Needle before knife: changing methods of managing breast abnormalities

Determining the best way to diagnose a breast abnormality.

First published in What's Up Doc, Issue 17, 2011.

We have just had the annual celebration of all things breast-related that takes place in October every year throughout the world.

Since October was designated as National Breast Cancer Awareness Month in 1985 each year breast charities, breast specialists and the media work together  to remind women (and men!) of how wonderful breasts are, and the importance of maintaining breast health. Women are encouraged to carry out breast self-examinations every month, get annual screening mammograms over the age of forty, and clinicians are reminded to screen women with a clinical breast examination every six months and discuss breast health with their female clients at every clinical episode.

But what if our patient picks up a problem? What if a woman does feel a lump or notice a suspicious discharge. What is the best way to manage such a situation?

Facts and fears

The first and most important discussion to have with a patient who has discovered a lump is to remind her that most lumps are benign. Of ten women presenting with a suspicious lump to her family doctor or general surgeon, only one will be malignant. That doesn’t mean each lump shouldn’t be managed expeditiously until a definitive diagnosis is reached, but it is also important to reassure the patient and manage her fears.

After this discussion, it is essential to confirm the clinical findings with objective tests in EVERY case. The aim of a breast specialist team is to obtain a definitive, non-operative diagnosis of every breast abnormality in the most effective and efficient way. If a woman has no underlying breast problem she can be reassured as soon as possible, but if she does have a malignancy then it will be diagnosed without delay.

Triple assessment is terrific assessment

Every breast abnormality is best managed with a triple assessment approach. This combines a clinical breast examination by the family doctor, surgeon or breast specialist, with a diagnostic imaging and then a biopsy with definitive histopathology. When all three assessments correlate, the accuracy of diagnosis is almost 100%.

When the findings do not match or the patient is reassured on clinical exam alone, small or early cancers can be missed, particularly in young women: in women under 45, 25% of women experience delay after finding a lump due to inappropriate reassurance by a doctor without biopsy. This is in comparison to 5% of all women. This figure is even greater for women under 30 (yes, they do get cancer too!). In the USA, 69% of all breast cancer malpractice claims are in women under forty, and delay in diagnosis by a doctor is most frequently the cause.

I can see clearly now…            

       
Once a lump or other abnormality is seen or described by the patient, best practice is to get confirmation on imaging before considering any biopsy. This might be an ultrasound if the woman is younger than 35, or a mammogram and sonar if she is older. Sonar is very good at picking up abnormalities in dense breasts (which occur at any age), cystic lesions, and can increase accuracy compared to mammogram alone. The new era of digital mammography greatly increases accuracy in younger women (less than 50) and in dense breasts, and should be encouraged in these groups of women.

Digital mammography and specialist breast radiologists also ensure increased accuracy when considering biopsy of masses or suspicious areas. International guidelines for managing breast abnormalities recommend only one interventional procedure for diagnosis which is best achieved by an image-guided percutaneous needle biopsy. This might be a stereotactic core biopsy or sonar guided but image-guidance ensures the abnormality has been well-visualised which means the biopsy is more likely to be definitive, and that any swelling or haematoma that develops from the biopsy will not cause inaccuracies in the mammogram, as can happen if the biopsy is done first. This can over-estimate the size of the lesion and unnecessary surgery- another cause for malpractice claims.

To cut is to cure: isn’t surgical excision the best diagnosis?

It is common that unguided biopsies, particularly FNAs, lead to inconclusive cytology results. FNA alone also is a poor test to determine any characteristics of the lesion. Even if malignant cells are seen, an FNA alone cannot even conclude whether the cancer is invasive or in-situ, let alone hormone-receptor status, grade or type. When an FNA is inconclusive, bloody or indeterminate, the solution is often thought to be that ‘bigger is better’ and then head for surgical excision.

There are a number of issues associated with this approach of surgical biopsy, which can have cosmetic, oncologic and financial implications. The more tissue that is removed from the breast the more likely it will be distorted and disfigured. The cost to the patient is higher, in time from work, hospital admission and cost of procedure. In addition, it is a fallacy that a surgical biopsy provides both diagnosis and treatment, as more operations are usually required for margin clearing or axillary surgery, and in many cases it limits the type of breast-conserving surgery that can be offered later: the goal of a biopsy, whether by needle or surgery is to diagnose not treat.

Breast specialists throughout the world all agree on the importance of avoiding surgical biopsies. American and European guidelines all agree that less than 10-20% of all diagnoses should be based on a surgical biopsy and these should be reserved for the hardest patients to diagnose: very near to implants or chest wall, patient choice or a lesion not seen on any imaging. We are reminded “the operating room is for treatment not for diagnosis.” Most women should have an image-guided core biopsy with 3-5 cores obtained. In this way the patient is left with a pin-prick scar and minimal pain, she has avoided a costly hospital admission, and her breast specialist or doctor is able to give her definitive reassurance of a benign lesion, or discuss a multi-disciplinary management plan of a breast cancer.

What does all this mean?

At this time when women are becoming more and more breast aware, clinicians will see more concerned women with normal and abnormal findings in their breasts. It is important to remember triple assessment for all lesions and a good image-guided core biopsy will enable early and definite diagnosis in nearly 100% of women. Involvement of a breast specialist as part of your multi-disciplinary team will result in less surgical biopsies, earlier diagnosis and smoother care for your patient.

Dr Carol Ann Benn and Dr Sarah Rayne are specialist surgeons with an interest in breast disease. They work at both Helen Joseph Breast Unit and the Netcare Breast Care Centre in Johannesburg. They are also lecturers in the Department of Surgery at University of the Witwatersrand, and work to educate healthcare professionals and the public about breast health.

For further information or advice contact 0860 233 233 or breasthealth@netcare.co.za