Less Need for Needles – A Study presented at Britain’s oldest surgical Royal College has shown that following new national guidance along with improved imaging techniques has significantly reduced the need to carry out breast biopsies in younger women, without missing cancer.

An audit study from Forth Valley Royal Hospital presented at the prestigious annual Audit Symposium run by the Royal College of Surgeons of Edinburgh (www.rcsed.ac.uk); confirmed that breast lump needle biopsies can be reduced by over 50% following national evidence based guidelines and using state-of-the-art imaging techniques. This approach; trialled successfully at his own hospital; can significantly help reduce the unnecessary fear and physical side effects such as pain, bleeding or bruising (haematoma), as well as the costs associated with the procedure.

The number of younger women presenting to a one-stop clinic with palpable lumps is increasing; also, the incidence of breast cancer has doubled over the last 25 years.

Conventionally, triple assessment is advised for the assessment of breast lump i.e. clinical assessment, imaging (mammography and/or ultrasound) and breast biopsy. It meant that, in the past, all women presenting with breast lump were recommended needle biopsy, regardless of age, even if palpable lumps had only benign features on clinical examination and imaging.

The study presented by Subodh Seth , an Associate Specialist in Surgery, NHS Forth Valley, found that benign pathology was predicted accurately with combined clinical and radiological assessment, meaning that breast needle biopsies are not always necessary for women younger than 25-years-old, in whom breast cancer is extremely rare (incidence of breast cancer <25 years is 0.04%)

 “Finding a breast lump is very distressing for women and then having to  undergo an invasive procedure can be traumatic and stressful,” said Subodh, “By reducing the need to take breast lump samples in certain groups of women, we can improve their healthcare experience without the risk of missing any cancers.”  

There are several issues involved in getting a biopsy from patients who are otherwise healthy:

• Biopsies are invasive, and taken with a 14 gauge needle (over 2mm wide – 4 times wider than the standard needle used for injections).
• There are potential complications of infection and haematoma (internal tissue blood clots) .
• Also, women are then waiting for approximately about a week for the results and this can be psychologically distressing for them and their families.
• Additionally, there are number of medical professionals that work to take and analyse these samples–usually surgeons and radiologists taking biopsies and pathologists analyzing them. Further, additional time is then spent on multidisciplinary meetings to discuss biopsy results and clinician time is needed to communicate the results and additional administrative costs are incurred, such as writing and sending letters of confirmation.

The study analysed results for close to 900 cancer cases over 5 years in catchment area of Forth Valley. There was no cancer in less than 25year age-group during the study period. 93.8% of cancers were diagnosed in women who were above 40 years. Study concluded that biopsy is not always needed in younger patients (<25years) presenting with solid lump. If there are any malignant features, these are evident on clinical examination or imaging, therefore, routine core biopsies should not be advocated to rule out malignant cancer in these patients.

The data showed that biopsies have already reduced by over 50% since the national guidelines were implemented in 2013, without missing any cancers.

The pathway was hence modified for those younger women presenting with a non-cystic breast lump (fibroadenoma). They are now offered clinical examination and ultrasound. On ultrasound, lumps are then assessed by the Radiologists using the Stavros criteria (5):

• Lesion is oval, wider than it is tall
• Well defined and smooth margins
• 2-3 lobules with a fine capsule detectable on ultrasound.

If these criteria are present, then the lump can be reliably reported as benign, without the need to undergo biopsy.

The data showed that biopsies have already reduced by over 50% since the new national guidelines were implemented in 2013, without missing any cancers.

“The College always strives to improve patient care and outcomes by challenging what is often accepted wisdom,” said Mr Mike Lavelle-Jones, consultant colorectal surgeon and President of the RCSEd,“Exploring statistical data regarding the effectiveness of treatments and pathways is extremely valuable to the surgical community, and by extension, to patients. Our Audit Symposium is an ideal platform to share knowledge and best practice on the management of health conditions – especially those that are on the rise such as breast cancer.”