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Biopsy FAQ

    After being screened for breast cancer, a suspicious lump has been
    found.  How is the lump biopsied?

    Primarily, there are three ways to biopsy a suspicious lump:(1) fine needle
    biopsy (FNA), (2) large gauge needle (core) biopsy,  and (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.


    These statements have not been evaluated by the U.S. Food & Drug Administration.  The supplements discussed are
    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.
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    Web page updated July 13,  2010.

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Thanks in advance.


The take home
question is:

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

The Chen (2002)
needle biopsy study
and other studies
suggest needle
biopsies may not only
raise the risk of
spreading cancer cells
within the breast
tissue itself to such a
degree that radiation
therapy is
recommended, but
Hansen (2004)
suggests that these
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.