Diagnostics & Testing - Black TNBC Sanctuary

TNBC is typically diagnosed in a two-stage process. If you have a lump in your breast or another breast cancer symptom, your doctor will start with imaging. If your doctor sees anything unusual during imaging, they may recommend a follow-up biopsy to determine if what they see is breast cancer or something else (like a cyst or benign tumor).

If the biopsy does come back positive for cancer cells, pathologists test those cells using a staining method to detect ER, PR, and HER2 to determine the subtype of cancer. For triple negative breast cancer, that final pathology test comes back negative for ER, PR, and HER2.

Diagnostic mammograms and other diagnostic tests should be covered by your insurance, but you might have a copay or coinsurance associated with them depending on your specific plan. If you have insurance, call your insurance provider and ask them what you should expect. If you don’t have insurance or your copay is keeping you from getting testing that you need, visit our health insurance and financial resources sections.

1. Diagnostic Imaging

Many Black women diagnosed with breast cancer find a lump or another breast cancer symptom themselves, which is why regular breast self-exams and knowing your normal is incredibly important. In the event that you or your doctor sees or feels something off, your doctor should schedule a follow-up examination using one of the following imaging options:

Mammograms

During a mammogram, an individual’s breast is compressed using two plates. Spreading out the breast in this way makes it easier to see what’s going on. The squeeze you feel during a mammogram should only last for 10 to 15 seconds at a time. During this time, low-dose x-ray pictures are taken. Each breast is compressed multiple times in order to get images at different angles. The entire process can take about 20 minutes.

Mammograms can be uncomfortable for some women, but any discomfort should go away immediately after.

For a standard (2D) mammogram, at least one picture is taken at each angle. For a 3D mammogram, many pictures are taken at different angles and then constructed into one complete image to provide a better view of each breast. 3D mammograms may increase detection while also decreasing false-positive rates. For women under 40 and women with dense breasts (which are more likely to occur in Black women), 3D mammograms may be recommended by their doctor for more accurate screening.

During a 2D mammogram, an individual is exposed to about 0.4 millisieverts (mSv) of radiation, which is about the same amount of radiation someone would be exposed to in their normal daily life over a seven-week period. 3D mammograms expose individuals to similar amounts of radiation as 2D mammograms, but the exposure might be slightly lower or slightly higher.

Ultrasound

During an ultrasound, sound waves and their echoes are used to create pictures of the inside of a breast. These images can show certain breast changes—such as fluid-filled cysts—that might be more difficult to see on a mammogram and can be useful to look at breast changes that can be felt but are not detected on a mammogram. Ultrasounds may be recommended as a follow-up test to get a better look at a concerning area already found on a mammogram. Ultrasounds are widely available and do not expose an individual to any radiation.

For individuals under the age of 30, ultrasound is often the first test recommended. This is because mammograms are less accurate at examining the dense breast tissue common in young people. For those between 30 and 40 years of age, an ultrasound is commonly used in addition to a 3D mammogram.

MRI

For magnetic resonance imaging (MRI), you lie down on your back before being slid into a machine that looks like a long, narrow tube. Once inside, radio waves and magnets are used to make detailed pictures of a breast.

Unlike a standard MRI, a breast MRI includes the use of a breast coil (which may not be available at all hospitals and imaging facilities). During the process, you lie face down with your arms above your head and your breasts hanging down through an opening in the table. You will be instructed to remain as still as possible and hold your breath during certain parts of the test. You will also be injected with a contrast material called gadolinium to help show any abnormalities, so it is important to let the person conducting the MRI know about any allergies or any past issues with contrast or dye in imaging tests.

The whole test usually takes about 30 to 45 minutes. Researchers are also currently investigating the use of abbreviated MRIs (or FAST MRI), in which fewer images are taken to speed up the process.

An MRI may be used in individuals with a high risk of breast cancer in addition to a mammogram. An MRI is not recommended on its own because it can miss some cancers that a mammogram may find.

While diagnostic testing can be nerve-wracking and scary, you should not be in pain after any of these imaging methods.

