Breast Cancer ChoicesTM  
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Scrutinizing the evidence for breast
cancer procedures and treatments
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    After being screened for breast cancer, a suspicious lump has been
    found. How can they determine if the lump is cancerous?

    There are three kinds of biopsies:
    1.   fine needle biopsy (FNA),
    2.   core biopsy which is sometimes called sterotactic biopsy
    3.   excisional biopsy during which the whole lump is surgically removed.

    I have just had a mammogram and my doctor sees a suspicious mass
    in my breast.  My doctor has suggested a needle biopsy.  Is there any
    downside to this procedure?

    Background: Needle biopsies pierce the suspicious breast mass to draw
    out tissue for analysis.  Some researchers fear these procedures may
    spread (or seed) the cancer, causing something called "needle track
    metastasis." Others feel this possibility is not a significant concern or that
    the immune system, surgery and/or radiation that follows will clean up the
    area. Each individual must review the information that is presented in this BIOPSY
    section with her doctor and decide for herself whether or not to undergo these
    procedures.

    In June 2004, the results of the bombshell Hansen study, "Manipulation
    of The Primary Breast Tumor and The Incidence of Sentinel Node Metastases From
    Invasive Breast Cancer," were published in the American Medical Association's
    prestigious journal, Archives of Surgery,  revealing that patients undergoing  fine
    needle biopsies were 50% more likely to have micrometastases spread to the
    sentinel lymph node than those patients having the entire tumor removed for biopsy.

    The implication of this discovery is that a woman without lymph node involvement,  
    who would have been staged at a low level,  now will be staged higher, her disease
    considered more advanced, and more aggressive treatment might be recommended.

    Over the years, several researchers have voiced serious reservations about routine
    needle biopsies, but they were mostly ignored by their colleagues. Hansen's
    research team cited their predecessors, and  the research path leads back several
    decades. It's hard to understand why The Archives of Surgery study, which embodies
    all of these reservations about needle biopsies, didn't make the front page of the
    New York Times.

    Cancer authority, Ralph Moss, comments in his February 6th, 2005 Moss Reports
    Newsletter:

    "Imagine the outrage these patients will feel when they learn that many of these
    sentinel node metastases were caused not by the natural progression of their
    disease but directly by the actions of well-intentioned (but ill informed) doctors.
    Imagine, further, what will happen when patients find out that questions have been
    raised about the safety and advisability of needle biopsies for a number of years by
    some of the finest minds in oncology. Imagine the disruption of the smooth functioning
    of the "cancer industry" when patients start demanding less invasive ways of
    diagnosing tumors.  And imagine the class action lawsuits."  

    Significant parts of the Hansen study below are highlighted in red. Patients  may want
    to include it in their Patient Portfolio.
      __________________________

    Manipulation of the Primary Breast Tumor and the Incidence of
    Sentinel Node Metastases From Invasive Breast Cancer

    Nora M. Hansen, MD; Xing Ye, MS; Baiba J. Grube, MD; Armando
    E. Giuliano, MD

    Arch Surg. 2004;139:634-640. Hypothesis  The incidence of
    sentinel node (SN) metastases from invasive breast cancer
    might be affected by the technique used to obtain biopsy
    specimens from the primary tumor before sentinel lymph node
    dissection. Design  Prospective database study. Setting  The
    John Wayne Cancer Institute.

    Patients and Methods  We identified 663 patients with
    biopsy-proven invasive breast cancer who underwent sentinel
    lymph node dissection between January 1, 1995, and April 30,
    1999. Patients were divided into 3 groups based on type of
    biopsy: fine-needle aspiration (FNA), large-gauge needle core,
    and excisional. A logistic regression model was used to
    correlate tumor size, tumor grade, and type of biopsy with the
    incidence of SN metastases.

