Referral to a breast clinic - types of test

Once a doctor or nurse has examined your breasts and the lymph nodes (glands) under the arm (axilla) you may need further tests. Along with the doctor’s examination, these are together known as a triple assessment and are made up of the procedures listed below.

Mammogram

A mammogram is a breast x-ray. A female mammographer (an expert in taking breast x-rays) will ask you to undress to the waist and stand in front of the mammography machine. If you are pregnant or think you may be pregnant, you should tell the mammographer as radiation can damage a growing baby.

You will usually have a mammogram of both breasts. The breast is rested on the x-ray machine then gently but firmly compressed by a Perspex plate so that all the breast tissue can be seen. Two or more images of each breast will usually be taken so that the breast tissue can be viewed from different angles.

Some women find having a mammogram quite uncomfortable or describe it as painful, but it only lasts a few seconds and doesn’t harm your breasts. The breast is compressed in order to keep it still and get a clear picture.

Digital mammography – where the image is taken electronically and stored directly on a computer in digital form – is becoming more common and is gradually being introduced into more breast units. It’s expected in the future to replace conventional mammograms, where the image is created directly on to a film.

Some people worry about the radiation used for breast x-rays. However, mammograms only need a very low dose of radiation – similar to the amount a person receives by flying from London to Australia and back. The dose is monitored and adjusted according to the individual, ensuring that it is as low as possible while still providing a good-quality image.

Because younger women’s breast tissue can be dense, which can make the x-ray image less clear and changes harder to identify, mammograms are less commonly used in women under 40. However, they may sometimes be needed to complete an assessment.

Further mammograms

Further mammograms at different angles or with magnification are sometimes needed to examine particular areas of the breast in greater detail. For more information see our booklet Your breast clinic appointment.

Ultrasound scan

An ultrasound scan uses high-frequency sound waves instead of x-rays to produce an image of the breast tissue. This is similar to the type of imaging used to scan babies in the mother’s womb during pregnancy. An ultrasound scan is painless and generally completed in a few minutes, although the length of time varies.

You will be asked to undress to the waist and lie on a couch with your arm above your head. To help gain a clear image of the breast, lubricating gel will be spread over the area of your breast to be imaged and the clinician will use a hand-held scanning probe (called a transducer), which will be moved over the breast to look at the underlying breast tissue. The area under your arm (axilla) may also be scanned.

Regardless of age, an ultrasound scan will usually be done in addition to mammograms. It provides different information to a mammogram image, which is why both are usually used.

If a lump or an area of concern is found during the breast examination, mammogram or ultrasound scan, a sample of breast cells or breast tissue will be taken from the breast. This can be a core biopsy or fine needle aspiration (FNA). Both these tests can be done with or without ultrasound imaging for guidance.

Core biopsy

A core biopsy uses a needle to obtain a sample of tissue. You will be given a local anaesthetic to numb the area before a sample is taken. The specialist may take several tissue samples at the same time. These will be sent to the laboratory and examined under a microscope to establish a diagnosis.

If the area of concern can only be seen on a mammogram, you may have a stereotactic core biopsy. This is where a sample of tissue is taken using a needle as before, but the mammogram machine is linked to a computer. This helps locate the exact position of the area to be sampled. For this procedure you may be asked to sit or to lie down on a specialised examination couch. It may feel a little uncomfortable, as the mammogram plates are pressed on to the breast throughout the procedure. Images of the breast are taken from two different angles to help guide the needle to the area.

Whichever way the core biopsy is performed, you will usually have a small dressing or a plaster applied, and be asked to keep this on for a day or so afterwards. Sometimes very thin strips of adhesive tape are used to help the edges of the wound to close.

Once the local anaesthetic wears off you may find that your breast aches and becomes bruised. You can take pain relief if the area is tender or painful. You will be given more information about this before you leave the clinic. For more information see our booklet Your breast clinic appointment.

After a core biopsy, it will take several days before your results are available.

Your result may be described to you as one of the following:

• B1 – normal breast tissue
• B2 – benign (not cancer)
• B3 – uncertain but probably benign
• B4 – suspicious and possibly malignant (cancer)
• B5 – malignant (cancer).

Further tests or treatment are usually needed for a result showing B3, B4 or B5, or where the findings of the tests don’t agree.

Fine needle aspiration

FNA involves taking one or more samples of breast cells using a fine needle and syringe. This can be uncomfortable but rarely requires local anaesthetic. You may be asked to wear a plaster for a few hours over the site where the needle has been used. The sample will be sent to the laboratory, where it is looked at under a microscope and the results may be available on the same day or very soon after your clinic appointment.

Your result may be described to you as one of the following:

• C1 – inadequate sample (not enough cells for diagnosis)
• C2 – benign (not cancer)
• C3 – unusual or abnormal or uncertain but probably benign
• C4 – suspicious and possibly malignant (cancer)
• C5 – malignant (cancer).

The specialist will use the result to help them decide whether further tests and investigations or treatments are needed. Further tests or treatments are usually needed for a result showing C3, C4 or C5, or where the findings of the tests don’t agree.

Other tests

Triple assessment is most often all that is needed to make a diagnosis. However, sometimes you may need other tests.

Punch biopsy

A punch biopsy may be used when there is a change to the skin of the breast or nipple. It takes a very small cylindrical piece of tissue from the area of change. You will be given a local anaesthetic before a tiny cutter device takes the sample. You will need to wear a small dressing or plaster afterwards.

Vacuum assisted biopsy

If a previous biopsy has not given a clear result and more breast tissue is needed to make a diagnosis, or if the area of concern is difficult to target, you may be offered a vacuum assisted biopsy. This takes a little longer than a core biopsy and is done using mammogram or ultrasound guidance.

After an injection of local anaesthetic, a small cut is made in the skin. A hollow probe connected to a vacuum device is passed through the cut. Using ultrasound or mammography as a guide, breast tissue is sucked through the probe by the vacuum into a collecting chamber. This enables removal of several tissue samples without having to remove the probe. These samples will be sent to the laboratory and examined under a microscope to establish a diagnosis.

In other cases, wire localisation may be needed. This is when, after an injection of local anaesthetic, a guide wire is inserted into the breast using mammogram or ultrasound for guidance. It is used accurately to mark the location of an area of concern that can’t be felt but can be seen on mammogram or ultrasound. This ensures greater accuracy when a sample of tissue is removed from the area by biopsy during an operation under general anaesthetic. The sample will then be examined under a microscope.

If you’d like more information about any tests you may be having, you can call Breast Cancer Care’s free Helpline on 0808 800 6000 (Text Relay 18001).

Visit the Royal College of Radiologist website to take a virtual tour of a hospital radiology department to find out more.

Content last review January 2012; next planned review 2013