Women experiencing breast symptoms or breast changes, such as a lump, localized pain, nipple symptoms or skin changes, require appropriate diagnostic evaluation, as do women who are recalled for further testing because of positive screening mammography.
Diagnosing breast cancer is based on a triple test comprising clinical examination, imaging (usually mammography and/or ultrasonography) and needle biopsy. Assessment entails performing the appropriate elements of the triple test, factoring in the patients’ characteristics and presentation, and should be performed before beginning treatment.
Appropriate assessment helps to accurately discriminate between those who have breast cancer and those who have benign conditions (such as fibroadenoma) or normal breast changes and can be reassured or safely managed with follow-up, obviating the need for surgical intervention.
Ultrasonography is almost universally used to assess localized symptoms, as an initial imaging modality in young women, to identify and characterize screen- detected abnormalities and, preferentially, for imaging- guided percutaneous biopsy. Breast ultrasonography may also be used to characterize and biopsy axillary lymph nodes in women suspected of having breast cancer.
Imaging evaluation also includes MRI for specific clinical indications, such as in women for whom conventional imaging tests have been equivocal, inconclusive or discordant, for evaluating women with breast implants and for evaluating women with axillary nodal metastases but no detectable (occult) breast tumour.
Preoperative MRI is also selectively used for staging newly diagnosed disease, but this is a debated practice given the limited evidence on whether it enhances a patient’s clinical outcomes. However, MRI is advised for preoperative assessment of newly diagnosed invasive lobular cancers.