Stereotactic Breast Biopsy:
What You Should Know But Probably Weren't Told
TOWNSEND LETTER for DOCTORS & PATIENTS - JUNE 2004
"The project is so compelling, the benefits to our community and region are 80 great, that I have no doubt we will reach our goal of $300,000 for our Stereotactic Breast Biopsy machine," wrote Mike Munck, the St. Peter's Hospital Foundation's executive. vice president in Helena, Montana. Like numerous community hospitals across the country, fund-raising campaigns are in full gear to persuade the local community of the "desperate" need for this latest piece of high tech medical wizardry in the fight against breast cancer. Hearing only one side of the story, however, I wondered what the unasked and unanswered questions were, and I wondered if a fund raiser does not have a moral and ethical obligation to disclose all the facts. Potential donors would want, I am sure, all important questions elucidated and answered to their satisfaction before they make their contributions. So, to this end, a little research has uncovered the following questions and answers which present "the other side of the story" and offer to counter-balance the unfortunately one-sided fund-raising campaign.
Question. Are there any risks inherent in the stereotactic needle biopsy procedure?
Answer. Yes. A survey of histological studies reveals that there is a clear : danger of seeding needle tracks with malignant cells "displaced in breast stroma or in lymphovascular channels, associated with the traumatic effects of a needling procedure," according to Dr. Rosen, Department of Pathology, Memorial Sloan-Kettering Cancer I Center. Consequently, Dr. Rosen warns that "with tissue disruption," lymphatic and vascular channels may also be breached, and it is conceivable that detached epithelial fragments may enter vascular channels and perhaps even be transported to lymph nodes."?
Question. What is the frequency of malignant needle track seeding?
Answer. The frequency with which this occurs and the degree to which this leads to metastases is uncertain. Studies range from an insignificant .003% frequency of malignant needle track seeding to a horrifying 89%.2 Clearly, more research is needed to assess accurately the actual incidence. It is extremely important to understand, however, as Dr. Austin clarifies in Breast Cancer: What You Should Know (But May Not Be Told) About Prevention, Diagnosis, and Treatment, that it is not breast cancer per se that kills: "What kills patients is the spread of cancer to distant parts of the body - distal metastasis. "
Question. Isn't this really a moot concern because if a biopsy reveals a malignant lesion it will be removed anyway? .
Answer. Maybe. The question is whether the whole needle track would be removed during surgery, i.e., surgeons unaware of the malignant needle track seeding problem may not do the necessary excision. Furthermore, it must also be asked as to how long it takes for malignant cells leaked into a vascular channel to be distributed to other areas of the body (e.g., neighboring lymph nodes)? In all likelihood this would be fait accompli long before a scheduled surgery.
Question. What are a patient's diagnostic procedural options if she chooses not to undergo fine needle biopsy?
Answer. Critics of the procedure recommend lumpectomy with subsequent histological examination once the tumor is safely removed, or surgical excision of the needle track after biopsy,"
Question. Is there a problem of "false negatives" (i.e., even though a malignant tumor is present, it is missed with the needle so the pathology report is negative) with stereotactic needle biopsy?
Answer. Allegedly, the X-ray guided needling in the stereotactic procedure will reduce greatly the number of "false negatives" which run as high as 23% in non-stereotactic needle biopsy procedures!"
Question. Is there a danger inherent in the additional radiation exposure?
Answer. Clearly "yes." According to Dr. Gofman, MD, PhD, in Radiation and Human Health: A Comprehensive Investigation of the Evidence Relating Low Level Radiation to Cancer and Other Diseases, ionizing radiation is a known carcinogen, there is no safe exposure level to ionizing radiation, and the effects of radiation exposure are cumulative throughout one's life.
Specific to breast cancer, Dr. Gofman presents compelling evidence in his new book, Preventing Breast Cancer: The Story of a Major, Proven, Preventable Cause of This Disease, that about 75% of those cancers are caused by exposure to ionizing radiation, principally' from medical X-rays. People should not forget the massive and heavily promoted early detection mammogram program in the 1950s and 1960s of women under 50 which was scrapped by the National Cancer Institute because the incidence of cancers caused by repeated radiation exposure was unacceptable. That program "caused between 55,000 and 65,000 future cancer deaths per year!" according to Dr. Gofman, a radiologist with a doctorate in medical physics, who headed a $24,500,000 seven-year study on the effects of radiation on human health.
Question. Could the $300,000 raised by the St. Peter's Hospital Foundation be better spent?
