Breast Cancer Diagnosis and Surgery

Breast cancer diagnosis starts with imaging of both breasts before any needle is used: ultrasound under 40, mammography from 40. A core biopsy then confirms the cancer and its receptor status, staging follows, and only then is the first treatment, chemotherapy or surgery, chosen. Dr. Rajesh Kumar Jain, Principal Director - Surgical Oncology, BLK-Max Super Speciality Hospital, New Delhi, India, treats each step as a decision that shapes the next.

Dr. Jain has practised surgical oncology in New Delhi for 28 years, and breast cancer is at the centre of his operating practice alongside head and neck, gynaecological, soft tissue, urological and selected gastrointestinal cancers. His teaching to doctors across Africa was deliberately practical: what to do first, what to avoid, and which investigations matter when resources are limited. Early diagnosis, he stressed, is what makes cure possible.

The breast cancer pathway in six decisions

Every woman who presents with a breast lump moves through the same sequence of decisions. Getting the order right protects the accuracy of everything that follows.

1. Imaging before biopsy. Ultrasound or mammography of both breasts, chosen by age, comes first.
2. Core biopsy, not fine needle aspiration. Only a tissue core shows the cancer type and receptor status.
3. Staging. The extent of the investigation depends on the size of the tumour and the state of the axilla. The practical options where PET-CT is unavailable are set out in staging breast cancer without PET-CT.
4. Receptor status. Oestrogen receptor (ER), progesterone receptor (PR) and HER2 status decide whether chemotherapy or surgery comes first.
5. Surgery. Breast conservation or mastectomy, sentinel node biopsy or axillary dissection, with or without reconstruction. The decision rules are covered in breast conservation surgery vs mastectomy.
6. Adjuvant treatment. Chemotherapy, hormone therapy, targeted therapy and radiotherapy, sequenced by a tumour board, with genomic testing used to spare selected women chemotherapy. These are covered in when chemotherapy can be avoided in early breast cancer.

Breast lump diagnosis starts with imaging, not a needle

Imaging always comes before fine needle aspiration cytology (FNAC) or a biopsy; this is Dr. Jain's first rule. A needle passed into a lesion creates a small haematoma (a collection of blood) inside it, which alters its appearance on imaging. A mammogram or ultrasound performed after a needle test is therefore less reliable than one performed before it. The order costs nothing and preserves the accuracy of the imaging.

Ultrasound or mammogram? The choice by age

A woman under 40 has an ultrasound first, and a woman of 40 or over has a mammogram. The choice depends on age, and the reason is the composition of the breast. Breast tissue is made of two components, glandular tissue and fat. Before the age of 40, most women have more glandular tissue and less fat. After 40, the proportion of fat rises and the glandular tissue recedes.

Mammography performs well in a fatty breast and poorly in a glandular one, where a lesion can be hidden by dense tissue. Dr. Jain's rule follows directly:

• Under 40 years: ultrasound of both breasts.
• 40 years and above: mammography of both breasts.

Both breasts, every time

When a woman presents with a lump in one breast, both breasts are imaged together, even when the other side is clinically normal. "There is no mammography or ultrasound or MRI which is called unilateral," Dr. Jain told the audience. Bilateral imaging is the standard for mammography, ultrasound and MRI alike.

When breast MRI is needed

MRI is not a routine test for a breast lump. Dr. Jain reserves it for three situations:

1. Inconclusive mammography or ultrasound. When neither test can characterise the lesion, MRI is the next step.
2. Suspected multicentric disease before breast conservation. Multicentric disease means cancer in more than one quadrant of the breast. When there are multiple lesions or diffuse microcalcification throughout the breast and breast conservation surgery is being considered, MRI is mandatory, because it shows which quadrants contain disease.
3. Axillary lymph node metastasis with no visible breast primary. Some women present with an enlarged axillary node and no lump in the breast. In most such cases the primary cancer is in the breast but is too small to see on mammography or ultrasound. MRI is used to find it.

Outside these indications, mammography or ultrasound is sufficient.

BI-RADS categories 0 to 6: what each one means and demands

Every breast imaging report ends with a BI-RADS category, which tells the treating doctor whether to reassure, follow up or biopsy. BI-RADS stands for Breast Imaging Reporting and Data System, a standard scale from 0 to 6 that grades how suspicious a finding is. The categories and the action each one calls for are summarised below.

BI-RADS 2 findings include popcorn calcification, vascular calcification and the typical round, smooth appearance of a fibroadenoma. They are abnormalities, but certainly benign, and a biopsy adds nothing.

BI-RADS 3 findings look benign but carry a small residual risk of cancer, which the BI-RADS system defines as 2% or less. Not every BI-RADS 3 lesion should be biopsied. Dr. Jain biopsies them in three groups of women:

• women with a strong family history, such as a mother, sister or other first-degree relative with breast cancer;
• women known to carry a BRCA1 or BRCA2 mutation;
• women who remain anxious that they have cancer and are not reassured by the doctor's explanation.

