Consensus Panel Calls For Expanded Role Of Needle Biopsies, MRI And Less Invasive Procedures

In a consensus paper published in October's Journal of the AmericanCollege of Surgeons (JACS), 23 leading surgeons, radiologists,pathologistsand oncologists say minimally invasive needle breast biopsies andsentinel node biopsies should be performed more routinely than theycurrently are. Inthe case of breast biopsies, the experts say open surgical biopsiesshould almost never be done, though experts estimate that nearly athird of the 1.7 million breast biopsies performed in the nation arestill done this way.

"New technology has changed the face of breast cancer," saidconsensus panel chair Melvin J. Silverstein, M.D., professor of surgeryand Henrietta C. Lee Chair in Breast Cancer Research at the Keck Schoolof Medicine. "We can do things much less invasively than ever before,and doctors and women need to take advantage of these advances wheneverthey can."

The American Cancer Society estimates that 211,240 women willbe diagnosed with invasive breast cancer and more than 40,000 will diefrom the disease this year.

The panel concluded that minimally invasive needle breast biopsy is"the procedure of choice for image-detected breast abnormalities" andkeeps themajority of women with non-cancerous findings out of the operatingroom. For those who do have breast cancer, needle biopsies allow forbetterpre-operative planning for breast surgery.

A needle biopsy is performed through an incision about the size of amatch head, requires no stitches and can be done in a doctor's office.According tothe American Cancer Society, about eight of every 10 breast biopsiesperformed turn out to be benign.

The panel added that vacuum-assisted needle biopsies are preferred formicrocalcifications, a common breast finding, because of the biopsies'highaccuracy and more complete tissue removal than conventional needlebiopsies.

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 istreated," said Silverstein, chief of the breast service at LAC+USCMedical Center and director of the Harold E. and Henrietta C. LeeBreast Center at USC/Norris Comprehensive Cancer Center. "If a surgeonknows the abnormality is breast cancer before an operation, he or shecan more precisely plan the optimal location of the incisions in thebreast for breast conservation. With pre-operative planning, morecomplete and precise removal of the cancer is more likely, generallysparing patients a second surgery. A biopsy is for diagnosis, surgeryis for treatment."

The panel called the less invasive sentinel lymph node biopsy the"preferred method" for accurately staging image-detected breast cancerin mostpatients. The traditional procedure is axillary node dissection, theremoval of nearly 15 to 30 lymph nodes. In sentinel lymph node biopsyone to threelymph nodes are removed resulting in fewer complications, fasterrecovery and a lower probability of lymphedema, a painful swelling ofthe arm.

The panel also looked at the emerging role of magnetic resonanceimaging, or MRI, in diagnosing breast cancer. The panel concluded thatevidencesupports MRI's use in diagnosing disease among young patients at highrisk for breast cancer and that it can be helpful for diagnosis whenmammography,ultrasound and clinical findings are inconclusive.

In the area of radiation therapy, the panel concluded that acceleratedpartial breast irradiation (APBI) "may allow more patients to undergobreast conserving therapy more quickly, at lower cost, and with lessrisk of long-term complications." Traditionally, radiation oncologiststreat the entire breast, which can result in breast shrinkage, as wellas side effects on the heart and lungs. Until definitive data arecollected, though, the panel recommended restricting APBI use only toclinical trials.

Finally, the panel recommended that surgeons train inoncoplastic surgery, the combination of plastic surgery and cancersurgery, to help avoid poorcosmetic results and increase the number of women who can be treatedwith breast-conserving surgery rather than mastectomy.

"We hope this consensus encourages doctors to review themethods they currently use and helps women become more aware of theiroptions," Silverstein said.

The consensus paper "Image-Detected Breast Cancer: State-of-the-ArtDiagnosis and Treatment," was developed from a conference sponsored byUSC/Norris Comprehensive Cancer Center and the Keck School earlier thisyear and was supported by an educational grant from EthiconEndo-Surgery Inc., a Johnson & Johnson company. It updates a JACSconsensus article published September 2001.

All conference participants co-authored the JACS consensus paper.