Answer. Many health experts would suggest that the money might be better spent on establishing an educational prevention program for Helena area women. They argue that the prevalent tendency in modern medicine to seek answers in high technology after the fact is misdirected. Organizations like the American Holistic Medical Association, the American Preventive Medical Association, and the American Association of Naturopathic Physicians argue that it makes more sense to focus on preventing the development of problematic breast lesions rather than symptomatically dealing with them with questionable technology and therapies - after they have developed. Robert Kradjian, MD, a breast cancer surgeon for 30 years, stresses in his book, Save Yourself from Breast Cancer, that early detection is not the same as prevention, but unfortunately, physicians only advise mammograms for "prevention," misleading women into believing that early detection leads to cures. Early detection leads to early treatment, but a diagnostic procedure is not prevention, and money spent on diagnostic equipment such as the Stereotactic Breast Biopsy machine does not contribute to the prevention of breast cancer, only to the detection of cancer once it has developed. Since breast cancer in its earliest form is present in the body for 8 to 10 years with an opportunity to metastasize long before it can be detected, Dr. Kradjian feels strongly that prevention is the only answer to this deadly epidemic. Given this information, many would argue that with a largely preventable cancer like breast cancer (see Breast Cancer: What You Should Know (But May Not Be Told) About Prevention, Diagnosis, and Treatment and Save Yourself from Breast Cancer), that money spent on education and prevention would have a far more significant impact on breast cancer incidence and mortality than dealing with incidences after the fact. I have witnessed the anger and feeling of betrayal by the medical system of breast cancer victims who, after being run through the orthodox medical treadmill of mammography to biopsy to surgery to radiation and chemotherapy, learn that it all may have been preventable had they been given the right information and education (not to mention the possibility that the diagnostic procedures caused the cancer that it later detected!)
Question. Is it really true that breast cancer is largely preventable?
Answer. Yes. Only 3 to 5% of breast cancers are genetic. The known risk factors suggest that from 25 to 30% are caused by such factors as improper diet, alcohol intake, oral contraceptives and hormone replacement therapy, lack of exercise, and environmental toxins like pesticides. The remaining 70% or so are attributable to ionizing radiation." Obviously, all of these factors are largely controllable by knowledgeable women who take responsibility for their own health.
Question. Wouldn't the ideal be to have the diagnostic technology and a comprehensive quality prevention program?
Answer. Of course, but many would argue that the limited dollars available to the community would best be put towards prevention first, technology second. The most sensible program for women at this time may be in information and education, not technology.
Question. If I had a wife or daughter with a suspicious breast lesion would I recommend the procedure? In other words, do the benefits outweigh the risks?
Answer. It's her body and future, not mine, so the decision is rightfully hers. I would insist, however, that she make her decision only after she was clearly and fully informed of all the risks, benefits, diagnostic options, and treatment options, including orthodox and unorthodox. (see Breast Cancer: What You Should Know (But May Not Be Told) About Prevention, Diagnosis, and Treatment and Save Yourself from Breast Cancer).
In summary, the crucial question for potential donors is whether they want to support the purchase of a Stereotactic Breast Biopsy machine in the knowledge that: (1) they may be contributing to possible malignant needle track seeding and subsequent metastases in women who undergo the procedure, (2) the procedure adds to the cumulative dosage of mutagenic ionizing radiation exposure, and (8) their money may be better applied to a prevention program.
Whitney S. Hibbard
2905 N. Montana Ave., PMB 242 Helena, Montana 59601 USA
1. Youngson BJ, Epithelial displacement in surgical breast specimens following needling procedures. TM American Journal of Surgical Pathology 1994; 18(9):896-903,
2. Struve-Christensen E, Iatrogenic dissemination of tumor cells along the needle track after percutaneous transthoracic lung biopsy. Danish Med Bulletin 1978; 25(2):8287.
3. Grabau DA, Andersen JA, Graversen HP, Dyreborg U, Needle biopsy of breast cancer. Appearance of tumor cells along the needle track. Eur J Surg Oncol 1993; 19(2):192-94.
4. Hindle WH, Navin J, Breast aspiration cytology: A neglected gynecological procedure. Am J Obmt Gyneeol1983; 146(5):482·87.
5. Enviromnent and Health Weekly 1418, Dec. 1, 1994.
Whit Hibbard, PhD (candidate) of Helena, Montana is an author and doctoral student at Saybrook Graduate School in San Francisco.