    Results  Of the 676 cancers, 126 were biopsied by FNA, 227 by large-gauge
    needle core biopsy, and 323 by excisional biopsy before sentinel lymph node
    dissection. Mean patient age was 58 years (range, 28-96 years),
    and mean tumor size was 1.85 cm (range, 0.1-9.0 cm). In
    multivariate analysis based on known prognostic factors, the
    incidence of SN metastases was higher in patients whose cancer
    was diagnosed by FNA (odds ratio, 1.531; 95% confidence
    interval, 0.973-2.406; P = .07, Wald test) or large-gauge needle
    core biopsy (odds ratio, 1.484; 95% confidence interval,
    1.018-2.164; P = .04, Wald test) than by excision. Tumor size
    (P<.001) and grade (P = .06) also were significant prognostic factors.

    Conclusions  Manipulation of an intact tumor by FNA or
    large-gauge needle core biopsy is associated with an increase in
    the incidence of SN metastases, perhaps due in part to the
    mechanical disruption of the tumor by the needle. The clinical
    significance of this phenomenon is unclear.
    ----------------------------------------------------------------------------------

    According to the Hansen study, whether the increased incidence of sentinel node
    metastases will promote a regional recurrence or affect overall survival is unknown.
    Will a core biopsy increase the chance of a local recurrence? Another research team,
    led by A. Chen, published "Local Recurrence of Breast Cancer After Breast Cancer
    Therapy in Patients Examined by Means of Stereotactic Core-Needle Biopsy," in the
    journal Radiology in 2002 after finding that a core biopsy followd by a lumpectomy
    and radiation does not increase the risk of a local recurrence.  It is worth noting that
    the authors of this study speculate that there might be an increased risk of a local
    recurrence unless adjuvant radiation is used.   (See Thurfjell, et al., Acta Radiologica,
    [2000 ] and Chen, et al.,Radiology,[2002] in the MEDICAL ARTICLES BIOPSY section.)


























    What is the impact of the increased incidence of SN metastases on overall
    survival?

    The American College of Surgeons' Z0010 study will address the significance of
    micrometastases in the regional lymph nodes of patients with invasive breast cancer.

    Cited below are relevant excerpts from the much respected Townsend Letter for
    Doctors and Patients ( 2004). The article elaborates upon the problems with
    stereotactic  (also called "core" biopsies because a bigger needle is used to draw
    out tissue) biopsies.

    Stereotactic Breast Biopsy: what you should know but probably weren't told

    Townsend Letter for Doctors and Patients, June, 2004 by Whitney S. Hibbard
    [excerpted]

    Question. Are there any risks inherent in the stereotactic needle biopsy
    procedure?

    Answer. Yes. A survey of histological studies reveals that there is a clear
    danger of seeding needle tracks with malignant cells "displaced in breast
    stroma or in lymphovascular channels, associated with the traumatic effects of
    a needling procedure," according to Dr. Rosen, Department of Pathology,
    Memorial Sloan-Kettering Cancer Center. Consequently, Dr. Rosen warns that
    "with tissue disruption, lymphatic and vascular channels may also be breached,
    and it is conceivable that detached epithelial fragments may enter vascular
    channels and perhaps even be transported to lymph nodes." (1)

    Question. What is the frequency of malignant needle track seeding?

    Answer. The frequency with which this occurs and the degree to which this
    leads to metastases is uncertain. Studies range from an insignificant .003%
    frequency of malignant needle track seeding to a horrifying 89%. (2) Clearly,
    more research is needed to assess accurately the actual incidence. It is
    extremely important to understand, however, as Dr. Austin clarifies in Breast
    Cancer: What You Should Know (But May Not Be Told) About Prevention,
    Diagnosis, and Treatment, that it is not breast
    cancer per se that kills: "What kills patients is the spread of cancer to distant
    parts of the body--distal metastasis."

    Question. Isn't this really a moot concern because if a biopsy reveals a
    malignant lesion it will be removed anyway?

