Breast Cancer Diagnosis

Triple Diagnostic Assessment

Once a patient has been referred for specialist services under a two week wait referral for suspected cancer they should initially receive triple diagnostic assessment comprising of:

  • Clinical Assessment
  • Breast Imaging (ultrasound or mammography)
  • Biopsy (fine needle aspiration or core biopsy)


Ultrasound vs Mammogram

  • Younger women have denser breasts with more glandular breasts
  • Ultrasound:
    • Typically used to assess lumps in younger women (e.g. <30)
    • Useful in distinguishing solid lumps (e.g. fibroadenoma / cancer) from cystic lumps
  • Mammogram:
    • More effective in older women
    • Pick up calcifications missed by ultrasound


Lymph Node Assessment

  • Before surgery: everybody offered axillary ultrasound and ultrasound guided biopsy of any abnormal nodes
  • During surgery: where no abnormal lymph nodes are found using Sentinal Lymph Node Biopsy


Sentinal Lymph Node Biopsy

  • Performed during breast surgery for cancer
  • Where no abnormal lymph nodes identified prior to surgery
  • Isotope contrast and a blue dye are injected into the tumour area
  • This is carried through the lymphatics to the first lymph node (the sentinel node)
  • This node shows up blue and on the isotope scanner
  • This node is then sampled to stage the cancer


Oestrogen Receptor Status (ER)

  • Performed on the tumour cells
  • Determines whether oestrogen promotes growth of breast cancer cells
  • Helps to guide chemotherapy choice and prognosis


Human Epidermal Growth Receptor 2 Status (HER2)

  • Performed on tumour cells
  • Determines the presence of HER2
  • Helps guide chemotherapy choice and prognosis


Gene Expression Profiling

  • “Oncotype DX” measures the expression of various genes related to breast cancer
  • Offered to women with ER ve, HER2 –ve, lymph node –ve disease
  • Helps predict the likelihood of distant recurrence of disease after surgery
  • Helps guide the decision about giving chemotherapy post operatively



  • TNM system used

T (tumour)

  • TX – unable to assess size
  • Tis – DCIS
  • T1 – < 2cm
  • T2 – 2-5 cm
  • T3 – >5cm
  • T4 – spread to skin or chest wall

N (nodes)

  • NX – unable to assess nodes
  • N0 – no nodal spread
  • N1 – spread to axillary nodes but nodes are mobile
  • N2 – spread to axillary nodes (and fixed) or to internal mammary nodes
  • N3 – spread to axilla and internal mammary nodes or to infraclavicular or supraclavicular nodes

M (metastasis)

  • M0 – no metastasis
  • M1 – metastasis


Multi-Disciplinary Team (MDT)

All patients should be discussed at MDT for future planning:

  • After initial triple assessment and diagnosis of cancer
  • After abnormal staging tests
  • After further pathology and results
  • After recurrence of the disease
  • At any point where a treatment decision will be made
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