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.
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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.)
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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.
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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. |
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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 |
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information discussed is not intended to diagnose, treat, cure, or prevent any disease.
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