Breast Cancer Warning Signs, Self-Examination and Biopsy

The warning signs of breast cancer are a lump in the breast or armpit (often painless), dimpling or a change in skin texture, a newly inverted nipple, nipple discharge that may be bloody, a change in breast shape or size, redness or a scaly patch, and swollen lymph nodes. Monthly breast self-examination helps women notice these changes early, and any of them warrants imaging and, if suspicious, a guided biopsy.

Dr. Sahil Bambroo, Senior Consultant, Medical Oncology, BLK-Max Super Speciality Hospital, New Delhi, India, at the time of this masterclass, built the diagnostic part of his session around three practical points for doctors working outside specialist centres: recognise the signs early, teach women to examine themselves, and never let the fear of biopsy delay a diagnosis. How the diagnosis then shapes treatment is covered in the medical oncology guide to breast cancer management.

Breast cancer warning signs that should never be ignored

Dr. Bambroo listed the common symptoms of breast cancer as:

• a lump in the breast or armpit, which may be painless;
• dimpling of the breast or changes in skin texture;
• breast or nipple pain;
• an inverted nipple or nipple discharge, which can occasionally be blood;
• changes in the shape and size of the breast;
• a red or scaly patch on the skin;
• swollen lymph nodes around the breast or elsewhere in the body.

He then walked through the same changes as clinical red flags, the findings that should prompt further evaluation whenever they are seen on examination:

• any hard or soft lump in the breast, armpit or chest wall;
• breast sores that do not heal after a course of antibiotics;
• redness, puckering or thickening of the skin of the breast;
• an inverted or sucked-in nipple;
• a change in breast shape or size;
• any bloody, cloudy or otherwise abnormal discharge from the nipple.

The point for the referring doctor is that none of these signs is specific, but every one of them deserves a workup rather than reassurance.

Inflammatory breast cancer: the cancer that looks like an infection

One presentation deserves particular attention. Inflammatory breast cancer, in which cancer cells block the lymph vessels in the skin, makes the breast red and warm. Seen in a peripheral outpatient clinic, it can look like cellulitis (a bacterial infection of the skin) or a breast infection, and the natural response is to prescribe a course of antibiotics and see whether the patient improves.

Dr. Bambroo's warning was that it is at times very difficult to tell these conditions apart in the clinic without evaluation or follow-up. Only a doctor who keeps inflammatory breast cancer in mind will send the patient to a surgeon or specialist for an opinion. A red, warm breast that does not settle on antibiotics should be treated as possible cancer until proven otherwise.

How to perform a breast self-examination

Dr. Bambroo advised that every woman should be taught breast self-examination and should do it at least once a month, two or three days after her period. His method:

1. Choose the moment. Preferably after taking a bath.
2. Raise the arm. Examine the breast and the armpit thoroughly with the arm raised.
3. Use the finger pads with shower gel or massage oil.
4. Cover the whole breast systematically, using up-and-down, wedge and circular movements.
5. Feel and look for any lump, dimpling, abnormal change or deformity, and for any leakage from the nipple.

Self-examination matters especially for younger women, who fall outside most screening programmes and need to be educated to recognise early signs, as discussed in breast cancer in young women.

First imaging for a breast lump: mammogram or ultrasound

When a lump or any other change needs evaluation, the simplest and best next step is imaging. Dr. Bambroo described the mammogram as a very basic and very good technique for identifying breast lesions that require evaluation. A mammogram is an X-ray of the breast: the breast is compressed between two plates and a beam of radiation is passed through it, and an abnormal tumour can be seen clearly on the film. In young women, ultrasound is the usual first test, because their breast tissue is denser and mammograms are harder to read.

For population screening schedules by age, see the cancer screening guidelines article.

Why an experienced radiologist matters

Mammography has limits. Dr. Bambroo showed a mammogram of an invasive lobular carcinoma (a cancer that starts in the milk glands) that looked almost normal, because this type of cancer can be very difficult to pick up. For this reason he recommends that mammograms be read and reported by an experienced radiologist, and that any doubt leads to referral to a surgical or medical oncologist. The specialist can then arrange an MRI of the breast, a guided biopsy or further scans, so that cancers are picked up early.

