A woman finds a lump in her breast. After a mammogram and ultrasound, her radiologist says that the only way to determine if it's cancer is to do a biopsy (removal and analysis of a small tissue sample).

Or: After a routine mammogram, a woman with lumpy breasts is informed that suspicious-looking calcifications have appeared. Again, a biopsy is recommended.

Such scenarios are common. Each year in the US, more than 1.6 million breast biopsies are done. But that's small comfort when you need a biopsy-because the situation naturally provokes a lot of anxiety.

Recent study: Women waiting for breast biopsy results have levels of the stress hormone cortisol equal to those of women actually diagnosed with breast cancer. The flood of cortisol can impair immune function.

Reassuring: Only about 20% of breast biopsies turn out to reveal cancer.. and knowing what to expect helps ease stress.

What To Do First

From your primary care doctor or gynecologist, get a referral to a breast radiologist, a doctor who specializes in breast imaging and biopsies.

Best: Ask any breast radiologist you are considering if he/she is a member of the Society of Breast Imaging or is affiliated with a facility certified as a Breast Imaging Center of Excellence by the American College of Radiology, These credentials indicate adherence to high standards.

Ask the breast radiologist about various biopsy techniques (see below). The technique used depends on the location and size of the lump, how suspicious the area looks and other factors.

Concern: A national panel of experts recently concluded that nonsurgical needle biopsy should be the "gold standard for initial diagnosis of breast abnormalities-yet about 35% of initial breast biopsies in the US still are done using more invasive open surgery.

Recent study: Patients who received guidance in self-hypnotic relaxation before and during their breast biopsies experienced significantly less emotional distress and less physical discomfort. Ask your doctor if the biopsy facility provides procedure hypnosis...or consult a hypnotherapy professional for instruction and or an audiotape you can listen to during your procedure.

Referrals to a hypnotist: American Society of Clinical Hypnosis, 630-980-4740, www.asch. net.

Nonsurgical Biopsy

Percutaneous through the skin needle biopsy usually is done at a doctor's office or breast-imaging center. Often an imaging technique, such as mammography, MRI or ultrasound, is used to pinpoint the area to be biopsied. Typically, an injection of local anesthesia is given... the procedure requires no stitches.. and there is little or no scarring. Sometimes a tiny metal clip is left in the breast to mark the biopsy site for future reference-in case surgery is needed to remove a malignancy, for instance, or to show that a particular benign cyst has been tested. Options…

  • Fine needle biopsy. Using a fine needle with a hollow center, the doctor withdraws a sample of cells. The least invasive biopsy procedure, this takes a few minutes, and results may be available within hours.

But: It is appropriate only in limited cases, such as when a palpable (easily felt) mass is present and there is a significant risk for false-negative results because with the small sample, cancerous cells may be missed.

  • Core needle biopsy. A thicker hollow needle is inserted one or more times to extract samples of breast tissue. This type of biopsy is appropriate in most cases and takes about 20 to 30 minutes. It is more accurate than fine needle biopsy because actual breast tissue (not just a sample of cells) is examined.

With vacuum-assisted core needle biopsy, a needle is inserted through a very small incision, then a tiny vacuum and cutting device extracts breast tissue samples. This takes 20 to 60 minutes and may be used when larger samples are needed.

Recovery: After a needle biopsy, use ice packs as directed by your doctor to minimize discomfort, swelling and bruising. You may take non-prescription acetaminophen (Tylenol). Keep the area dry and avoid strenuous activity for 24 to 48 hours.

Surgical Biopsy

This procedure may be warranted when a needle biopsy is inconclusive or the suspicious area is not accessible with a needle biopsy. Generally there is some scarring.

Often the procedure involves a breast radiologist, who uses imaging tests to locate and mark (with a tiny wire) the precise area to be biopsied... and a surgeon, who does the surgery.

Best: Ask your doctor for a referral to a surgeon whose practice consists primarily of breast procedures or who has completed a fellowship in breast surgery.

A surgical biopsy usually is done in a surgical center or a hospital outpatient department using local anesthesia plus sedation to make you drowsy). If you take a blood thinner, such as as pirin or warfarin (Coumadin), ask your doctor about temporarily discontinuing it before surgery to avoid excess bleeding.

How it is done: Using a scalpel, the surgeon cuts through the skin. With an incisional biopsy, just a portion of the suspicious tissue is removed. This gives the best cosmetic results—which is important, considering that the majority of breast biopsies turn out to be benign. With an excisional biopsy, the goal is to remove all abnormal tissue, which may reduce the odds of needing additional surgery if cancer is diagnosed. Stitches are used to close the incision.

Recovery: You may be told to rest for one to two days and avoid strenuous activity for two weeks. Your doctor may prescribe pain medication. See your doctor as directed for your postoperative check

Pros and cons: This is the surest way to get a definitive diagnosis, with the smallest risk for a false negative result.

But: Compared with needle biopsy, a surgical biopsy involves more discomfort, more scarring and a higher risk for complications.

Getting The Results

Ask the doctor who performs your biopsy when and by whom the radiologist, surgeon or primary care doctor-you will be given your results. On average, it takes two to five days to analyze the tissue

This waiting period can be very stressful.

To reduce anxiety: Express your emotions-confide in loved ones, write in a journal. Keeping fears and feelings pent up increases stress and lowers immune response.

If results are negative…

  • Ask your doctor when you should repeat imaging tests-in a few weeks, a few months or a year.
  • Discuss your breast cancer risk factors-menstrual history, family history, breast density, radiation exposure, alcohol use-and ask if you should see a breast specialist or genetic counselor.
  • Tell your doctor right away if you notice changes in your breasts.

If results are positive…

  • Find out if more tests are needed to determine the cancer's stage.
  • Get a referral to an oncologist.
  • Research treatment options. Treatment decisions do not need to be made all at once, but having a sense of what lies ahead can make the process more manageable.

Test Reduces Need for Breast Biopsies

After a suspicious mass is detected in the A breast through mammography or an MRI, patients typically are sent for an ultrasound. An elastogram, which looks at the stiffness of tissue, can be taken at the same time.

Benign (noncancerous) masses tend to measure smaller on elastograms in comparison with the standard ultrasound image...suspicious ones usually are larger

Not all offices that do ultrasounds offer elastograms—ask your doctor.

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