    Answer. Maybe. The question is whether the whole needle track would be
    removed during surgery, i.e., surgeons unaware of the malignant needle track
    seeding problem may not do the necessary excision. Furthermore, it must also
    be asked as to how long it takes for malignant cells leaked into a vascular
    channel to be distributed to otherareas of the body (e.g., neighboring lymph
    nodes)? In all likelihood this would be fait accompli long before a scheduled
    surgery.

    Question. What are a patient's diagnostic procedural options if she chooses
    not to undergo fine needle biopsy?

    Answer. Critics of the procedure recommend lumpectomy with subsequent
    histological examination once the tumor is safely removed, or surgical excision
    of the needle track after biopsy. (3)

    Question. Is there a problem of "false negatives" (i.e., even though a
    malignant tumor is present, it is missed with the needle so the pathology
    report is negative) with stereotactic needle biopsy?

    Answer. Allegedly, the X-ray guided needling in the stereotactic procedure will
    reduce greatly the number of "false negatives" which run as high as 23% in non-
    stereotactic needle biopsy procedures! (4)

    Question. Is there a danger inherent in the additional radiation exposure?

    Answer. Clearly "yes." According to Dr. Gofman, MD, PhD, in Radiation and
    Human Health: A Comprehensive Investigation of the Evidence Relating Low
    Level Radiation to Cancer and Other Diseases, ionizing radiation is a known
    carcinogen, there is no safe exposure level to ionizing radiation, and the
    effects of radiation exposure are cumulative throughout one's life. Specific to
    breast cancer, Dr. Gofman presents compelling evidence in his new book,
    Preventing Breast Cancer:  The Story of a Major,Proven, Preventable Cause of
    This Disease, that about 75% of those cancers are caused by exposure to
    ionizing radiation, principally from medical X-rays. People should not forget the
    massive and heavily promoted early detection mammogram program in the
    1950s and 1960s of women under 50 which was scrapped by the National
    Cancer Institute because the incidence of cancers caused by repeated
    radiation exposure was unacceptable. That program "caused between 55,000
    and 65,000 future cancer deaths per year!" according to Dr. Gofman, a
    radiologist with a doctorate in medical physics, who headed a $24,500,000
    seven-year study on the effects of radiation on human health.

    [end of excerpt]

    See full article, Hibbard W, "Stereotactic Breast Biopsy",2004 article in MEDICAL
    ARTICLES BIOPSY section.)

    ----------------------------------------------------------------------------------
    Since both FNA and core needle biopsies may be associated with a higher
    incidence of sentinel lymph node metastases than that associated with
    surgical biopsy, is there any downside to undergoing excisional surgical
    biopsy, which will remove the whole tumor?

    In the previously cited article published in The Breast (2000), Dr. Robert Rosser
    advocates altering the surgical technique to avoid trauma to the breast in order to
    prevent any possible creation of injury-induced micrometastases, which he calls  
    traumets.

    Dr. Rosser writes, "The surgical technique should be altered to avoid grasping a
    tumor at any time.  Retraction and control of the tumor would be better
    accomplished by placing a large retention suture through the tumor, perhaps
    several times through the tumor and using the suture to control the tumor while
    cutting around it."

    I've decided to take my chances with a needle biopsy. If I am
    premenopausal, is there any advantage to timing the biopsy procedure
    with a particular part of my menstrual cycle?

    For premenopausal women, timing the surgical procedure with the menstrual cycle
    has now been studied in the context of needle biopsy as well as in that of breast
    surgery. It appears that timing breast piercing or surgery after ovulation is worth   
    considering. A relevant study follows:

    J Surg Oncol. 2000 Jul;74(3):232-6.
    Menses and breast cancer: does timing of mammographically
    directed core biopsy affect outcome?
    Macleod J, Fraser R, Horeczko N.
    Department of Surgery, University of Alberta, Edmonton, Canada.