2. Biopsy

If your doctor sees anything suspicious of cancer during imaging, they will recommend a follow-up biopsy to determine if what they see is breast cancer or something else (like a cyst or benign tumor). During a biopsy, your doctor will take a small sample from your breast and test it. Types of biopsy may include:

Fine Needle Aspiration: For this procedure, a thin, hollow needle attached to a syringe is used to extract a small amount of breast tissue or liquid from the concerning area. This is most often used when the concerning area is likely to be a fluid-filled sac (also known as a cyst). When performed with an ultrasound, the procedure can take around 20 to 30 minutes. Afterwards, your doctor may tell you to limit strenuous activity for a day or so. This is the least invasive type of biopsy, but its accuracy is lower than other types. If the results of this biopsy are inconclusive, a different biopsy type might be recommended.
Core Needle Biopsy: This is usually the preferred method of biopsy, because it removes more breast tissue than fine needle aspiration but doesn’t require surgery. Doctors use a hollow needle used to extract breast tissue from the concerning areas identified by your earlier mammogram, ultrasound, or MRI. The procedure is typically quick and your doctor might instruct you to limit strenuous activity for a day or so after.
Surgical Biopsy: If the results of a needle biopsy aren’t clear, then your doctor may recommend one of two surgical biopsy options. During incisional biopsy only part of the unusual area is removed, while an excisional biopsy removes the entire tumor or unusual area and sometimes a little bit of the surrounding normal breast tissue. Excisional biopsy is the most accurate method for diagnosis. Additionally, it might offer more peace of mind to the patient, since the entire tumor is removed. However, incisional biopsy is a less invasive surgery, leaving more of the breast intact, resulting in shorter healing times and less change in appearance.

Detecting Metastatic TNBC

If a biopsy confirms a diagnosis of cancer, then further diagnostic tests may be performed to see if the cancer has spread to other parts of the body. Some of the tests used to detect the spread of TNBC may include:

Lymph Node Surgery: The lymph nodes in the armpit area are a common place for breast cancer to spread to, so a biopsy of an enlarged lymph node is typically one of the first tests health care professionals will perform to see if the cancer has spread.
Bone Scan: The use of a radioactive tracer (a substance that is easy to follow and find in the body, much like a GPS tracker) to detect if cancer has spread to the bone. Tracers don’t stay in your body—you will pee it out over the course of 24 hours.
Computerized Tomography (CT) Scan: X-rays are taken from different angles to produce 3D images of areas outside the breast, including the bone, lungs, and liver.
Positron Emission Tomography (PET): A radioactive sugar (known as FDG) is used to see if breast cancer may have spread. It may also be paired with a CT scan.
X-ray: A chest x-ray may be used to detect cancer in the lungs.

Newer or Experimental Screening Options

While mammograms, ultrasounds, and MRI are the most commonly used imaging techniques, other methods exist. Some of these methods are currently used, but others are still being tested to see if they can deliver better or similar results. Ask your doctor and/or reach out to us if you would like to learn more about any of these options.

During molecular breast imaging (MBI)—also called scintimammography or breast-specific gamma imaging (BSGI)—the breast is gently compressed while a camera looks for a radioactive tracer (a substance that is easy to follow and find in the body, much like a GPS tracker). Tracers don’t stay in your body—you will pee it out over the course of 24 hours. This is mostly used to follow up after another imaging option has been tried or to help determine the size and location of already diagnosed breast cancer. It can also be used as an option for individuals with dense breasts.

Positron emission mammography (PEM) combines elements of PET scans and mammograms. A tracer (a substance that is easy to follow and find in the body, much like a GPS tracker) is injected into the blood before a mammogram to better detect small clusters of cancer cells. Tracers don’t stay in your body—you will pee it out over the course of 24 hours.
Contrast-enhanced spectral mammography (CESM) involves the injection of contrast dye containing iodine into the blood before two sets of mammograms, each of which uses a different radiation level. This test, which provides greater contrast than standard mammography, can be used after a standard mammogram to provide a better look at areas that appeared unusual or in individuals just diagnosed to assess the size and location of the tumor.
Elastography can be performed during an ultrasound and involves slightly compressing the breast to detect the firmness of a concerning area. This may be useful in determining if an area is more likely to be benign (not cancer), since tumors tend to be firmer and stiffer than surrounding breast tissue.

In optical imaging tests, light is passed into the breast. The amount of light that returns or passes through the tissue is then measured. This test does not involve the use of radiation or the compression of the breast. It is being studied with other tests such as MRI, ultrasound, or 3D mammography.
More diagnostic techniques for TNBC that could be used in the future include the use blood-based liquid biopsy to scan for evidence of cancer in a person’s blood; the use of nanobiosensors to detect TNBC cells; and digital polymerase chain reaction (dPCR) which looks for specific genes by the cancer cells.

Don’t be afraid to ask your doctor which type of imaging and/or biopsy they recommend for you and why.