Diagnostic tests for metastatic breast cancer

Photo of a patient having a mammogram (John Foxx / Stockbyte / Thinkstock)

A number of different kinds of tests can be used to detect breast cancer or metastatic tumors elsewhere in the body. They are often combined to get a more accurate diagnosis. The treatment approach can then be chosen based on the outcomes of the tests.

Your doctor is the first person to go to if you suspect you might have breast cancer, or if you think it has become worse or come back again. This might be your family doctor, your gynecologist or a specialist for outpatient cancer treatment. Different types of tests might be needed, depending on your symptoms. Your doctor might examine you or refer you to a hospital or specialized breast cancer center.

A breast cancer center is a specialized hospital department or several specialized departments that work together. In Germany, special “certified” breast cancer centers examine and treat people who have cancer according to special criteria to ensure high quality care. Specialists working in breast cancer centers include gynecologists, psycho-oncologists, nurses and other medical professionals.

Before any examination the doctor will always ask you about your symptoms, your general state of health and medical history.

It is important that the doctor takes the time to explain the following things:

  • Why the examination needs to be done
  • How it is done and what can be found out by doing it
  • Whether it is associated with any risks or side effects (e.g. exposure to radiation or a wound after minor surgery)
  • What other kinds of examinations are possible
  • What can be done if you decide not to have the examinations
  • When you will get the results and discuss them

You always have the right to refuse any of the tests.

The examinations and staging approach listed here are those described in the latest, German-language, breast cancer clinical practice guideline issued by the German Cancer Society and the German Society of Gynecology and Obstetrics. Clinical practice guidelines act as decision aids for doctors and patients. They aim to help guarantee that treatment is the best it can be and quality-assured. Evidence-based guidelines will ideally be based on the results of good-quality research.

Tests that are done if it is thought you might have breast cancer

Different kinds of tests are used to detect breast cancer or check whether a tumor has grown back. They are often combined to get a more accurate diagnosis. The following tests are the most common:

All of these tests will include an examination of the other breast as well. If there is an abnormal lump, the doctor will usually take a tissue sample (biopsy). The sample will then be tested in a laboratory to find out whether it is cancerous. If they find cancer cells in the sample, it is called a “positive result.”

Tests that can be done if it is thought you might have metastases

If you have general symptoms or if you have been diagnosed with breast cancer (again), your doctor will want to check whether the tumor has also spread to other parts of your body (metastasis). This can be done using the following imaging techniques:

If anything abnormal is detected, that part of the body can be examined more closely. Further tests could include more x-rays, computed tomography (CT), magnetic resonance imaging (MRI), or possibly positron emission tomography (PET) in some situations. Some devices combine positron emission tomography and computed tomography (PET/CT). A tissue sample will be taken too, if possible (biopsy).

It is not always necessary to do all the possible examinations. Your doctor will help you decide which tests make sense and are most suitable for you.

Classification of the tumor

Once the diagnostic tests have been done, the doctor can assess how far the cancer has progressed.

Location, size and degree of spreading

In Germany and other countries, the TNM staging system is normally used to classify a cancerous tumor:

Characteristic Abbreviation What it means
Tumor size
(T = Tumor)
T0 No tumor was found
  T1 The tumor is 2 cm in diameter or smaller
  T2 The tumor is between 2 and 5 cm in diameter
  T3 The tumor is more than 5 cm in diameter
  T4 Independent of size, the tumor has spread to the chest wall below, or to the skin
Lymph nodes
(N = node)
N0 There are no tumors in the lymph nodes
  N1 to N3 The numbers 1 to 3 stand for location and number of affected regional lymph nodes Tumors found in lymph nodes that are not in the drainage area of the affected organ are regarded as distant metastases.
(Distant) metastatic tumors
(M = metastatic)
M0

No metastatic tumors were found

  M1

(Distant) metastatic tumors were found

Assessment X

A particular parameter cannot be assessed. This may be because it has not been examined or that there are no clear results (for instance: NX = lymph node involvement cannot be assessed).

The following abbreviations can be added to the basic TNM classification to provide more information:

  • c (for “clinical”) indicates that the diagnosis is based on a physical examination or symptoms.
  • p (for “pathological”) means that the diagnosis is based on tissue tested in a laboratory.
  • r (for “recurrence”) means that a tumor has reappeared.
  • y indicates that the tumor has already been treated with chemotherapy.

