How Breast Cancer Is Diagnosed

A diagnosis of breast cancer is life-changing, but it doesn’t have to be life-threatening.

While breast cancer can be deadly for all women if not diagnosed at an early stage, people have remarkable outcomes when diagnosed early. Unfortunately, this does not always happen. Black women are less often diagnosed with stage 1 breast cancer, when it's highly treatable, than White women. They also more often receive a diagnosis of triple-negative breast cancer, an aggressive form of breast cancer that requires urgent treatment. 

Early detection and prevention are the keys to turning these statistics around.

This article will discuss the role of mammograms, self-examinations, ultrasounds, and other tests in the diagnosis of breast cancer and provide insights into the effect of breast cancer on Black women.

Self-Examination

Breast self-exam, or regularly examining your breasts on your own, is sometimes recommended as a first line of defense for finding breast cancer, along with screenings such as mammograms.

The five steps of a breast self-examination are:

1. Look. Make sure that your breasts are their usual size, shape, and color. If there is redness, swelling, puckering, dimpling, changes in skin color, or your nipples are more elevated than usual, contact your healthcare provider.
2. Raise your arms and look for any of the same changes.
3. Examine your breasts for any discharge, especially in the nipple area. Bloody discharge may be a warning sign of breast cancer.
4. Feel your breasts while lying down. Use a firm, smooth touch with the first few finger pads of your hand, keeping the fingers flat and together. Use a circular motion, about the size of a quarter, examining the entire breast from top to bottom, side to side—from your collarbone to the top of your abdomen, and from your armpit to your cleavage. Push hard enough that you are feeling deep into the tissue but not so hard that you injure yourself.
5. Repeat step four while standing up. Report any painless lumps or suspected changes in your breasts to your healthcare provider immediately.

No one will know your breasts better than you do, so routine exams may be helpful.

Although regular breast self-exams haven’t been shown to reduce mortality rates and may even cause harm by prompting unnecessary biopsies, many healthcare providers still believe that the benefits of this no-cost preventive measure outweigh the risks.

Breast self-exams are a great way to help you to get to know your breasts better and readily identify changes that may be warning signs of breast cancer. If you are experiencing symptoms or noticing changes in your breasts, do not hesitate to call a healthcare provider. Most lumps are noncancerous, but do not assume that they are. Be sure that you confirm this with a healthcare professional.

Physical Examination

Your healthcare provider will take a detailed history prior to performing a physical exam. A detailed history is needed to assess your risk for breast cancer prior to ordering potentially invasive tests or labs.

Breast cancer usually shows no symptoms in its earliest stages. Oftentimes, there is no lump, and only 5% of people present with pain or discomfort.  

The most common breast problems that prompt people to see a healthcare provider are:

• Breast pain
• Nipple discharge
• Palpable mass

Most women with these complaints have benign breast disease. On physical examination, a healthcare provider will look at the breast, perform a breast examination, and check for associated signs of potential breast cancer.

If the physical examination is normal—that is, it reveals no evidence of a breast mass—then you are free to go home. You should be reassured and instructed in breast self-examination before you leave your appointment.

If there is any uncertainty after your physical exam, an ultrasound may be performed. Oftentimes this can be done immediately, and you will not have to return for a separate visit. If no mass is found, you may be asked to return for a follow-up visit in two to four months. During that time, you may also be asked to have a mammogram unless you are younger than 35 years old. In younger women, mammography is rarely useful.

Labs and Tests

If breast cancer is suspected, you will be asked to get a mammogram and biopsy (the removal of tissue for examination).

If your biopsy detects breast cancer, your oncologist may suggest additional lab tests to assist with prognosis (the likely outcome of the disease).

The two most common lab tests are the:

• Hormone receptor test
• The HER2/neu test

Your healthcare provider will send you to a lab to have blood drawn to check the status of these receptors. By knowing your receptor status, your healthcare provider can suggest certain treatment options and begin to assist you in formulating a treatment plan.

Estrogen, progesterone, and HER/Neu are the three receptors that are being assessed. If any of the three are present, then they can be treated with hormone-modulating chemotherapies. But if they are not present, different treatments besides mastectomy (surgery to remove all or part of the breast) and radiation must be considered to rid the body of cancer.

The latter, called triple-negative breast cancer, is rare but more common in Black women. It is often more aggressive and can be fatal without timely treatment. 

Imaging

Whenever breast cancer is suspected the three steps that are taken are:

• Clinical examination
• Imaging (usually a mammogram, an ultrasound, or both)
• Needle biopsy

Clinical examination and imaging are almost always performed, while needle biopsy is performed if a healthcare provider's clinical suspicion is confirmed by an exam and the imaging results.

Ultrasound

A breast ultrasound uses sound waves to create an image of the breast tissue. Breast ultrasounds are not used to screen for breast cancer because of the higher-than-average possibility of missing cancer, especially early signs like tiny calcium deposits called microcalcifications. 

However, ultrasounds play a major role in breast examinations because they can help rule out other causes of breast changes—like fluid-filled cysts—that are harder to identify on mammograms. Ultrasounds can differentiate between fluid-filled cysts that are benign and noncancerous versus solid masses that need to be investigated further. 

Mammogram

A mammogram is a low-dose X-ray that can help find breast cancer.

Mammograms are the premier screening tool used to detect early breast cancer. Cancers show up white on X-rays, but so does dense breast tissue, making it harder to spot cancer. 