    BACKGROUND AND OBJECTIVES: Studies have shown molecular, genetic and
    cellular changes in breast cancer during the menstrual cycle. Changes in
    proliferative and metastatic potential of breast cancer cells during menses could
    explain improved survival when tumors are surgically removed in the luteal [after
    ovulation] phase. This study examined if timing of mammography/core biopsy (MAM-
    CB) also affected breast cancer prognosis (histological tumor grade). METHODS:
    Eighty-five premenopausal women undergoing MAM-CB at one clinic between March
    1995 and February 1998 were retrospectively studied. All patients had Stage I or II
    breast cancer surgically treated. Patients were grouped by phase of menses at MAM-
    CB:follicular (F, Days 0-14) or luteal (L, Days 15-35). Groups were comparable in age,
    menarche, family history, nulliparity, breastfeeding, and total percentage of clinically
    palpable tumors. Pathological characteristics of the tumors (tumor size, tumor type,
    estrogen and progesterone receptor status, axillary lymph node status, the presence
    of lymphatic or vascular invasion and extranodal metastasis) was also comparable
    across the 2 groups.
    RESULTS: Low-grade tumors were more frequent in the MAM-CB group L, whereas
    high-grade tumors were more common in the MAM-CB group F (P = 0.002, chi2(4) =
    17.06). CONCLUSIONS: Timing of MAM-CB in relation to menses may be a factor
    influencing breast cancer outcome. Future studies examining the effect of menses
    on the outcome of breast cancer should consider the potential effect of the timing of
    MAM-CB.
    ------------------------------------------------------------------------

    I do not want anyone cutting into my breast. Are there alternatives to surgery?

    We have never heard of anyone getting rid of a cancerous tumor without surgery.
    People have shrunken tumors with hormone modulation, and people have used a
    specific iodine therapy to shrink cysts  but neither person shrank actual diagnosed
    cancerous tumors to the point of disappearance. Conventional medicine might
    suggest using"neo- adjuvant" chemotherapy to shrink the mass, but this
    methodology  is customarily used in conjunction with a later surgery--which is why
    it's also called pre-operative chemotherapy.

    What about these cancer salves I read about? Do they remove the tumor
    without surgery?

    Cancer salves may work, but no one associated with the online group has
    experienced any lasting benefit associated with using them to treat breast tumors.

    My biopsy came back positive for cancer.  I want a second and maybe a third
    opinion. How long do I have to make a decision about what kind of surgical
    procedure to have?

    Any reputable doctor will tell you there is time to schedule second and third opinions
    after a breast cancer diagnosis, but bear in mind that studies and articles show that
    expeditious surgery may counteract potentially negative effects of cells displaced by
    past needle biopsies.

Please report dead
links or suggestions
about this page.

Thanks in advance.

The take home
question is:

Do you really want to
undergo a diagnostic
needle biopsy, which
may increase your risk
of spreading cancer
cells when removing
the whole tumor with
an excisional biopsy is
an option?


Chen (2002)
suggested needle
biopsies may not only
spreading cancer cells
within the breast
tissue itself to such a
degree that radiation
therapy is
recommended, but
Hansen (2004)
biopsies may also
spread them farther,
beyond the breast, to
the sentinel node.
.
.  

Make sure you actually
have breast cancer.

Get a second opinion on
your biopsy slides.

Every year many women
are misdiagnosed and
needlessly go through
surgery, treatment and
hormone suppression.

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See video explaining
different kinds of biopsies

    These statements have not been evaluated by the U.S. Food & Drug Administration.  The
    information discussed is not intended to diagnose, treat, cure, or prevent any disease.

    This website is intended as information only. The editors of this site are not medically-trained.
    Please consult your licensed health care practitioner before implementing any health strategy.

    The information provided on this site is designed to support, not replace, the relationship that
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    Inc., a 501 (c) (3) nonprofit organization run entirely by unpaid volunteers.
    Contact us with comments or for reprint permission at admin@breastcancerchoices.org

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