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Breast Cancer Options

Date: Sat, 30 Dec 1995 21:00:28 CDT

Catt's Claws reader Nancy Phillips, M.D., Assistant Professor, Pathology St. Louis University School of Medicine, subspecialist in gynecologic and breast pathology and researcher in genetics of ovarian cancer took some exception to our and the news media's coverage re biopsies for breast cancer determination.

We feel this subject is so important and so misunderstood that Dr. Phillips' entire letter should be published (with the exception of our exchange regarding opera that we both love and in that, too, she is much more knowledgeable):

Her preliminary comments: "Yes, there are careless docs, well-meaning fossil docs, crooked docs, and insecure indecisive docs, all of whom can delay diagnoses. "Yes, I see disaster patients with distant metastases show up at my university for bone marrow transplants. 30 years old, 2 year-history of enlarging mass with alarming mammographic characteristics, solid by ultrasound (bad - not a benign cyst), her doc did not think that cancer was likely in such a young woman. True about the age, but *1. occasional young women get cancer, and the incidence is 100% if YOU are the patient *2. palpable changing mass with worrisome mammographic/ultrasound features MUST be biopsied, young or old, woman or man (men get breast cancer at 1/100 the incidence of women, and generally do worse since tumors eat into chest wall and lymphatics since there isn't much to a man's breast).")

--- Dr. Phillips' article:.....

There are three breast biopsy options:

1. traditional surgical biopsies, which attempt to remove all abnormal tissue for pathology examination;

2. fine needle aspiration, in which a very fine needle is inserted into a palpable mass, cells sucked out with a syringe, and a cytology preparation made that resembles a Pap smear;

3. needle core (Tru-cut) biopsy, in which a thicker needle is used to extract several pieces of tissue measuring 1 millimeter (1/25 inch) in diameter and up to 2.5 centimeters (1 inch) in length. The core biopsy is usually done under mammographic visualization to obtain tissue from a non-palpable mammographic abnormality such as microcalcifications that are sometimes (NOT always) associated with cancer.

Each method has advantages and disadvantages. The traditional surgical biopsy enables the pathologist to examine all of the worrisome tissue, whereas the other two methods only obtain part of the worrisome area. Often, the pathologist can make a diagnosis on a small sample, but there are times when the pathologist cannot make a definitive diagnosis, and prudence dictates getting the traditional surgical biopsy to resolve the uncertainty.

Furthermore, if only a small portion of the lesion is sampled, the crucial area can be missed.

Advantages of the smaller biopsies include not having to undergo surgery, lower cost, breast less sore afterward (though not a painless procedure).

In experienced hands, the small biopsies can be very accurate on suitable patients, and the fine needle aspirations have been standard-of- care in Sweden for 25 years with excellent accuracy. Even in the Swedish experience (the longest in the world), there are patients who must get a surgical biopsy after an inconclusive result on aspiration biopsy.

So, how to choose a method..?

1. Fine needle aspiration and mammographically-directed biopsies are relatively new in this country, and many surgeons, pathologists, and radiologists don't have much (or any) experience in these methods. These methods also require good communication between the three specialists, especially during the inevitable learning phase when the procedure is being introduced to the institution or practitioners.

At this point, the best bet is to obtain these small biopsies at university hospitals or university-affiliate community hospitals in larger cities.

If a small-biopsy program is being started by good pathologists, radiologists, and surgeons, all with common sense and prudence, the rate of missed diagnosis will be very low but more patients will require subsequent surgical biopsy to resolve diagnostic uncertainty than would be re-biopsied by a program with long experience (eg.Karolinska Institute, Sweden, the foremost center for aspiration).

It will be several years before the small biopsies are well established in non-academic centers, so if you live in an isolated location, traditional surgical biopsy, for which all surgeons, pathologists, and radiologists have had at least some training and experience, may be the safe choice in most situations.

2. If a lesion is obviously cancer and the goal is to make a tissue diagnosis before proceeding with the definitive mastectomy or lumpectomy with axillary (armpit) lymph node dissection, any of the three methods is likely to work. If someone comes into our center with a stony-hard mass distorting the breast, or with skin changes, we do the aspiration biopsy in most cases. Likewise, if the lesion looks benign on mammogram (little rounded mass), a small biopsy can confirm that the lesion is a benign fibroadenoma and give the patient peace of mind.

3. If the lesion is indeterminate on mammogram and the patient has a history of proliferative breast disease that may be difficult to distinguish from pre-cancer, or has a strong family history, going straight to surgical biopsy is sensible. All the problem tissue can be examined by the pathologist. Making breast diagnoses is not always straight forward, and the pathologist is helped significantly by seeing the whole lesion. Medicine, and particularly the specialties requiring pattern recognition skill i.e., pathology and radiology, is still as much art as science."

End of article. Dr. Phillips added:

Irene, this is wordy but covers the points that I want the public to understand. Medical choices in breast care tend to be rather complex because the field is changing and because what may suit one patient will not be appropriate for another. Merry Solstice.)

Thank you doctor and merry every day to you. A physician who cares and takes the time (for free) to share her knowledge about this very difficult and personal subject is very precious. Thank you - and readers, remember your monthly exam of the breast you want to save.