As a surgical oncologist treating breast cancer I hope to share some insights that may be of interest and help to our patient community.

Susan, a 40-year-old business woman and mother of two, receives a call from her doctor’s office informing her that the lump she felt in her breast appears abnormal on the mammogram that was obtained last week. Her doctor would like her to come in for a biopsy.

This scenario, and others like it, occurs nearly every day. Breast lumps are very common findings and fortunately are often benign (i.e., not cancer). However, a breast lump may also be the first sign of a breast cancer and, therefore, finding a lump in your breast is something that needs to be taken very seriously.

Potential Signs of Breast Cancer

It is important to know that a breast lump is not the only way breast cancer can present itself. Often the earliest signs of breast cancer cannot be felt and are only identified by a mammogram (x-ray of the breast). This is why appropriate screening for breast cancer can be helpful. Outcomes of breast cancer are generally better when detected at an earlier stage.

Other potential signs of breast cancer may include: 

  • Dimpling or puckering of the skin in the breast
  • Sudden or gradual inversion of the nipple
  • Redness or swelling of the breast
  • Thickening of the skin over the breast
  • Swollen lymph nodes under the arm or above the collar bone
  • Unusual breast pain
  • Change in the shape of the breast
  • Certain forms of nipple discharge
  • A rash or crusting involving the nipple
  • Abnormal mammogram

In reality, any change to the breast; especially in a woman who is beyond menopause (when the risk of breast cancer is higher), should be taken seriously. You should try not to panic, but also do not ignore any change in your breast.

What to do if You Find a Lump – the Biopsy

If you do find a lump or other concerning change in your breast, you should see your doctor right away. After your breasts are examined by your doctor, further testing with a diagnostic mammogram and breast ultrasound may be obtained. These breast imaging studies can sometimes differentiate a suspicious breast finding from something that is benign – like a cyst. In those cases, a biopsy may not be necessary. However, if the nature of the breast finding is suspicious or even questionable, then a biopsy is the only way to determine with certainty whether or not it is a cancer. A biopsy removes a sample from the area of concern so that it can be analyzed under a microscope to determine its nature. Biopsy samples can be obtained using a needle or by a surgical operation to remove all or a portion of the area of concern.

A study of women waiting for a breast biopsy reported that most experienced very high levels of concern; even when they were told that the results were likely to be benign. Women describe the waiting period as “torture,” “inhumane,” “a killer,” and “the worst part.” These women identified several ways to improve this process, which health care providers would do well to follow.

  • Providing more information
  • Shortening the waiting time between detection and biopsy
  • Offering support
  • Addressing the patient’s personal priorities and concerns
  • Involving family members

It is important for women to know that even if your doctor does not recommend a biopsy, if you are still very concerned that something is wrong with your breast you can talk to your doctor about your concerns or seek a second opinion.

Core Needle Biopsy

If a biopsy is required it is best to have the biopsy performed with a core-needle biopsy. A core-needle biopsy is a procedure performed in the doctor’s office or clinic while you are awake, using local anesthesia (i.e., numbing medication injected into the breast). A special needle about the size of a thin pen is then inserted into the breast and removes a small cylinder, or core, of the area of concern. It can be performed by a radiologist or a surgeon, but it is not an operation.

Core needle biopsies are often performed using ultrasound or other breast imaging techniques (e.g., MRI or mammography/x-rays) to visualize and guide the needle into the correct area of concern in the breast. However, if the area of concern is easily felt, the core-needle biopsy can be done by hand while feeling the lump (i.e., palpation-guided core-needle biopsy). A small metallic clip is often left at the site of the biopsy as a marker to help doctors know the exact location that the biopsy was taken. The clip is safe and does not react with the rest of your body. Once in place, the clip can be seen on subsequent breast imaging (e.g., mammogram). If surgery is necessary the clip can serve as a marker to guide your surgeon to know where to operate; this is especially helpful if the area of concern was something that was only seen on mammogram and not something that can be felt.

