The operating room is for treating breast cancer, not diagnosing it. That was the take-home message of a webcast presentation titled "Needle Not Knife" by Sheldon Feldman, MD, chief of breast surgery at Columbia University Medical Center (New York), who is pushing needle biopsy over surgical biopsy. For most patients, he said, surgery is "unnecessary" unless cancer is found.
The webcast – which also addressed several other hot topics in breast cancer – was hosted by the American Society of Breast Surgeons (Columbia, Maryland) as part of its 10th annual meeting in San Diego.
According to Feldman, 1.6 million women in the U.S. will have a breast biopsy this year and 80% of those biopsies will be benign and not require treatment. Yet, 40% of women still undergo open surgical biopsy rather than the less invasive needle biopsy, he noted.
The expense, pain, anxiety, general anesthesia, loss of time from work, and surgical scar are some of the drawbacks of a surgical biopsy, Feldman said. A needle biopsy, on the other hand, is accurate, requires only local anesthesia, leaves no scar, and is less expensive, he said.
Feldman referred to an editorial written by Mel Silverstein in the January issue of the Journal of the American College of Surgeons titled "Where's the Outrage," in which Silverstein says it is unacceptable that 36% of patients at major medical centers still undergo surgical biopsy.
"The big misconception when this initially broke was that if a patient sees a radiologist they'll get a needle biopsy and if they see a surgeon they'll get a surgical biopsy," Feldman said.
Another reason patients should not have to undergo surgery for the initial diagnosis of breast cancer, Feldman argued, is that if cancer is found, most will require another operation for treatment. Also – and perhaps most importantly – he says that, "a surgical biopsy for initial breast cancer diagnoses can compromise treatment options for women."
If a needle biopsy determines that a woman does have cancer, there can be a full discussion, additional testing, and multidisciplinary evaluation to allow for a properly planned cancer operation to include sentinel node biopsy and possible reconstruction, Feldman noted. A needle biopsy also reduces the likelihood that the patient will require additional surgery and have a suboptimal surgical result, he said.
There is more than one method of performing a needle biopsy. Feldman said a stereotactic biopsy is used to biopsy a nodule or suspicious calcifications seen on a mammogram. This method uses mammography to image the lesion and combines images 15 degrees in each direction to calculate depth. This procedure is done with the patient placed prone with her breast through a hole in the table while the biopsy is performed under the table.
An ultrasound guided needle biopsy is performed using ultrasound guidance when an abnormality is identified. Feldman said this method also could be used for breast masses that are palpable to allow for very accurate needle placement for biopsy. This is a simpler method, he noted, because it is done in real time without X-ray and the procedure is quicker and more comfortable for the patient.
The needle vs. knife debate also is expanding beyond diagnostics to therapy, Feldman said. He noted several ablation techniques: radio frequency ablation, cryotherapy, interstitial laser thermal therapy, high intensity focused ultrasound, and microwave.
During another presentation in last week's webcast, for those wondering exactly what it is that a breast surgeon does these days, Donald Lannin, MD, executive director of the Yale-New Haven Breast Center (New Haven, Connecticut), provided an answer.
"Over the past 10 to 15 years breast care has become much more complicated and much more multidisciplinary," Lannin said. For example, there are now radiologists, pathologists, medical oncologists, radiation oncologists, geneticists, and plastic surgeons involved with breast care, he noted. An increasing number of multidisciplinary breast centers have also popped up in recent years.
At Yale-New Haven Breast Center, researchers reviewed more than 10,000 patient visits to the center during 2006 and 2007. They found that 22% of these 10,000 some visits were new patient visits and 78% were established patient visits. Of 2,334 new patient visits: 8% underwent biopsy in the office by a surgeon, 21% by a radiologist; 29% underwent surgery; and 22% were ultimately diagnosed with cancer. Of those 22%, Lannin said, 11% were referred to the center already diagnosed with cancer while another 11% were diagnosed during workup of other symptoms.
The most common reason for referral to the breast center was an abnormal mammogram (35%) or because there was a mass found by the patient (29%). Lannin also noted that only about a third of patients (33%) required surgery, while 67% underwent non-operative management of the disease.
"Breast surgeons are really the leaders in coordinating multidisciplinary care," Lannin said. "In most of the patients we saw, over 90% were referred."
One of main functions of a breast surgeon is to interpret MRIs or decide who would benefit from an MRI, Lannin said. After initial workup and treatment, only about 41% of patients were released back to their primary care physicians and 59% were recommended for follow up visits either to monitor for cancer recurrence in those that had cancer or to follow up on an indeterminate imaging or physical exam findings or for monitoring because they are considered high risk for developing the disease.
Breast surgeons evaluate patients with breast masses, breast pain and nipple discharge. They also evaluate patients with abnormal mammograms, MRI or ultrasound. They are the "breast center gatekeepers," Lannin said. The surgeon makes the diagnosis of breast cancer, refers patients to medical oncology, radiation oncology and plastic surgery, coordinates care with other specialities, and follows high-risk patients and "difficult breasts," he said.
"The specialty of breast surgery is unique in its non-operative volume and extensive duration of follow-up," Lannin said. "Strategies need to be designed to make this process more time efficient for the surgeon."
For example, he said an increased use of physician's assistants and advanced practice registered nurses working under the supervision of the surgeon would help, as would training non-surgeon breast physicians to allow the breast surgeon to focus on surgical issues.