There’s no single ‘flowchart’ protocol for scans for breast cancer, and that’s a Good Thing

21 Oct 2022

By Luan Lawrenson-Woods

Just like the treatment for breast cancer is becoming more individualised, so too are the tools that are used for diagnosis and surveillance. There are different types of scans and imaging methods that can be used. When they are used will depend upon lots of different factors. That can seem frustrating when you are trying to work out what scans you may have. Or when you have been referred for a type of imaging that someone else you know with a breast cancer diagnosis hasn’t had (or vice versa).

Dr Sam Sood (FRACS), a Specialist Breast Oncoplastic and General Surgeon, explains that there are different protocols and procedures, and it comes down to the individual circumstances of a patient.

Diagnostic imaging

Dr Sam outlines the difference between diagnostic imaging and routine screening. The same type of imaging methods may be used but for different reasons, “Diagnostic imaging is when someone has found a lump or other sign of concern and they need to get a mammogram and ultrasound. We know there is a problem that we will focus on, and we can ‘hone in’ on that one area through magnification views, for example. A tomosynthesis mammogram would usually be done for diagnostic imaging too, which is a 3D mammogram that can show more detail”. These imaging methods are also used to look in more detail at the rest of the overall breast/s as well. A biopsy may also be done at this time too.

If you are recalled for further assessment following a routine screening mammogram, you may have an MRI to get more detailed imaging of the abnormality seen on the mammogram.

Staging scans

If you are diagnosed with breast cancer, you may need some further scans to identify how extensive your breast cancer is, to help inform your treatment plan. This may include an MRI if one has not already been done.

A CT scan and/or PET scan may be used to establish the ‘staging’ of your cancer – whether it is localised and is contained within the breast or has extended beyond the breast. Dr Sam is keen to highlight that the protocols for staging “Differ from institution to institution, but in our institution, and many institutions in New South Wales, we would do staging scans if someone has lymph node positive disease, where there are signs that the cancer has spread into the regional lymph nodes”.

Lymph node positive disease may be indicated through external signs (like an enlarged lymph node under the arm) or from scan results and/or a sentinel node biopsy (when lymph nodes in the breast are removed during surgery and tested for cancer cells). “Then we would get a CT scan, a PET scan or a whole-body scan to make sure that there was no spread to other parts of the body, like the lungs, bones or other organs”, explains Dr Sam.

Dr Sam understands the anxiety women have about whether the cancer has metastasised to other parts of the body but reassures that “If cancer hasn’t gone into the lymph nodes, the chances of it being anywhere else is very low and we potentially do more harm than good by scanning a lot. Staging scans, like CT and PET have much more radiation than a mammogram, so we have to be very judicious about who we offer them to”.

Surveillance imaging

Surveillance imaging is for people who’ve had breast cancer and completed ‘active’ treatment. Dr Sam explains that “It’s called surveillance because we are now ‘surveying’ that area to make sure that they don’t get a recurrence. If they have a breast, their surveillance should be a mammogram and ultrasound. If it’s a woman who’s had a mastectomy and no reconstruction, then it should just be an ultrasound of the chest. If they’ve had breast reconstruction, then it should be an ultrasound of the reconstructed breast”. Men can have an ultrasound of their chest.

It is important to have surveillance scans after a mastectomy because of a breast cancer diagnosis. “A mastectomy doesn’t remove 100% of the breast and there are some breast cells below the skin”, Dr Sam explains.

Women who have not had breast cancer but had a risk-reduction mastectomy can still have regular imaging as part of their ongoing breast assessments. What their plan is will depend on their personal circumstances, and Dr Sam recommends that this is discussed with their GP or specialist.

If you are in ‘active’ treatment for breast cancer or have advanced, metastatic breast cancer, then your scanning protocol will be tailored to you, taking into consideration your cancer pathology, your treatment or how you’re responding to treatment. Scanning protocols may also be linked to clinical trials.

Individualised care is key to successful treatment, “The breast is actually a very complex gland and it's ever changing. And there's lots of different ways to look at it, so imaging needs to be individualised”, explains Dr Sam.

There are lots of different permutations of factors such as cancer sub-type, grade and stage, as well as genetic risk, family health history and your personal health history that inform what imaging or scanning is recommended for you. Dr Sam stresses “It’s very important to note that there is no one flowchart that ‘fits all’. That’s why we, the specialists, are here. We have to process all that information and deliver an individualised plan for each person that we see. Having scans causes anxiety. Finding something on a scan also starts off a ‘cascade’ process. If an MRI, for example, finds a benign cyst then that will start off a process of biopsy and other investigations. It’s a domino effect. So, it’s really important that a specialist oversees the process to avoid this, who will put together an individualised plan because that is what we are trained to do”.

If you’ve recently been diagnosed with breast cancer, Pink Hope has online resources to support you here and here.

And remember, even if you have surveillance screening, you still need to do regular self-breast checks. Sign up for Pink Hope’s reminder here 

Check out Pink Hope’s Glossary for more detail about some of the terms used here