The benefit of a core-needle biopsy is that if the lump or area of concern turns out not to be a cancer, then women can have the option of not going through surgery to remove it. Even when the biopsy does reveal a cancer, having that information before the operation allows the surgeon to address all of the special concerns that need to be considered during a breast cancer operation. Multiple research studies have demonstrated that performing a core-needle biopsy for the diagnosis of breast cancer before surgery decreases the chances of having to have multiple operations to appropriately treat the cancer. Otherwise women end up undergoing one surgery for the biopsy, wait a few days to get the results, and then may require another surgery to specifically address cancer issues (i.e., getting enough of a margin around the cancer and assessing lymph nodes for spread of cancer).

Knowing the cancer diagnosis in advance of surgery also allows women to make choices between lumpectomy and mastectomy, with or without reconstruction. As the saying goes: the good carpenter measures twice and cuts once. Surprisingly, the rates of core-needle biopsy compared to open surgical biopsies performed nationwide are lower than most breast specialists believe to be ideal. Fortunately, several breast cancer physicians and breast cancer organizations are making progress promoting core-needle biopsies as a measure of quality in breast cancer care.

What Happens After a Core Needle Biopsy

There are usually only minor, temporary restrictions on your activity after the core-needle biopsy procedure. It typically takes a few days to get the results from the pathologist who analyzes the tissue specimen. I recommend asking your doctor how long to expect until the results of the biopsy are ready and how you will be informed. Always make certain to close this communication loop. If you do not hear back from your doctor’s office after the biopsy, do not assume that the results must have been benign. In fact, even some benign breast conditions can increase your risk of developing breast cancer and may need to be addressed by a specialist. If the results of the breast biopsy do not show cancer then you should speak to your doctor to find out if any follow-up is needed. If the results of the biopsy do indicate cancer then you will need to speak with a cancer specialist about your treatment options.

Now there are rare circumstances where a needle biopsy is not feasible or the results are inconclusive and a surgical biopsy is necessary; however, these are the exception to the rule. If you are told that you need a biopsy and surgery is recommended I would recommend asking your doctor if a needle biopsy could be performed instead.  Cancer should be treated in the operating room, not diagnosed there. I’ve occasionally had women referred to me in order to have a surgical biopsy performed of a questionable breast finding. Many times, I have been able to have these women successfully undergo core needle biopsies instead of surgery. In some of these cases the core needle biopsy demonstrated that breast finding was not a cancer and they did not require an operation at all.

So what about Susan from our opening scenario? Well, she certainly made the right decision to see her doctor about her breast lump and to go ahead with the mammogram. An ultrasound may also be a good idea. She should speak with her doctor about the findings and schedule the recommended biopsy. Her health care team would do well to provide her with detailed information about the biopsy process, answer any questions she may have and address her specific concerns. The wait time for the biopsy should be as short as possible for her convenience. If possible, her breast biopsy should be performed as a core-needle biopsy. Susan should be sure to ask her doctor if she will have any limitations after the biopsy, how soon the results will be available, and how the biopsy results will be conveyed to her. She should get a copy of the biopsy results for her personal records. Hopefully, her results will be negative (i.e. ,benign); however, if the results prove to be cancer, we will talk about tips for getting the best possible care in a future blog.

Additional Resources: For Women Facing a Breast Biopsy: American Cancer Society 

Ted James, MD, is a surgical oncologist and Director of the Skin and Soft Tissue Surgical Oncology program at the University of Vermont Medical Center. He serves as Vermont State Chair for the Commission on Cancer and is a Professor of Surgery at the Larner College of Medicine at UVM.  His is also Vice Chair of the New England Board  of the American Cancer Society.

 

Ted James, MD, is a surgical oncologist and Director of the Skin and Soft Tissue Surgical Oncology program at the University of Vermont Medical Center and is an Associate Professor of Surgery at the Larner College of Medicine at UVM.

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