BI-RADS 4 covers a broad band of suspicion, from low to high, and Dr. Jain is categorical that every BI-RADS 4 lesion must be biopsied. BI-RADS 5 is most probably malignant and is always biopsied. BI-RADS 6 applies when cancer has already been proven by biopsy or FNAC and imaging is then performed.

Core biopsy vs FNAC for a breast lump

A breast lump is diagnosed by core needle biopsy, not FNAC, once imaging is complete. A core needle biopsy, also called a Tru-Cut biopsy, removes a small cylinder of tissue. Dr. Jain advises against FNAC of a breast lump. FNAC can only indicate whether cells look malignant or benign. A core biopsy shows three things that treatment depends on:

• the histological type of cancer;
• the status of the hormone receptors, ER and PR;
• the status of HER2, a growth-signalling gene.

FNAC still has one clear role. When a woman has a breast lump and a small axillary node whose nature is uncertain, an ultrasound-guided FNAC of the node can prove that it is metastatic. For the primary breast lump, the answer is always a core biopsy.

Receptor status: the result that sets the treatment sequence

The receptor profile, tested on the biopsy by immunohistochemistry (a staining test that shows which receptors the cancer cells carry), divides early breast cancer into groups that are treated in a different order.

Triple-negative breast cancer (TNBC) is negative for ER, PR and HER2. Dr. Jain put it at around 15 to 20% of cases and described it as a very aggressive type that needs appropriate treatment at the earliest. Even when TNBC is early, his practice is to begin with neoadjuvant chemotherapy (chemotherapy given before surgery) for around four and a half to five months, reassess the response, operate, and finish with radiotherapy.

ER-positive, HER2-negative early breast cancer is lower risk, and surgery remains the first treatment, as it always has been.

HER2-positive disease is high risk whatever its other features, and it needs anti-HER2 targeted therapy. When immunohistochemistry is equivocal, a fluorescence in situ hybridisation (FISH) test settles whether HER2 is positive.

How staging and receptor status combine to decide the first treatment, including the definition of locally advanced disease, is set out in staging breast cancer without PET-CT.

Surgical management in brief

For operable early breast cancer, surgery is the backbone of cure. Dr. Jain's view, given when asked what the definitive treatment of breast cancer is, was that no single modality cures a solid tumour on its own. Chemotherapy alone, radiotherapy alone or hormone therapy alone cannot cure breast cancer; surgery has to be part of the plan, combined with whichever adjuvant treatments the pathology calls for.

The surgical decisions are three. The first is whether the breast can be conserved, which depends above all on whether radiotherapy can be given afterwards. The second is how to manage the axilla: sentinel lymph node biopsy where the training and facilities exist, or a complete axillary dissection, which Dr. Jain combines with the LYMPHA lymphatic bypass to protect the arm from lymphoedema (chronic arm swelling). The third is whether to reconstruct the breast at the same operation or later. Each is covered in breast conservation surgery vs mastectomy.

After surgery, the full pathology report arrives in around 10 days and the case goes to a tumour board, a meeting of surgeons, medical oncologists, radiation oncologists and pathologists, which plans adjuvant treatment (treatment given after the operation). For women with hormone-positive, HER2-negative early disease, genomic risk tests can identify those who can safely omit chemotherapy. Dr. Jain's experience with these tests, along with hormone therapy, radiotherapy, survival by stage and rehabilitation, is covered in when chemotherapy can be avoided in early breast cancer.

Breast cancer treatment cost in India: the doctor's estimates

Around USD 15,000 should be sufficient for most patients, covering surgery and basic chemotherapy, in Dr. Jain's rough estimate for treatment at BLK-Max. Asked what families should expect to pay, he broke it down as follows:

• Surgery: around USD 5,000, all-inclusive.
• [Chemotherapy](/treatment-cost/chemotherapy): around USD 10,000 additional.
• [Radiotherapy](/treatment-cost/radiation-therapy-radiotherapy): around USD 3,500 to 4,000.
• Prolonged targeted therapy such as trastuzumab: could add another USD 10,000, though this part of treatment can be given in the patient's home country.

His practical summary was that surgery, the part that needs specialist expertise, costs around USD 5,000, and basic chemotherapy a further USD 8,000 to 10,000. He described these as rough estimates and said that patients who cannot afford treatment should let the team know, because help is offered wherever possible. Procedure-level figures are on the breast cancer surgery cost page.

Treating patients jointly with referring doctors

Dr. Jain's position on referral is that whatever can be done well in the patient's own country should be done there. He offers video consultations to review a case once the reports are available, and will say without bias which patients need treatment in New Delhi. If a cure can be achieved through advice alone, he welcomes it. His summary for referring doctors was to "discuss, discuss and discuss" for the benefit of patients. The questions doctors raised during the session, from familial cancer to staging in a limited set-up, are collected in the live discussion from this masterclass.

Dr. Jain returned in September 2026 with a wider session on surgical oncology. Its guide to recent trends in surgical oncology and its breast cancer treatment protocol by stage and subtype complement this guide. His full profile is on the Dr. Rajesh Kumar Jain doctor page, and related guides sit in the oncology specialty hub.