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This section covers the following topics:
- Tumor testing for treatment selection
- tests for prognosis in breast cancer
- Genetic testing for inherited mutations
testing for treatment selection
tests look at samples of blood, tumor or other tissue for changes or abnormalities caused by cancer. These tests can give doctors clues about the cancer, including:
- how fast the cancer is growing
- which treatments are most likely to work
- whether or not the cancer is responding to treatment or growing
- whether or not the cancer has come back after remission
tests may be used to select treatments, and help patients avoid side effects from treatments that will not work for them. tests used to select a specific treatment are sometimes called "companion diagnostic tests." These tests may be done on tumor tissue or (in many cases) on blood. See our Testing section for more information.
receptors (ER), progesterone receptors (PR) and
After breast cancer tissue is removed by surgery or biopsy, all breast cancers are tested for three common biomarkers:
- Hormone receptors: Testing is done to look for two separate hormone receptors, receptors (ER) and progesterone receptors (PR).
- Cancers that test positive for and progesterone receptors are known as . They may also be called . These cancers are often treated with hormone therapies.
- Cancers that test negative for and progesterone receptors are known as or HR-negative. These cancers are not usually treated with hormone therapy.
- is a protein that is found on all breast cancer cells. Tests measure the amount of protein in the tumor and provide a score from 0 to 3+.
- Cancers with a score of 3+ are considered . These cancers are often treated with drugs called "anti-HER2 agents."
- Cancers with a score of 1+ or 2+ are considered HER2-low. This is a relatively new label for breast cancer. In the past, these cancers would have been called or borderline. Advanced HER2-low breast cancers may be treated with the anti-HER2 agent Enhertu (T-DXd).
- Cancers with a score of 0 are called . These cancers are not treated with anti-HER2 agents.
Other biomarkers used for breast cancer treatment selection
Additional testing may be done to study the genes and proteins within the cancer to help doctors choose the best treatment. Some treatments will work best for people whose cancer cells have specific changes. These treatments are sometimes called targeted therapies. The for a specific is sometimes called a . Some tests look for only one at a time, while others may test for all many biomarkers at the same time. Panel tests look for multiple markers, including FDA-approved treatments as well as those that have not yet been proven effective in breast cancer. Examples of multiple tumor tests for breast cancer include:
- FoundationOne
- MSK-IMPACT
- Tempus xT
Examples of biomarkers used to guide breast cancer treatment include:
- ESR1 mutation testing in advanced breast cancer for treatment with the drug Oserdu (olacestrant).
- PIK3CA mutation testing in ER-positive, advanced breast cancer for treatment with the drug PIQRAY (alpelisib).
- , PIK3 or AKT1 mutation testing in , advanced breast cancer for treatment with the Truqap (capivasertib).
- PD-L1: Testing for the protein can help find people with advanced () who are most likely to respond to the drug Keytruda (pembrolizumab).
- Additional tumor testing may help people learn if they are eligible for certain clinical trials.
tests for prognosis in breast cancer
These tests are used for people with ER/PR-positive cancers to predict:
- if the cancer is likely to come back
- the benefit of adding chemotherapy to the treatment plan
- how long hormonal therapy should be used
Some examples of the most commonly used prognostic tests for breast cancer are listed below:
- Oncotype Dx
- Breast Cancer Index
- MammaPrint
- Prosigna
Genetic tests for inherited mutations for treatment selection
Genetic testing for an may be used to guide treatment selection for people diagnosed with breast cancer.
- People with advanced breast cancer who test positive for an inherited or mutation may benefit from treatments known as PARP inhibitors. Two PARP inhibitors—Lynparza and —are approved as for treating advanced breast cancer in people with a or mutation.
- Lynparza may be used to as after treatment for people with an inherited or mutation who have breast cancer this is high risk for recurrence.
- People who test positive for other inherited gene mutations may qualify for clinical trials looking at targeted therapies to treat hereditary breast cancer.