The tumor stage is then determined based on this information about the location, size and degree of spreading, as well as on other test results. Tumors are classified as stage 0, I, II, III or IV. Stage 0 means there are abnormal tissue changes that are considered to be early stages of cancer, and stage IV means the cancer has spread.

Tumor growth

In a process called grading, tumor cells from the tissue sample are examined under a microscope to see how much they differ from healthy cells. The basic rule of thumb is that the more they have mutated, the faster they can grow and penetrate surrounding tissue. The grades G1 to G3 are used to describe tumor cells. The higher the grade, the more malignant the tumor - and the faster it will usually grow.

The influence of hormones

The female sex hormones estrogen and progesterone promote the growth of healthy breast tissue. They can also promote the growth of cancer cells, which originally stem from healthy tissue. But the hormones can only have this effect if the cancer cells involved have certain receptors (places where the hormones can latch on to). These receptors can be detected in laboratory tests. The hormone receptor status indicates whether or not the cancer cells have these receptors. If they do, the status is “positive.” In this case, tumor growth can usually be slowed down using hormone therapy.

The effect of growth factors

Human epidermal growth factor receptors (HERs) are proteins found on the cell surface. They transmit signals to the inside of the cell, telling it to divide. If a cell has many HERs, it will divide more often. If cancer cells have a lot of type 2 HERs (called HER2 receptors), the HER2 status is “positive.” Then the cancer can be treated with therapies that aim to influence the growth factors and slow down tumor growth.

Other influencing factors

The following information is also important for the doctor:

If you have had breast cancer before: How was the tumor classified? How was it treated? How effective were the different treatments? When did you first have breast cancer?

  • How old are you, and have you gone through menopause?
  • How is your general health?
  • Do you have any other illnesses?
  • Do you take any medication regularly?

Discussing the diagnosis and planning therapy

It is quite normal not to remember all of the important information shortly after receiving such an upsetting diagnosis. It is also common to feel scared and confused, and need some time to come to terms with the news. It can then be a good idea to make an appointment with your doctor to discuss any questions you still have. Taking some notes before the appointment can help you remember what you want to ask about. You could also invite a friend or relative to come along. Joining a self-help group to share experiences with other women with breast cancer is another way to find support.

You can always get a second opinion too. This is fairly common, and you can decide whether or not you want to tell the first doctor that you are getting a second opinion. Statutory health insurers in Germany will usually cover the costs. But you can contact your insurer to double-check.

There are often several different treatment options once the diagnosis has been made. Breast cancer treatment is almost never urgently needed, so you will have time to consider the different options. Doctors – for instance, specialists at a certified breast cancer center will – will usually draw up a treatment plan for metastatic breast cancer. The next step is up to you: You can choose which treatment to have on your own, discuss the decision with your doctor, or let them decide what the best course of action is. Not having any treatment or only having a part of the treatment may also be an option. Maintaining a good quality of life for as long as possible is more important to some women than having targeted cancer therapy. In any event, you should feel free to ask your doctor about anything you still want to know about.

The following questions might help you to make a decision about whether to have treatment:

  • How can the treatment improve your health?
  • What are the possible side effects?
  • How would the therapy influence your quality of life? How would it affect your career and family in everyday life?
  • What other treatment options are available? How do their advantages and disadvantages compare?
  • What happens if you decide not to have the cancer treated for now? What would the likely course of the disease be in that case?
  • Is there research on new medications designed to treat metastatic breast cancer that may be an option for you?

The importance of trust

Talking with doctors, family members and friends can help you to find answers to those kinds of questions. You can also talk to a psycho-oncologist or psychologist, or ask women who have been in a similar situation about their experiences, for example in a self-help group.

A trusting relationship with your doctors is a vital part of your treatment. Many women want to discuss the next steps of treatment with the same doctor. But others might feel that their doctor isn’t taking enough time to help them with questions or anxieties, or isn’t taking their own wishes into consideration when it comes to the treatment decision.

Even though this might come as a surprise, some doctors may also find it difficult to deal with knowing their patient has metastatic breast cancer and that there is probably no way to fully cure it. They might overcompensate by taking too much action (too many treatments and examinations) or avoiding longer talks about it. If you think that might be the case with your doctor, you can bring it up with them or see another doctor.