Physicians should strive to replace traditional, invasive procedures for diagnosing breast cancer with proven, less-invasive diagnostic methods, according to an international panel of breast cancer experts convened at the Keck School of Medicine of the University of Southern California.
In a consensus paper published in October's Journal of the American College of Surgeons (JACS), 23 leading surgeons, radiologists, pathologists and oncologists say minimally invasive needle breast biopsies and sentinel node biopsies should be performed more routinely than they currently are. In the case of breast biopsies, the experts say open surgical biopsies should almost never be done, though experts estimate that nearly a third of the 1.7 million breast biopsies performed in the nation are still done this way.
ÒNew technology has changed the face of breast cancer," said consensus panel chair Melvin J. Silverstein, M.D., professor of surgery and Henrietta C. Lee Chair in Breast Cancer Research at the Keck School of Medicine. "We can do things much less invasively than ever before, and doctors and women need to take advantage of these advances whenever they can."
The American Cancer Society estimates that 211,240 women will be diagnosed with invasive breast cancer and more than 40,000 will die from the disease this year.
The panel concluded that minimally invasive needle breast biopsy is "the procedure of choice for image-detected breast abnormalities" and keeps the majority of women with non-cancerous findings out of the operating room. For those who do have breast cancer, needle biopsies allow for better pre-operative planning for breast surgery.
A needle biopsy is performed through an incision about the size of a match head, requires no stitches and can be done in a doctor's office. According to the American Cancer Society, about eight of every 10 breast biopsies performed turn out to be benign.
The panel added that vacuum-assisted needle biopsies are preferred for microcalcifications, a common breast finding, because of the biopsies' high accuracy and more complete tissue removal than conventional needle biopsies.
The panel also said minimally invasive needle breast biopsies can result in significant cost savings.
"The way breast cancer is diagnosed often affects the way it is treated," said Silverstein, chief of the breast service at LAC+USC Medical Center and director of the Harold E. and Henrietta C. Lee Breast Center at USC/Norris Comprehensive Cancer Center. "If a surgeon knows the abnormality is breast cancer before an operation, he or she can more precisely plan the optimal location of the incisions in the breast for breast conservation. With pre-operative planning, more complete and precise removal of the cancer is more likely, generally sparing patients a second surgery. A biopsy is for diagnosis, surgery is for treatment."
The panel called the less invasive sentinel lymph node biopsy the "preferred method" for accurately staging image-detected breast cancer in most patients. The traditional procedure is axillary node dissection, the removal of nearly 15 to 30 lymph nodes. In sentinel lymph node biopsy one to three lymph nodes are removed resulting in fewer complications, faster recovery and a lower probability of lymphedema, a painful swelling of the arm.
The panel also looked at the emerging role of magnetic resonance imaging, or MRI, in diagnosing breast cancer. The panel concluded that evidence supports MRI's use in diagnosing disease among young patients at high risk for breast cancer and that it can be helpful for diagnosis when mammography, ultrasound and clinical findings are inconclusive.
In the area of radiation therapy, the panel concluded that accelerated partial breast irradiation (APBI) "may allow more patients to undergo breast conserving therapy more quickly, at lower cost, and with less risk of long-term complications." Traditionally, radiation oncologists treat the entire breast, which can result in breast shrinkage, as well as side effects on the heart and lungs. Until definitive data are collected, though, the panel recommended restricting APBI use only to clinical trials.
Finally, the panel recommended that surgeons train in oncoplastic surgery, the combination of plastic surgery and cancer surgery, to help avoid poor cosmetic results and increase the number of women who can be treated with breast-conserving surgery rather than mastectomy.
"We hope this consensus encourages doctors to review the methods they currently use and helps women become more aware of their options," Silverstein said.