Diagnostic tests for metastatic breast cancer

Before doing any examinations, the doctor will always ask you about your symptoms, your general health and medical history. Then the doctor should take the time to carefully explain the following things:

• Why the examination needs to be done
• How it’s done
• What you can find out by doing it
• Whether it’s associated with any risks or side effects (e.g. a wound after minor surgery or exposure to radiation)
• 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

As a patient, you always have the right to be given information about these things, and to decide not to have a test that is recommended.

The following tests are often used to diagnose breast cancer or check whether a tumor in the breast has come back:

• Examination by hand (palpation) – of the breast, surgery scar and armpits
• Chest x-ray (mammography)
• Ultrasound ( sonography)
• Magnetic resonance imaging (MRI, MRT)

In all these examinations, the second breast is examined too. If there’s an abnormal lump, the doctor will usually take a tissue sample (biopsy). A laboratory will then test this sample to find out whether it’s cancerous.

If you have general symptoms or if breast cancer has been diagnosed (again), your doctor will check whether the tumor has also spread to other parts of your body. The following imaging techniques can be used for this purpose:

• Chest x-ray
• Bone scan (bone scintigraphy)
• Ultrasound of the liver
• Computed tomography (CT) scan

If these tests find anything abnormal or if the results are not clear, then doctors will examine the affected part of the body more closely. This may be done using more x-rays, magnetic resonance imaging (MRI) and, in some situations, positron emission tomography ( PET). Some devices combine positron emission tomography and computed tomography ( PET/ CT). If possible, a tissue sample will be taken and examined in a laboratory (biopsy) to look for cancer cells.

Your doctor will help you decide which diagnostic tests and procedures make sense and are most suitable for you.

After the examinations are done, the doctor can assess how far the cancer has progressed.

In Germany and many other countries, tumors are usually classified according to the TNM staging system:

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 and size of the tumor, the degree of spreading, and 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.

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 female sex hormones estrogen and progesterone promote the growth of healthy breast tissue. They can also speed up the growth of cancer cells, which originally stem from healthy tissue. But the hormones only have this effect if the cancer cells 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.

Human epidermal growth factor receptors (HERs) are proteins found on the cell surface. They pass on signals to the inside of the cell, telling it to divide. If a cell has many HERs, it will multiply more often. If cancer cells have a lot of type 2 HERs (called HER2 receptors), the HER2 status is “positive.” Then the growth of the cancer cells can be slowed down with treatments that influence growth 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 various 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?

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. Writing down questions before seeing the doctor can help you to remember what you want to ask about. You could also invite a friend, relative or partner to come along. Joining a support group to share experiences with other women in a similar situation can help a lot too.

You can always get a second opinion from a different doctor. This is fairly common, and you can decide whether or not to tell the first doctor that you're getting a second opinion. In Germany, statutory health insurers will usually cover the costs of getting a second opinion. 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. Specialized doctors – for instance, at a certified breast cancer center – will usually draw up a treatment plan for metastatic breast cancer. It is up to you whether you want to decide on a treatment together with your doctor or whether you would prefer to leave the decision up to them. 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.

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

• How could 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, everyday life and family?
• What other treatment options are available? How do their pros and cons compare?
• What would happen if you decide not to have the cancer treated for now? What would the likely course of the disease be then?
• Are there any clinical trials testing new medications for women with metastatic breast cancer that may be an option for you?

If you think you still need more information, don't hesitate to ask your doctor.

Talking with doctors, family members and friends can help you to find answers to any questions you may still have. 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 support group for women with metastatic breast cancer.

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 also find it very hard to deal with knowing that their patient has metastatic breast cancer and that there's probably no way to fully cure it. They might overcompensate by taking too much action (too many treatments and examinations) or avoiding longer talks. If you think that might be the case with your doctor, and you don’t feel like you’re in good hands because of it, you can bring it up with them or see another doctor.