The U.S. Preventive Services Task Force (USPSTF) recommends delaying screening mammograms until the age of 50, but this puts Black women at a disadvantage. The data collected for the USPSTF recommendations mainly represent White women and do not adequately reflect the higher-risk Black female population.

The American Cancer Society (ACS) recommends annual or biennial mammogram screening as early as age 45 for those who do not have a family history of breast cancer.

Ultimately, the choice to get a mammogram is up to you, although studies show that women are often happiest with their decisions when they are made with the guidance of a trusted healthcare provider in a process known as shared decision making.

Effect on Black Women

Black women are dying from breast cancer at an alarming rate and the following conclusions from the ACS's Breast Cancer Facts and Figures 2019–2020 may provide some insight on the crisis at hand:

• Black women are not translating breast health awareness into tangible actions. A recent survey found that 92% of Black women believe that breast health is important, but only 25% say that they have recently discussed breast health with their family, friends, or colleagues. And, only 17% have taken steps to understand their risk for breast cancer.
• Black women are more likely to present with advanced-stage cancer upon detection.
• Black women are less likely to have health insurance and, therefore, are more likely to skip or neglect mammograms. 
• Lack of insurance leads to a lack of access to care. Getting a mammogram without insurance is expensive and providers do not offer enough low-cost options. Eliminating the racial wealth gap would solve access to care issues, but that is a long way off. Meanwhile, Black women may struggle to pay for, or stress over the cost of, healthcare services like mammograms and lab work. Some Black women may not follow up on abnormal mammogram results because they can’t afford the diagnostic testing, wish to avoid bad news, or both.
• Black women often go to lower-quality healthcare facilities and receive lower-quality care so they don’t get the same prompt high-quality treatment that others receive. 
• Black women are two times more likely than White women to get triple-negative breast cancer, a rare and aggressive subtype that is often fatal due to its treatment-resistant nature. It is the only breast cancer subtype that does not have a therapy to prevent a recurrence.
• Younger Black women sometimes get diagnosed at later stages and are more likely to get a diagnosis of triple-negative breast cancer when they do.

The lack of diversity in breast cancer research means that some of the recommendations, such as the USPSTF's breast cancer screening guidelines, are not best practices for Black women. This can be a tough pill for Black women to swallow as they often must overcome medical mistrust and systemic problems. 

More inclusive research is needed on the race-specific differences in the following:

• Tumor biology
• Treatment options
• Environmental factors

Fortunately, including Black women in research studies is a prime focus in the scientific community. As a result, there has been a large increase in the number of personalized treatments that Black women have access to. While cost remains a concern, Black women now, more than ever, have the opportunity to access the individualized care and treatment options that they need to beat breast cancer.

Differential Diagnosis

Determining what constitutes a mass can be difficult, particularly in premenopausal women. Ultrasounds, mammograms, and biopsies are used in concert to determine whether or not you have cancer and, if positive, how widespread the cancer is.

Most lumps are noncancerous, but they all should be examined.

The differential diagnosis of a dominant breast mass includes:

• Macrocyst, a fluid-filled cyst
• Fibroadenoma
• Prominent areas of fibrocystic change
• Fat necrosis 
• Breast lymphoma
• Metastasis to the breast from other primary sites (such as ovarian cancer, neuroendocrine, or extramedullary acute myeloid leukemia)
• Papilloma, a small wart-like growth
• Duct ectasia

Access to Care

Despite getting breast cancer at rates equal to White women and advancements in screening and treatment, Black women have a 40% higher risk of dying. Among women under 50, the disparity is even greater with the mortality rate among young Black women doubling that of young White women.

For this reason, every Black woman should consider getting a screening mammogram at the age of 40 and every year thereafter. 

It should also be noted that screening guidelines that recommend delaying screening mammograms until the age of 50, such as the USPSTF's guidelines, are often based on data from a population that is predominantly White. When Black women follow those guidelines, they are put at a disadvantage and can receive a delayed diagnosis since the highest rates of new breast cancer diagnosis are made in Black women aged 50 and younger. 

According to one recent study, the three most commonly reported barriers to mammography are:

• Fear of cost
• Fear of mammogram-associated pain
• Fear of getting bad news

Systemic problems—such as lack of insurance, concerns over the ability to pay, having no primary care healthcare provider, and having biased care—add another level of difficulty for Black women. 

Some additional factors associated with lower mammogram completion rates include:

• Being under the age of 60 
• Having a health plan membership of less than five years
• Having an annual family income of less than $40,000
• Being obese and fearing "too much pain" from mammograms
• Having recently immigrated to the United States
• Living in a rural area

No woman should go without a mammogram, whether there are concerns about pain, bad news, or cost. Going to an appointment with a friend may ease your fears, and many providers will work with you to offset the cost of your mammogram. 

Breast Cancer Doctor Discussion Guide

Get our printable guide for your next doctor's appointment to help you ask the right questions.

Download PDF

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A Word From Verywell

Checking your breasts often, getting a routine mammogram, and knowing your family history are keys to optimal breast health. Early detection means you have a better chance to treat your cancer successfully with affordable options.

Getting a diagnosis of breast cancer is understandably scary and much of your anxiety may result from a fear of the unknown. Remember that most breast cancers are curable and medical advances are helping people to live longer lives.