Myths About Breast Cancer Biopsy Procedure

5 Reasons Why a Core Biopsy is Safe and Essential in Breast Cancer

A Core Biopsy is a procedure in which a tiny piece of the breast lump is excised using a small sutureless incision. The tissue removed is tested for a variety of markers that not only confirm the presence of cancer but also give information.

about the type, aggressiveness, hormone, and chemo-sensitivity of cancer; and several other data points that help make treatment decisions personalized to your type of cancer that optimizes outcomes.

Over the last few years, I’ve come across several patients who have raised concerns and I sum them up in their own words:

1. “No doctor, no biopsy just excise it. My aunt says if you disturb the tumour cells, they will spread to the entire body!”
2. “Why do we need to biopsy a painless breast?”
3. “Biopsy is done under local anaesthesia, while excision of the lump is under general anaesthesia. Why should I undergo the procedure under local anaesthesia, which I am told is quite painful?”
4. “When you can get the entire lump out, why do we need a small chunk?! It’s all a money-making business!!”

Let’s address each of these concerns, starting with a basic understanding of the core biopsy procedure.

Core biopsy is performed using a special hollow needle mounted on a special spring-loaded gun, which is why it is often referred to as a “Gun Biopsy”.

This spring action allows the needle to move in and out of the lump quickly, acquiring a small cylinder of tissue with each pass through the tissue. The patient is nearly pain-free during as well as after the procedure.

For smaller lumps that are not palpable to the hand, a core biopsy may be carried out under Ultrasonography or mammography guidance.

Sometimes after the core biopsy, there may be a small hematoma (blood clot) at that site. The patient may perceive this as an increase in the size of the tumour (this may be the reason behind the common misconception that cancer spreads after the biopsy).

This clot which may be associated with minimal heaviness, swelling and discolouration of the skin, resolves within a week.

Breast cancer is the commonest type of cancer affecting women and the incidence is highest in the 50 – 69 years age group. Only 6 % of patients have pain as a symptom associated with the lump. 83% of ladies present with a painless breast lump.

The remaining cases present with a nipple discharge, dimpling over the breast or some skin changes. It is, therefore, quite understandable that the patient is reluctant to undergo a biopsy for a relatively asymptomatic lump.

Even more difficult is the situation where the diagnosis is purely on mammography and there is no lump palpable. It is to allay these concerns that I decided to write this blog.

Here Are 5 Reasons Why You Need a Core Biopsy :

1. Diagnosis of the Disease :

Not all breast lumps are cancers, and not all cancers present as lumps. So core biopsy is a gold standard test to confirm a diagnosis. To date, hundreds of publications have addressed the subject of a breast cancer biopsy and none of these studies have noted any adverse effect on outcomes related to the biopsy.

2. To Perform Immunohistochemistry (IHC) :

IHC is a special test done on the biopsy sample. It helps to determine the presence of estrogen, and progesterone receptors on the cells (2 out of every 3 breast cancers express receptors to the hormones estrogen and progesterone)(1), and grow and spread in response to the secretion of these hormones).

Having this information allows us to consider a class of drugs that block these receptors that dramatically improve outcomes and the survival of the patient. Another receptor that is tested is the Human Epidermal Growth Factor Receptor-2 (HER2).

A class of drugs (the commonest one being Trastuzumab) are extremely effective in tumors expressing this receptor, and reduce the recurrence rate of the disease by approximately 50%.(2)

3. Decision-Making for Surgery First or Chemotherapy First:

with the added information on the grade of cancer and the type of receptors present, we can very well predict how well it will respond to chemotherapy. Studies have shown that breast conservation is possible in around 35% of the patients who would have otherwise undergone mastectomy (removal of the entire breast), had they not been given chemotherapy first.

Also, there is evidence to show that aggressive tumors like the one with Her 2 receptors or ones without any receptors (referred to as triple-negative breast cancers or TNBC) can be treated more effectively with chemotherapy first followed by surgery.

A randomized controlled trial, CREATE X, as popularly known, was jointly conducted and reported from Japan and South Korea. The trial included 910 patients and concluded that patients with triple-negative breast cancer are at an advantage when they receive chemotherapy first.

Surgery when done after chemotherapy, gives an opportunity to pathologically assess the response of chemotherapy on cancer cells. If a pathologic complete response (no cancer cells seen on histopathologic assessment of surgical specimen) is not attained then the addition of an oral chemotherapy agent (Capcetabine) can reduce the disease recurrence by 14% and also give an 8% survival advantage. (3)

4. Highly Sensitive and Specific Test :

In the past, Fine Needle Aspiration Cytology (FNAC) was done as a means to diagnose breast cancer. FNAC is done using a very fine gauge needle. Only a few cells are obtained for evaluation. As a result, the false-negative rate of FNAC is very high.

Besides, it is practically impossible to determine an in-situ tumor (pre-cancerous lesion) from invasive cancer. The treatment may change dramatically based on this information since in-situ tumors do not respond to chemotherapy.

A core biopsy allows us to get adequate tissue to get all the possible information required to plan further treatment. Various studies have shown that sensitivity (ability to correctly identify true positives) of core biopsy of a breast lump is around 97% while specificity (ability to correctly identify true negatives) was around 98%.

In simpler terms, what these values indicate is that core biopsy is the most reliable test to confirm or refute the diagnosis of cancer and is considered to be the gold standard for diagnosing a breast lump.

5. Easy and Can be Done on a Daycare Basis :

You do not need any admission. It can be done as an OPD procedure or in a radiology suite. After the procedure, you can go about your daily activities as usual. The therapeutic planning of breast cancer is like figuring out a jigsaw puzzle, where all pieces of information are important to arrive at the most optimum plan for each patient.

The final goals of the treatment are equally important. For some women, especially the elderly, the cosmesis is not such an important aspect of treatment outcome; whereas for a young woman, it may be the most important outcome parameter.

To plan the treatment so that these goals are met without jeopardizing the chance of cure or long-term remission is dependent on several pieces of information and core biopsy is pivotal among them.

Finally, to Address the Question of an Excisional Biopsy Instead of a Core Biopsy–

An excisional biopsy involves a big incision (corresponding to the size of the tumor) to get the whole tumor out. It often happens that in inexperienced hands, this may amount to the removal of the tumor in multiple pieces which greatly increases the chances of recurrence.

Besides, performing an adequate breast conservation surgery safely becomes nearly impossible after such a biopsy, and the only option left may be a partial or complete mastectomy.

To conclude, core needle or gun biopsy is a safe, easy, daycare procedure that provides indispensable information for the diagnosis and treatment planning of breast cancer.