BREAST CANCER PART-6
Welcome to part 6 of educational series on breast cancer. In fifth part, we learned about strategies for prevention of breast cancer in women who are high risk, and the fact that there are no blood tests for diagnosis of breast cancer.
Question: Thank you Dr. Shah. But then, how to diagnose breast cancer? In other words, if there is a breast lump detected on examination, what should be the next step?
Answer: That assessment is based on examination and mammography/sonography. For a small lesion, where trucut(i.e. core) biopsy is not feasible, FNA (fine needle aspiration) is used. It is also helpful in lesions that are cystic on sonography.
If lump is high risk by either clinical or radiological criteria, FNA is generally not sufficient. Negative FNA does not rule out cancer, and positive FNA requires confirmation in most cases. Trucut biopsy is preferred, since it is least invasive, and yet provides enough tissue for complete diagnostic/prognostic tests. If not available, an incisional biopsy can be done, especially for lesions reaching skin. Excisional biopsy i.e. lumpectomy should be avoided in most cases. This is important to avoid need for two surgeries, since if positive, patients almost always need either a second larger lumpectomy by someone trained in cancer specific surgery or need a modified radical mastectomy and for axillary dissection.
Palpable lump with a normal mammogram needs equal attention. Remember that 20% of palpable cancerous lumps are not seen on mammography.
Que: What if breast lump is not palpable, but seen only on mammography?
Ans: Good question. These lesions are challenging since many of them are benign, hence over diagnosis with associated anxiety and invasive procedures need to be avoided. At the same time, this may be an opportunity to find very early cancer and improve results by many folds, at the same time reduce need for treatment such as chemotherapy.
Answer to this question is not always easy. American College of Radiology has set criteria for reporting of such lesions, to reduce under or over diagnosis. Based on the score, lesion is designated as e.g. low risk which should be followed with routine monitoring frequency. For some other scoring category, decision may be to repeat mammogram in 6 months, and keep close clinical monitoring. And for high risk lesions, immediate biopsy is recommended.
Since one cannot palpate early lesions seen on mammography, it is not possible to take an FNA or core biopsy of these lesions. There are special techniques to take a biopsy, such as needle localization biopsy. If such a facility is not available, a lumpectomy may be required. More invasive options are not preferred, since some of the lesions are benign, and a large number are precancerous (carcinoma in situ), which require a different approach.
Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA),
Diplomate American Board of Oncology and Hematology.
Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad. 079 26754001 www.shyamhemoncclinic.com