Four years after they first convened, a panel of 23 breast cancer experts has reached a consensus that newer, less-invasive diagnostic methods should replace older, more-invasive procedures for diagnosing breast cancer.

In a new consensus paper published in October’s Journal of the American College of Surgeons (JACS), the panel, assembled at the University of Southern California Keck School of Medicine (Los Angeles), says minimally invasive needle biopsies and sentinel node biopsies should be performed more routinely than they are.

“Technology is just constantly changing – it’s a big paper and a lot of conclusions, but perhaps the single most important conclusion ... is the panel felt that a breast biopsy is something that ought to be done with a needle as an outpatient [rather] than in an operating room,” Melvin Silverstein, MD, panel chairman and professor of surgery and Henrietta C. Lee chair and chief of breast services at Keck School of Medicine, told Diagnostics & Imaging Week. “The operating room ought to be reserved for treating patients, not making the diagnosis.”

Silverstein said that in the U.S., about 500,000 open-surgery biopsies still are performed each year out of the 1.7 million breast biopsies performed.

The American Cancer Society (ACS; Atlanta) estimates that 211,240 women will be diagnosed with invasive breast cancer and more than 40,000 will die from the disease this year.

One of the problems with the continuing use of surgical biopsies is that there might be “loss of revenue for some people” if surgical biopsies were abandoned, Silverstein said. Surgeons perform the surgical biopsies, while surgeons or radiologists perform the needle biopsies.

“No. 2, and probably more likely, is that many of them don’t know how to do the needle biopsy, and if you don’t know how to do something new, you do what you did 10 years ago,” he said.

But the panel concluded that minimally invasive needle breast biopsy keeps the majority of women with non-cancerous findings out of the operating room. For those that do have breast cancer, needle biopsies allow for better pre-operative planning for breast surgery.

A needle biopsy is performed through an incision about the size of a match head, requires no stitches and can be done in a doctor’s office. According to the ACS, about 8 out of 10 breast biopsies turn out to be benign.

The panel added that vacuum-assisted needle biopsies are preferred for microcalcifications, a common breast finding, because of their high accuracy and more complete tissue removal than conventional needle biopsies. The panel also said minimally invasive needle breast biopsies can result in significant cost savings.

“A needle biopsy has the opportunity of really saving time, effort, money, [and] pre-operative planning,” Silverstein told D&IW. “It just makes so much sense that the panel took a very strong position on this.”

He said in a prepared statement that “the way breast cancer is diagnosed often affects the way it is treated.”

Silverstein added: “If a surgeon knows the abnormality is breast cancer before an operation, he or she can more precisely plan the optimal location of the incision in the breast for breast conservation. With pre-operative planning, more complete and precise removal of the cancer is more likely, generally sparing patients a second surgery.”

The panel called the less-invasive sentinel lymph node biopsy “the preferred method” for accurately staging image-detected breast cancer in most patients. The traditional procedure is axillary node dissection, or the removal of 15 to 30 lymph nodes.

In sentinel lymph node biopsy, one to three lymph nodes are removed resulting in fewer complications, faster recovery and a lower probability of lymphedema.

The panel also looked at the emerging role of MRI in diagnosing breast cancer. The members concluded that there is sufficient evidence to support using it with younger patients, who usually have more dense breasts, and are at high risk for breast cancer. The panel said that MRI could be useful for patients when mammography or ultrasound are inconclusive.

The panel also concluded that accelerated partial breast irradiation (APBI) “may allow more patients to undergo breast-conserving therapy more quickly, at lower cost, and with less risk of long-term complications.”

While the traditional method of irradiation calls for radiating the entire breast, that can result not only in breast shrinkage, but also pulmonary and cardiac side effects. However, the panel recommended that APBI be used in clinical trials until more definitive data can be collected.

The panel recommended that surgeons also train in oncoplastic surgery, which is the combination of plastic surgery and cancer surgery, to help avoid poor cosmetic results. The hope is that this would increase the number of women who could be treated with breast-conserving surgery rather than mastectomy.

Silverstein said he would be presenting the paper at various meetings, including next week’s annual meeting of the American College of Surgeons (Chicago) in San Francisco. He added that he believes there is a “slow and gradual” adoption of recommendations such as those in the panel’s consensus paper.

“We hope this consensus encourages doctors to review the methods they currently use and helps women become more aware of their options,” he said.

The consensus paper was developed from a conference sponsored by USC/Norris Comprehensive Cancer Center and the Keck School of Medicine earlier this year and was supported by a grant from Ethicon Endo-Surgery (Cincinnati), a Johnson & Johnson (New Brunswick, New Jersey) company. It updates a JACS consensus article published in September 2001.