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The doctor depends on three tests to help to diagnose a breast cancer:

• Clinical Examination. Depending on his experience, a doctor can suspect whether a breast lump is cancerous or not by performing a clinical breast examination. Breast lumps or cancers smaller than 1.5cm diameter or situated deep in the breast cannot be detected by clinical palpation.  Accuracy of this diagnostic method is approximately 60 to 70%.

• Mammogram. This is an x-ray examination of the breast and a cancer can appear as an irregular mass, clustered microcalcifications or distortion of the breast tissue. Mammogram can detect breast cancer when it is small and not clinically palpable and hence is very useful in early detection of breast cancer. (See section on Breast Screening for more details on this test)

• Breast Ultrasound Scan. This method which uses sound waves to generate an image of the breast is useful in detecting breast lumps in the younger women (less than 35 years) in whom the breast is often lumpy and hence difficult to palpate and whose mammograms are difficult to interpret. Presently ultrasound scan is especially useful to differentiate between a solid lump and a cyst. A breast cancer appears as an irregular tall mass with indistinct margins on the ultrasound scan. The role of breast ultrasound is to complement x-ray mammogram.

Based on these three tests, a doctor is able to suspect whether a lump is present and whether it is cancerous.

Very often, a doctor will recommend a BIOPSY of a breast lump detected by any of the three tests in order to exclude a malignancy.  A biopsy is an invasive technique in which some tissue is obtained from the lump for laboratory tests to determine its exact nature.

The common biopsy techniques are:

• Fine Needle Aspiration (FNA). A small needle is introduced into the breast lump to sample it. The aspirate is smeared onto a glass side and analysed in the laboratory. An experienced pathologist is able to tell whether the cells in the aspirate are cancerous after studying them under the microscope. Even though it is simple and easy to perform, FNA is not as accurate as the other biopsy techniques for several reasons:
  
  

  (a) Inadequate number of cells sampled
  (b) Inexperienced pathologist
  (c) Inability to diagnose a noninvasive breast cancer (which requires a piece of the breast cancer for diagnosis)

• Core Needle Biopsy. The core needle is a slightly bigger needle and is able to obtain slices of a breast lump for analysis. Core needle biopsy is more accurate as it is based on analysis of a piece of the breast lump under the microscope (i.e. histological diagnosis). It can also diagnose noninvasive breast cancer. Automated core needle biopsy systems have been invented in which many slices of a breast lump can be obtained via one small skin puncture.

• Excision Biopsy. A doctor may recommend that the whole breast lump be removed (i.e. excised) for histology. This procedure can be performed under local anaesthesia or more often general anaesthesia. The advantage of excision is that the lump is wholly removed from the woman’s breast.

• Frozen Section. This is a technique to prepare tissue for histological examination quickly (about 15 to 30 mins). With frozen section, a breast cancer can be diagnosed with the patient under general anaesthesia and the proper cancer operation carried out. This saves the patient having to undergo two hospitalizations, one for the excision biopsy and the other for the cancer surgery.