I wrote an article a while back called “What Your Core Needle Biopsy Diagnosis Means” to help patients understand why sometimes even a “benign” diagnosis may require a surgical excision.  While writing that article, I spoke to many of my colleagues in breast pathology and breast imaging and found out that there is a marked difference in recommendations for surgery for certain core biopsy diagnoses dependent upon where in the United States a patient is diagnosed, specifically, the so-called “high risk” lesions:  lobular neoplasia (atypical lobular hyperplasia/lobular carcinoma in situ), flat epithelial atypia, papilloma, and radial scar. My colleague, Dr. Dianne Georgian-Smith of Harvard Medical School, and I performed an informal survey of our colleagues in breast pathology and breast imaging and the results were published in a Letter to the Editor in the American Journal of Roentgenology which is now available free at this link.  We also just gave a lecture on this topic at the 2010 American Roentgen Ray Society meeting May 3 in San Diego.  We polled our audience and found similar disparate results from doctors around the country and in other countries as to how to treat patients with a core biopsy diagnosis of one of these “high risk” lesions.

We were dismayed at how random the recommendations for surgery were. Based on the data we received, we realized many women could be undergoing unnecessary surgery or, conversely, many could not be getting the appropriate surgery to rule out a possible cancer.

Why is there no consensus? One main reason is the medical literature on core biopsy is full of conflicting data. Some studies say excise all of the above lesions, others say it’s not necessary.  How can this be? My opinion is that almost all, if not all, of the studies that have been published on these diagnoses are retrospective, meaning the doctors looked back at patients who had a diagnosis on core and then looked at what was present on their surgical excision.  The problem with most of these studies is that they are not controlled studies and thus there is a “selection bias” and most had small numbers of patients that were studied.

The bottom line is this…first, if you have a core biopsy make sure your diagnosis is correct– if need be, get a second opinion. Second, if you are recommended to have surgery, particularly if you have one of the above diagnoses, ask your surgeon why he/she is recommending surgery and what data that decision is based upon. Get as much information as you can before you make a decision to pursue surgery! If any of you is interested in references to all of these conflicting articles I would be happy to provide them to you.

For the sake of all women facing a core biopsy diagnosis of one of these lesions, we are hoping to get more patients and physicians interested in pursuing prospective clinical trials in the hope of standardizing how patients are treated following a core biopsy with a diagnosis of a “high risk” lesion.

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