Q. What exactly is a breast biopsy, and what is the pathologist looking for?
A. Women usually undergo a breast biopsy to have a suspicious area of breast tissue examined. Such suspicious areas are typically discovered during a clinical breast examination or via breast imaging (such as a mammogram). During a breast biopsy, a small tissue sample from the abnormal area is removed and examined by a pathologist using a microscope to check for breast cancer.
Q. What is the difference between an open surgical breast biopsy and a needle breast biopsy?
A. An open biopsy is a surgical procedure that requires local or general anesthesia and an incision in the breast to remove the abnormal area. A minimally invasive breast biopsy—also called a needle biopsy—is a simpler procedure in which the patient is given local anesthesia before a small, hollow needle is carefully guided into the suspected region, using the same imaging modality on which the abnormality was best visualized. A minimally invasive biopsy removes a core needle sample, resulting in no more than a 3-millimeter scar, whereas an open biopsy can leave scarring and indentation. With a needle biopsy, there is no need for general anesthesia, so it does not come with the risks associated with surgery.
Q. What are the risks and costs associated with each type of breast biopsy?
A. An open surgical biopsy carries the risk of infection, blood loss, and scarring, as an incision is made during the procedure that then has to be stitched closed. An open biopsy costs three to four times more on average than a needle biopsy.
Only about 15 to 20 percent of abnormalities detected by mammography turn out to be cancerous. Given that 80 to 85 percent of lesions are benign, a definitive diagnosis of cancer should be made using a needle biopsy as the first diagnostic step for all breast abnormalities. This allows for optimal preoperative workup and planning if cancer is found. It also gives a woman time to talk about various treatment options with her doctor to decide what’s best for her.
The American College of Surgeons published guidelines sanctioning the minimally invasive breast biopsy as the recommended procedure for diagnosing image-detected lesions, and the American Society of Breast Surgeons issued a statement in accordance with these guidelines. It is a quality standard that is advocated and embraced by most breast cancer organizations.
Q. Given that a needle biopsy is considered the gold standard, under what circumstances would an open biopsy be necessary?
A. There are relatively few women for whom an open surgical biopsy is medically necessary as the initial diagnostic procedure, but there are of course rare exceptions. In fewer than 5 percent of cases, it might not be possible to biopsy a lump with a needle due to positioning.
Q. What can I expect during and after a needle biopsy?
A. During a needle biopsy, you will remain awake, and your breast will be numbed with a local anesthetic. The lump will be located with image guidance, or by touch, and a core needle will be inserted through your skin into the lump to remove the sample tissue. Three to six samples are usually taken to ensure accuracy. Women should expect to feel some pressure but not any significant pain. After the procedure, you may experience slight bruising at the needle sites, but you will be able to carry on with your regular routine. A pathologist will examine the tissue samples, and a written report will be sent to your doctor with the results.
Q. Who performs a needle biopsy, and how can I locate the most qualified specialist in my area?
A. A surgeon or radiologist can perform a minimally invasive breast biopsy. Radiologists should be certified by the American Board of Radiology, and surgeons should be certified by the American Board of Surgery.
At Hoag Breast Care Center, where I serve as medical director, the minimally invasive breast biopsy is the standard of care for the initial tissue acquisition in both palpable and image-detected abnormalities—a policy that should be prevalent in more hospitals and centers across the country. At Hoag fewer than 5 percent of all breast biopsy cases require an open procedure.
If an open breast biopsy has been recommended for you, it’s important to seek a second opinion. Ask the surgeon or breast center you’ve been referred to about their rates for an open surgical biopsy versus a minimally invasive biopsy and ask if they take a specific position on breast biopsy techniques.
• Approximately 1.6 million women undergo breast biopsies annually.
• The American College of Surgeons and the American Society of Breast Surgeons both concur that a minimally invasive breast biopsy is the procedure of choice for image-detected abnormalities.
• Despite the fact that a needle biopsy is considered the gold standard in breast biopsy, a recent study showed that 40 percent of women are undergoing unnecessary open surgical breast biopsies.
• Only about 15 to 20 percent of abnormalities detected by mammography turn out to be cancerous.
• The accuracy rates for needle breast biopsies are equal to those for open surgical biopsies but with lower cost and less pain, scarring, and risk.