A February 18, 2011 New York Times article entitled “Study of Breast Biopsies Finds Surgery Used Too Extensively” refers to a review of breast biopsies done in Florida from 2003-2008, noting that 30% were done with a scalpel, usually in the operating room. This number is too high.
In the modern era, most breast biopsies should be done with a minimally invasive needle sampling and not as a more invasive, open surgical procedure. This is a trend that has been steadily evolving over my 30 year history caring for women with breast disease. These biopsies are quicker, cheaper and have fewer complications. When done by properly trained physicians with modern equipment, the reliability of a needle biopsy is equal to that of a surgical biopsy.
What we’re doing in a biopsy is taking a small tissue sample from an area of concern. If tests show that a sample is worrisome — malignant — we’ll take steps to remove it surgically. Technology has enabled us to do biopsies on smaller and smaller tissue samples in the past 20 years. Biopsies can be guided by ultrasound, with tissue removed by a vacuum-powered instrument that allows for multiple tissue samples to be collected during one insertion. A stereotactic biopsy is another method that involves computer imaging to guide the needle to an abnormal area too small to be felt by hand. The smaller the lesion, the earlier a potential cancer has been detected, and chances for successful treatment are that much greater.
There are cases where a lesion is small enough that a biopsy can remove it entirely, with no further surgical procedure required. Some patients may require a very small surgical resection to have the tumor removed. When a larger cancer is found in a patient, they may need more surgeries and possibly radiation and chemotherapy treatments. But every patient is a little bit different, which is why we have the nurse navigation system in place at BMH. Every patient’s care is tailor-made for them so depending on how their biopsy goes, their plan is mapped out pretty well with the best technology available to them.
It is hard to state exactly when needle biopsies for breast concerns became the “standard of care.” Dr Melvin Silverstein, a very respected breast surgeon, wrote an editorial in the January 2009 edition of the Journal of the American Medical Association entitled, “Where’s the Outrage?” His point was that women should be outraged that they were having a more invasive procedure than was necessary. To keep this in perspective, appreciate that there are close to 1.6 million breast biopsies done each year in the United States. The cost of a surgical biopsy is about double that of a needle biopsy. There is also more time away from work, more pain and more scarring.
The reasons behind continuing to perform open surgical breast biopsies are felt to be a combination of education, profit and “oncopolitics.” Dr. Eric Whitacre, president of the American Society of Breast Surgeons, notes that “many surgeons have been providing minimally invasive breast biopsy techniques for over two decades. For more than 15 years, some of our members have trained thousands of surgeons in minimally invasive breast biopsy techniques.”
As a surgeon at Brattleboro Memorial Hospital, working closely with our radiologists, I have been providing ultrasound and mammogram-guided needle biopsies for our patients for almost twenty years. I am very proud to note that while many of the larger, big city hospitals continue to do too many open surgical biopsies, here at Brattleboro Memorial Hospital, for more than a decade, the vast majority of our patient’s breast biopsies have been done using minimally invasive modern techniques. This is the result of the surgeons and radiologists at Brattleboro Memorial Hospital working closely together for the benefit of our patients.
Dr. Joseph Rosen is a staff surgeon at Brattleboro Memorial Hospital. He has been an active member of the American Society of Breast Surgeons since 1998.