With approximately 1.6 million breast biopsies performed every year in America, a breast biopsy is a relatively routine procedure for women to undergo.
Despite the fact that you’re in good company if your doctor recommends a biopsy, the stress and anxiety that accompany the procedure can make it feel anything but routine. We asked breast cancer surgeons what to expect before, during and after a breast biopsy to help demystify the procedure.
When is a biopsy recommended?
Dr. Nila H. Alsheik, section chief, Division of Breast Imaging at Advocate Lutheran General Caldwell Breast Center and chair, Breast Imaging, Advocate Health System, attributes the high number of biopsies performed annually to the increased utilization of screening mammography and adjunct screening whole breast ultrasound.
If a radiologist spots something abnormal on a screening mammogram, typically a diagnostic mammogram and an ultrasound are performed. If questions remain about what is seen by imaging, mammographers will frequently recommend biopsy. “Mammographers have a low threshold of biopsying areas that could be suspicious,” says Dr. Swati Kulkarni, MD, breast cancer surgeon at Northwestern Memorial Hospital.
Is biopsy always the best option?
The National Breast Cancer Foundation says that a biopsy is the only diagnostic procedure that can definitively determine if the suspicious area is cancerous. However, there are very specific instances in which watchful waiting with regular screening by imaging every six months to make sure there is no change could be an option instead of biopsy. Alsheik says those instances include cases in which the suspicious area is in the “probably benign” category — examples include noncalcified circumscribed solid mass, focal asymmetry, solitary grouping of benign appearing microcalcifications, fibroadenoma, isolated complicated cyst or clustered microcysts. In those instances, doctors often leave the decision of whether to biopsy or go with watchful waiting up to the patient.
“We do watch a lot of patients,” says Kulkarni. She says some wish to put off the biopsy procedure in favor of continued surveillance, whereas others don’t want the anxiety of waiting and having to return repeat imaging, and would rather know for sure what the mass is.
When facing a biopsy, Kulkarni says nervousness is to be expected, and that most of her patients are far more afraid of the results than the procedure itself. “Most biopsies are benign. That’s key to remember,” she says. Approximately 20 percent of women who have biopsies turn out to have cancer, according to breastcancer.org.
Dr. Claudia Perez, DO, a breast surgeon at Loyola Medicine, says that some women do also fear the actual procedure and the potential of pain, but offers reassurance that “the majority of patients undergo the biopsy with minimal pain and minimal complexity.”
And, the risks of missing a diagnosis by not performing a biopsy far outweigh the minimal risks as well as the emotional stress associated with the procedure. “It’s an incredibly safe procedure,” says Kulkarni. “A diagnosis of breast cancer has significant implications for patients. It’s better to be cautious and do a biopsy than miss a cancer.”
Perez agrees. “It’s a minimally invasive procedure, and it’s the reason why we get mammograms,” she says. “Finding cancer early allows us to treat it without the complications that come with a later diagnosis.”
Just before the start of the procedure, consent forms need to be signed. Perez suggests that patients use this time to ask questions, voice concerns, and ask to be walked through the process of the procedure. The procedure is often performed by a doctor the patients does not know, and patients should speak with the physician before being positioned for the biopsy. Perez says patients should know that they have a right to speak with the doctor before the procedure begins. “It’s always an option, it’s just not always presented,” she says. “Patients should communicate both before and during the procedure [and] should feel like they can advocate for themselves.”
There are several different kinds of biopsies, including fine needle aspiration, core needle and surgical biopsies. Core needle biopsies are “the clinical standard of care for histopathologic diagnosis of breast lesions,” says Alsheik. “Core needle biopsies are minimally invasive, less traumatic, and performed as an outpatient procedure with local anesthesia,” she explains.
With a core needle biopsy, the breast is numbed with a local anesthetic. The doctor, either a radiologist or surgeon, uses mammography or ultrasound to locate the suspicious area. A small cut, which the American Cancer Society says is typically around 1/4-inch long, is made in the skin. The doctor inserts the needle and takes between three and six samples with a hollow needle. Something to keep in mind: As the sample is taken, the needle makes a loud clicking noise.
The doctors say patients are welcome to request that the doctor walk them through every step of the procedure as it’s happening, or patients can can close their eyes and ask to know nothing, or opt for something somewhere in the middle. They recognize that some people want to know everything, while others wish to know nothing.
“Immediately after we complete the biopsy, doctors often leave a small metal clip in the breast. It is an incredibly tiny, barely visible titanium clip that is the size of a sesame seed,” explains Kulkarni. The clip marks the location of the biopsy should the results be suspicious or indeterminate, and, she says, “the clip allows us to localize and find that area during surgery and remove it to get a more complete idea of what’s going on.”
Kulkarni reassures patients that the clip does not cause any problems and says one of the most frequent questions about it is if it will cause issues at security checkpoints. It will not.
The cut is then closed with a sterile dressing; no stitches are needed.
Patients typically have a mammogram right after the procedure is complete to confirm proper placement of the clip. While that may not sound like the most pleasant experience, the local anesthetic is still in effect. Kulkarni says that the mammogram does not exacerbate the bleeding or bruising and, in fact, has the opposite effect. “Applying pressure usually helps stop the bleeding,” she explains.
Following the procedure, patients can typically drive themselves home. Symptoms can generally be managed with ice packs and Tylenol. Kulkarni also suggests wearing a supportive sports bra. Women are permitted to return to normal activities right away, with the exception of running, which can be resumed in a few days.
Complications do not happen often. “We only worry if the breast becomes hard and enlarged, but that is exceedingly rare,” says Kulkarni.
Some women are surprised by the bruising that appears in the days following the biopsy, which Kulkarni says can be “scary looking, but it’s not harmful.” She explains that with a needle biopsy, “even a small amount of bleeding in the breast can appear as an extensive bruise” but offers assurances that it goes away.
While there may be a scar visible from core needle biopsies at first, it is small and it typically fades quickly and is not visible at all in less than a year. The breast is not altered in appearance.
The biggest issue most women face after their breast biopsy is the wait for their pathology results. The length of the wait varies, from 24 hours to several days. The Susan G. Komen Foundation suggests that women stay busy while waiting and that they use their support system of family and friends to talk about their fears.
The Komen Foundation also suggest researching and learning more during the waiting period, but Perez advises patients to be careful when doing so. “There is a lot of misinformation out there. Be cautious, and don’t believe everything you read,” she says, adding that websites with addresses ending in .edu are best.
While the doctors understand the inclination to worry, they urge patients to try not to do so to the extent they can. “It’s something every woman who has a breast biopsy goes through, and while worry is not unusual or uncommon, they really should wait for final information,” says Perez, who reiterates that the majority of biopsies are benign.
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Shannan Younger is a writer living in the western suburbs of Chicago with her husband and teen daughter. Originally from Ohio, she received her undergraduate and law degrees from the University of Notre Dame. Her essays have been published in several anthologies and her work has been featured on a wide range of websites, from the Erma Bombeck Humor Writers Workshopto the BBC. She also blogs about parenting at Between Us Parents.
Shannan is the Illinois Champion Leader for Shot@Life, a campaign of the United Nations Foundation that supports vaccination efforts in developing countries to ensure life-saving vaccines reach the hardest to reach children. “Vaccines are one of the most effective ways to save the lives of children in developing countries and I’d love nothing more than to see diseases eradicated,” Shannan says. “We are so close to getting rid of polio for good!”