. This is known as metastatic or secondary cancer.

Grading

Grading refers to the appearance of the cancer cells under the microscope. The grade gives an idea of how quickly the cancer may develop. There are three grades: grade 1 (low- grade), grade 2 (moderate or intermediate grade) and grade 3 (high-grade).

Low-grade means that the cancer cells look very like the normal cells of the breast. They are usually slow growing and are less likely to spread.

In high-grade tumours the cells look very abnormal. They are likely to grow more quickly and are more likely to spread.

Moderate-grade or grade 2 cancers fall between these two grades and have a level of activity somewhere in between.

As well as describing the stage and grade of breast cancer, doctors will also check to see whether the tumour has hormone and HER receptors. Knowing the stage, grade and receptor status helps doctors to choose the most appropriate treatment for you.

Hormone and HER2 receptors

Some breast cancer cells have receptors, which allow particular types of hormones or proteins to attach to the cancer cell. A sample of the breast tissue will usually be tested to see if it has these receptors. Whether particular receptors are present or not will affect the type of treatment that you will need.

Hormone receptors

Many breast cancers have receptors for the hormone oestrogen. When oestrogen attaches to these receptors, it causes the cancer cells to grow. If a breast cancer has a significant number of oestrogen receptors it is known as being oestrogen-receptor positive (ER+). If it doesn't it is known as oestrogen-receptor negative (ER-). Knowing whether the tumour has oestrogen receptors or not helps the doctors to decide on the best treatment. A tumour that is ER+ is likely to respond to hormonal treatments , whereas a tumour that is ER- will not respond. Oestrogen-receptors are known as ER because of the American spelling of oestrogen as estrogen.

Some breast cancers have progesterone receptors and are known as progesterone-receptor positive (PR-positive). Usually, cancers that are ER+ will also be PR+. Progesterone receptors are less important than oestrogen receptors in predicting the likely response to hormone treatment.

HER2 receptors

Some cancers have receptors for a protein known as HER2 . Tumours that have high levels of these receptors are known as HER2-positive and may respond to treatment with drugs such as trastuzumab (Herceptin®) . Your doctor can tell you whether your cancer cells have these receptors.