From the Breast Diaries:

8 Reasons to Choose the Needle If You Need a Breast Biopsy

Image of Biopsy While killing time in foils under the dryer at my favorite hair salon, I was flipping through the October 2011 issue of Vogue and came across an interesting article, “Breast Check” by Elizabeth Weil.  Weil discusses the experience of her sister-in-law Kelly, who felt a lump in her breast that required a biopsy.  Kelly’s doctor performed an open surgical biopsy, and the results were benign (no cancer!).  Although relieved, the author wondered why Kelly was not sent to a radiologist for a needle biopsy (as in the example image above), and instead underwent the more invasive surgery.  Investigating the issue further, she discovered a study from The American Journal of Surgery published earlier in 2011, which reports that in Florida a large number – 30%– of breast biopsies are performed as surgeries and not as needle procedures, even though the needle biopsy is considered the standard of care.  The number of surgical biopsies should be closer to 10%, in an ideal world.

Why would there be so many surgical biopsies instead of the less invasive needle biopsy?  According to the authors of the above paper, in some areas of the country there are no radiologists available who have the training and experience necessary to perform the procedures safely, reliably, and accurately (lack of access).  In addition, the authors postulate that there are some surgeons who are not educated regarding the value of needle biopsies as opposed to surgery, and who might be motivated by financial incentive to do the biopsy themselves with surgery.  I would argue that the overwhelming majority of doctors do not fall into that description, but it would be naïve to think that they don’t exist.  I was once forbidden to speak to the patients of a now-retired surgeon who didn’t want his patients to even consider the option of a needle biopsy because he didn’t want to potentially lose the surgical case.  Since I’d read the mammograms on these women, they were technically my patients as well as his, and I ignored his edict.  He didn’t like me very much.

Here are a few reasons why a needle biopsy makes more sense than an open surgical biopsy for most women:

  1. Needle biopsies have proved to be just as accurate as surgical biopsies.  Considering the fact that 8 out of 10 breast biopsies will be benign (NOT cancer), many surgeries for benign conditions can be avoided.
  2. If the mass biopsied with a needle does turn out to be a cancer, the breast surgeon can plan the surgical treatment and biopsy of the lymph nodes under the arm to be performed in one trip to the operating room.  If the surgeon knows something is cancer before he/she performs the operation, he/she is more likely to get clean surgical margins, and the patient doesn’t have to return to the operating room again to get those clear margins.
  3. Patients are sometimes concerned that a needle biopsy can potentially cause a breast cancer to spread.  A few studies have addressed this issue, and have shown no increase in recurrence rates or decrease in survival in women who have had needle biopsies as opposed to surgical excisional biopsies.
  4. Surgical biopsies require IV sedation or sometimes general anesthesia, adding potential complications.  Needle biopsies are performed with local anesthesia (i.e. Lidocaine).
  5. A needle biopsy is much less invasive, with fewer complications.  It can be performed in an outpatient examination room in less than 20 minutes, without a trip to the Operating Room.  The patient can return to work the next day, unless the work requires lifting or heavy activity.
  6. No stitches, less scarring, and less potential for a surgery to deform the breast.  Cosmetic concerns are entirely valid!  Don’t let anyone shame you into thinking they aren’t.
  7. Future mammograms will not look much different after a needle biopsy.  However, after a surgical biopsy, the patient’s mammogram often looks quite different from those obtained before the surgery; this can sometimes make the mammogram more difficult to interpret accurately.
  8. A needle biopsy costs much less than a surgical biopsy.  In Florida, it is estimated that $37 million could be saved annually if the surgical biopsy rate is brought down to 10%.

The February 2012 edition of the Journal of the American College of Radiology published a rebuttal to the 2011 study from the American Journal of Surgery.  These investigators from Thomas Jefferson University Hospital argue that the numbers stated in the study of Florida biopsies are erroneous, and do not accurately reflect national figures from Medicare data.  They calculate that the surgical biopsy rate is more in the vicinity of 11% nationally, and they conclude that surgical breast biopsy is not being overused.

Be that as it may, it is best to know about this issue for yourself, so that if you are ever in the situation where you need to have a breast biopsy, you are informed enough to ask the right questions.  Keep in mind that there are occasional cases where a needle biopsy is not technically possible, and a surgical biopsy is truly indicated.  If your doctor recommends a surgical biopsy over a needle biopsy for your situation, you can always seek a second opinion to determine if surgery is truly the better choice in your case.

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