Expert Guidelines
The National Comprehensive Cancer Network has guidelines on who should undergo genetic counseling and testing. If you have been diagnosed with breast cancer, you should speak with a genetics expert about genetic testing if any of the following apply to you:
- You have a blood relative who has tested positive for an
- You have any of the following:
- Breast cancer at age 50 or younger
- Male breast cancer at any age
- Ovarian cancer at any age
- at any age
- Two separate breast cancer diagnoses
- Eastern European Jewish ancestry and breast cancer at any age
- Lobular breast cancer and a family history of diffuse gastric cancer
- For treatment decisions for people with breast cancer or people with early , breast cancer who are at high-risk for recurrence
- Testing of your tumor shows a mutation in a gene that is associated with
OR
- You have one or more close family members who have had:
- Young-onset or rare cancers
- Breast cancer at age 50 or younger
- Male breast cancer, ovarian cancer, pancreatic cancer, or cancer at any age
- Two separate cancer diagnoses
- prostate cancer or cancer that is high-risk or very-high-risk group.
The American Society of Breast Cancer Surgeons (ASBrS) released guidelines in 2019 that recommend all women diagnosed with breast cancer have access to genetic testing for inherited mutations in breast cancer genes.
If you are uncertain whether you meet the guidelines above and you are interested in or considering genetic testing, you should speak with a cancer genetics expert.
Paying For Care
Paying for testing
Insurance companies are required to cover the costs for cancer treatment. Health plans may vary on the amount of out-of-pocket costs and coverage for specific doctors, facilities, tests or treatments. Your doctor's office and treating hospital should disclose how much your treatment may cost you and work with you on a plan to cover the cost of your care.
Medicare will cover the cost for genetic testing and testing for people who meet certain criteria. Medicare coverage varies based on where you live. Visit this site to find and contact your regional Medicare provider for more information about coverage. The Medicaid website has a link to state Medicaid programs, which list specific eligibility for each state.
If you need information about finding an insurance plan, watch our video: Choosing Wisely: How to Pick Insurance Plans.Visit our Health Insurance Appeals page for additional information on insurance appeals.
Some laboratories have assistance programs that help cover the cost for tumor testing:
- Caris Tumor Profiling Financial Assistance Form
- Foundation Medicine Billing and Financial Assistance
- Myriad Cares
- Tempus Billing and Financial FAQs
Organizations that offer co-pay assistance:
Other resources:
- The American Cancer Society provides information and resources on covering the cost of cancer care. Public assistance, such as Medicaid may be available if you are ineligible for other programs.
- Triage Cancer offers tools and resources to help individuals cope with the financial aspects of a cancer diagnosis.
Paying For Care
Insurance coverage for genetic counseling and testing
Most health plans cover genetic counseling and testing for inherited gene mutations linked to cancer in people who meet the national guidelines. The cost of testing and your out-of-pocket charges may vary based on several factors.
People who are denied coverage for genetic testing can file an appeal (FORCE has sample appeal letters). Your healthcare provider can work with your insurance company and help you file an appeal if needed. Low cost testing may be available for $250 or less. Learn more about coverage for genetic counseling and testing here.
If you need information about finding an insurance plan, watch our video: Choosing Wisely: How to Pick Insurance Plans.
testing under the Affordable Care Act
Under the Affordable Care Act (ACA), insurance companies must pay for both genetic counseling and testing with no out-of-pocket costs for women who meet certain criteria. The ACA regulations are limited to testing for and only and do not cover genetic counseling or testing in all situations. You can learn more about testing under the ACA here.
Medicare and Medicaid coverage of genetic testing
Genetic counseling and testing is typically covered by Medicare for people already diagnosed with cancer who are in treatment or for whom test results may affect their care. Most state Medicaid programs cover genetic testing for and mutations for people who meet requirements, which vary by state. You can read more about Medicare and Medicaid coverage of genetic testing here.
Financial assistance or low cost genetic testing
JScreen is a national program based out of Emory University that provides low-cost at-home genetic counseling and testing with financial assistance available. Many laboratories offer low-cost genetic testing or financial assistance programs. Programs vary, so if you are not eligible for assistance through one lab, consider contacting other labs to see if you qualify .