The diagnostic workup for suspected breast cancer

When breast cancer is suspected, Dr. Bambroo's workup covers four areas:

• History and examination: the patient's history, menopausal status and a thorough physical examination.
• Fitness for treatment: routine blood counts and liver, kidney and cardiac assessment.
• Breast imaging: a mammogram and, where needed, an MRI.
• Tissue diagnosis and staging: a biopsy to confirm the disease, and further tests to assess the regional lymph nodes and look for metastatic disease.

He stressed that some patients need further evaluation with CT or PET scans, because early disease can be difficult to see even on a mammogram. Standard guidelines reserve CT and PET-CT for staging locally advanced or suspected metastatic disease, while breast MRI is the usual next test when a mammogram is inconclusive.

A staging example

Dr. Bambroo used a clinical case to show the workup in practice: a 57-year-old woman whose needle biopsy of a breast mass shows infiltrating ductal carcinoma (also called invasive ductal carcinoma, the commonest type). To stage her disease he would carry out a thorough physical examination, a mammogram, a chest X-ray, an ultrasound and a bone scan to understand the extent of spread. On the biopsy itself he would request ER, PR and HER2 testing to define the subtype. The stage, the subtype and the patient's age together determine the prognosis. Dr. Rajesh Kumar Jain discusses how to stage breast cancer where advanced imaging is limited in breast cancer staging without PET-CT.

Is a breast biopsy safe? The myth that biopsy spreads cancer

A breast biopsy done in a guided way is safe, and the belief that it spreads cancer is a myth. A definite diagnosis of any cancer requires tissue, and that means a biopsy. Many people believe that a biopsy is dangerous and can spread the disease. Dr. Bambroo was unequivocal that this is untrue: a guided biopsy is essential and does not cause physical harm. He showed an ultrasound-guided biopsy from a breast mass as an example of a procedure that can be done safely.

For the referring doctor, this is a counselling point as much as a clinical one. A patient who fears that a needle will spread her cancer may delay or refuse the one test that makes treatment possible.

How the biopsy is taken and tested

In early breast cancer, Dr. Bambroo's practice is a guided biopsy taken directly from the lesion itself, such as a lump in the breast. The laboratory technique is simple and needs nothing elaborate:

1. Fixation and histopathology. The tissue is fixed and examined under the microscope to diagnose the cancer and its type.
2. Immunohistochemistry (IHC). Stains on the same tissue show the oestrogen receptor, progesterone receptor and HER2 status, which define the subtype and the treatment.
3. FISH when HER2 is equivocal. If the HER2 result on IHC is borderline, a FISH test (fluorescence in situ hybridisation, which counts copies of the HER2 gene) confirms the HER2 status.

The choice of biopsy method itself (fine-needle, core or surgical) is explored in Dr. Jalaj Baxi's guide to breast cancer biopsy types.

Biopsy in metastatic disease

When the cancer has already spread to organs such as the lung, bone or liver, the biopsy is taken from the site that is most accessible, least dangerous for the patient and simplest to sample. In practice this often means a liver or lung biopsy to confirm that the disease is indeed metastatic.

Dr. Bambroo added an approach that general physicians may not expect. In patients who present with severe anaemia, or who are too unwell for any other biopsy without significant risk, the cancer may already be in the bone marrow. He has diagnosed metastatic breast cancer on bone marrow biopsy in a number of such patients, performed IHC on the marrow sample to confirm the subtype, and treated them on that basis with good results. The full exchange on this question is in the Live Discussion.

From diagnosis to a treatment plan

The diagnostic pathway ends with three facts about each cancer: whether it is invasive, which receptor subtype it is, and what stage it has reached. Together they decide whether treatment starts with surgery, chemotherapy, hormone therapy, anti-HER2 therapy or immunotherapy, as explained in the medical oncology guide to breast cancer management.