The triple diagnostics is the basis for a safe and rational breast work-up and consists of:
- a clinical examination
- image diagnostics
- needle biopsy
Systematic inspection and palpation of the breasts, axilla, and infra- and supraclavicular fossa provide the basis for further diagnostics. Palpatory findings are recorded with localization (four quadrants and retroareolar area), size in millimeters, consistency, and mobility in relation to surrounding structures.
Clinical mammography is performed in women who have symptoms or signs in the breasts. Mammography is also used as screening to identify tumors in the pre-clinical phase.
Ultrasound examination (ultrasonography) is today a very important supplement to mammography.
Magnetic Resonance Imaging (MRI) is a great improvement in breast diagnostics due to the high sensitivity for invasive breast carcinoma. In most studies, the sensitivity is found to be around 95-97%. With ductal carcinoma in situ (DCIS), the sensitivity is however considerably lower. Mammography and ultrasound are the fundamental diagnostics, while MRI is only indicated in special cases.
Fine needle aspiration cytology (FNAC) can be done where there is a clinically apparent/palpable lesion.
Non-palpable, mammographic and/or ultrasound apparent lesions can be punctured with a fine needle using ultrasound guidance or ultrasound-guided core biopsy.
Ultrasound guided core biopsy is used in addition to or alone, for the same indications as the fine needle biopsy.
A patient program for breast cancer
A "Patient program" for cancer shall provide predictability and security for patients and their families and is a national standardized process which is evidence based .
The general practitioner should do a clinical examination of the breast and axillae before referring to "Patient program". A private imaging institute should carry out a mammography and ultrasound examination with preferably ultrasound-guided core biopsy.
Criteria for referral to "Patient program"
Justified suspicion of breast cancer occurs when one or more symptoms exists:
- Palpatory suspect tumor. A palpatory suspect tumor is usually fixed and not well-defined. It can be fixed to the surrounding tissue, skin or fascia
- Newly occuring nipple inversion which is not possible to retract
- New skin inversion
- Wounds or eczema-like changes on or around the nipple or areola
- Clinically suspicious lymph nodes in the armpit
Examination for invasive breast cancer
When the diagnosis is verified, it is important to identify whether it is an operable (T1-2NO-1M0) or inoperable (T3-4N0-3M0-1 or T1-2N2-3MO-1) tumor. This has implications for which examinations are appropriate and for the choice of treatment.
Blood tests and x-ray examination of lungs are not considered mandatory for screening examination of metastases if the patient does not belong to a high-risk group. These examinations will be performed according to the general medical evaluation.
If there is no anamnestic information, symptoms or signs rising suspicion of distant metastases, the preoperative examination will be limited to:
Postoperative evaluation of high-risk groups with operable mammary cancer
These patients should be evaluated for metastases before adjuvant treatment if this does not significantly delay start of treatment.
The following groups are considered at high risk:
- Lymph node positive HER2 positive patients
- Lymph node positive trippel negative patients
In women with locally advanced disease or metastatic disease, it is necessary to perform additional examinations before treatment regimen is decided.
For primary inoperable cancer, the following examinations are performed:
- blood tests (preoperative routine tests including ALP, gammaGT, and s-Ca++)
- CT of thorax, abdomen and pelvis
- ultrasound or CT of liver (if needed)
- bone scintigraphy (supplemented with X-ray if needed) or MRI of the spine/pelvis
- mammography (also for possible response evaluation of systemic treatment) and ultrasound of breast/axilla and possibly MRI of the breast
- other examinations on individual indications
Each case should be discussed with an oncologist before implementation of treatment.
MUGA or ECHO examination of the heart should be performed in patients who are to be treated with FEC100 regimen (HER-2 positive and locally advanced), to disclose the tolerability.