When a Mammogram Leads to a Biopsy

With cancer, what you don’t know can hurt you

Few things grab your attention like a doctor telling you that you might have cancer. And although death rates from breast cancer have been in decline — likely due to earlier detection and advances in treatment methods — it’s hard to quiet the panicky thoughts that creep in when a lump is felt or a routine mammogram shows abnormal results.

If an abnormality in the breast warrants a closer look, doctors will recommend a breast biopsy to obtain a sample of cells or tissue that will be sent to a lab and examined by a pathologist. Biopsy results will determine whether the patient does indeed have cancer and what, if any, further treatment is needed.

One of the most common triggers for breast biopsies is calcifications, which are tiny calcium particles that appear as white spots or flecks on a mammogram. About 75 percent of women’s mammograms show calcifications, says Rebecca A. Zuurbier, MD, a breast radiologist at Dartmouth-Hitchcock Medical Center in Lebanon. Because of their small size, calcifications cannot usually be felt. They do not always lead to a biopsy and are often harmless; 80 percent of the time, Zuurbier says, calcifications that are biopsied turn out to be benign. But because they are sometimes a byproduct of cancerous cells, calcifications can be a cause of concern. Doctors look for telltale signs that cancer-related calcifications often exhibit, such as calcifications that occur in certain patterns or shapes, Zuurbier says.

The approach used for a breast biopsy will depend on factors such as the size, appearance and location of the suspicious area in the breast, but the three main types of breast biopsy are fine needle, in which a very thin needle is used to obtain a sample of fluid or cells from the breast; core biopsy, which requires a slightly larger hollow needle or probe to remove small samples of tissue from the breast; and surgical, in which all or part of the abnormal area is removed.

Core biopsies account for the majority of all biopsies, says Teresa A. Ponn, MD, FACS, a breast surgeon at Elliot Hospital in Manchester. During a core biopsy, the doctor removes a plug or cylinder of the suspicious tissue through a small nick in the patient’s skin. In many instances, imaging such as ultrasound or mammography will be used to direct the doctor to the abnormal area in the breast. Some doctors also use vacuum-assisted equipment in core biopsy procedures that enables them to snip and suction several samples from an area in the breast without repeatedly withdrawing and re-inserting the needle.

Often, after the samples are taken, a small metal clip, usually less than 1/8 of an inch in size, will be left behind in the breast to serve as a marker of the biopsied area in case the patient needs further surgery. If the abnormality is determined to be benign, the marker signals to healthcare providers that the area has already been examined. “It’s like leaving a breadcrumb for people down the road and to confirm for everyone that this is where we biopsied,” Zuurbier says.

Core biopsies are up to 99 percent accurate, Ponn says, and are minimally invasive, requiring only local anesthetic to numb the area, and tape rather than stitches to close the entry point in the skin. Usually, the woman can go about her day following the procedure but will need to wait for lab results to learn whether she has cancer (wait times vary depending on the hospital). After healing from a biopsy, women are not likely to notice any lasting changes in their breast due to the procedure. Scarring is barely, if at all, visible. And the risk of complications is low. Bruising and bleeding can occur but typically are minimal, as is the risk of infection.

Although breast biopsies don’t usually cause physical harm, there’s no denying the anxiety and fear they can bring. “It’s something that people have to measure in their own life in terms of what they can handle,” Ponn says, “but I have to tell you, missing a cancer and watching someone die as a result is not something you ever want to do.” The key is to find a reputable facility where you know you will be well cared for and less likely to undergo an unnecessary biopsy, Ponn says. “I think the thing that people don’t see is how many patients we don’t biopsy,” when they deal with doctors who have the knowledge and experience to know which abnormalities are not likely to represent a problem and only require close follow-up.

Unfortunately, some women find the possibility of bad news so frightening that they choose not to have mammograms, Ponn says. “But [breast cancer] is such a random disease. It strikes anybody, at almost any age. There’s no rhyme or reason. Nobody’s exempt.”

Indeed, sometimes people say what you don’t know won’t hurt you, but when it comes to breast cancer, Ponn says, “that isn’t the case.”