I wrote an article a while back on my blog called "What Your Core Needle Biopsy Diagnosis Means" to help patients understand why sometimes even a "benign" diagnosis may require a surgical excision.
While writing that article, I spoke to many of my colleagues in breast pathology and breast imaging and found out that there is a marked difference in recommendations for surgery for certain core biopsy diagnoses dependent upon where in the United States a patient is diagnosed.
We decided to partake in an informal survey of our colleagues and our results recently confirmed my initial impression.
We published a Letter to the Editor in the American Journal of Roentgenology this past May which highlights this issue.
First let me explain...
there has always been, and likely always will be, some differences in the way certain doctors and medical institutions treat patients.
I'm not sure that will ever change.
This is based on individual doctors' and hospitals' years of experience and their interpretation of the literature.
However, when it comes to core needle biopsy of the breast, there seem to be a set of diagnoses that we call the "gray" or "high risk" lesions in which the medical community cannot seem to come to a consensus regarding need for further treatment.
The diagnoses I'm talking about include the following -- lobular neoplasia (ALH/LCIS), papillary lesions, flat epithelial atypia, and radial scar.
Why no consensus? One main reason is the medical literature on core biopsy is full of conflicting data.
Some studies say excise all of the above lesions, others say it's not necessary.
How can this be? My opinion is that almost all, if not all, of the studies that have been published on these diagnoses are retrospective, meaning the doctors looked back at patients who had a diagnosis on core and then looked at what was present on their surgical excision.
The problem with most of these studies is that they are not controlled studies and thus there is a "selection bias" and most had small numbers of patients that were studied.
For example, a recent study as to why atypical lobular hyperplasia (ALH) should be excised was based on eighteen patients! One of the eighteen patients developed a cancer so the study said there is an approximately 6% risk of finding a cancer on surgical excision if there is ALH on core biopsy.
Thus, the study recommended all women with ALH on core biopsy should have an open surgical biopsy.
While that percentage is approximately correct, do we want to base our medical decision-making for all women in the United States on one of eighteen patients?? I would hope not.
We need much better prospective, controlled studies.
The bottom line is this...
first, if you have a core biopsy make sure your diagnosis is correct -- if need be, get a second opinion.
Second, if you are recommended to have surgery, particularly if you have one of the above diagnoses, ask your surgeon why he/she is recommending surgery and what data that decision is based upon.
Get as much information as you can before you make a decision to pursue surgery! If any of you is interested in references to all of these conflicting articles I would be happy to provide them to you.