THE MOSS REPORTS Newsletter (01/30/05)

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31 Jan 2005 01:20:23 -0000

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THE MOSS REPORTS Newsletter (01/30/05)

 

 

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Ralph W. Moss, Ph.D. Weekly CancerDecisions.com

Newsletter #169 01/30/05

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THE MOSS REPORTS

 

 

This week I begin a two-part discussion of an increasingly common

medical procedure – diagnostic needle biopsy.

 

Tens of thousands of needle biopsies are performed each year in the US

alone, and the procedure is universally assumed to be safe and

reliable. Yet there is evidence to suggest that needle biopsy may not

be as

harmless or uncomplicated a procedure as once thought. In fact, it may

in some cases inadvertently cause cancer cells to break away from a

tumor, thus enabling spread beyond the immediate tumor area.

 

Monitoring the world of cancer diagnosis and treatment has been my

life's work. The fruit of my thirty-year involvement in this field is

The

Moss Reports, a comprehensive library of reports detailing the

conventional and alternative treatment of more than two hundred different

cancer diagnoses.

 

For a cancer patient, a Moss Report represents an invaluable guide and

handbook for the journey ahead.

 

If you would like to order a Moss Report for yourself or someone you

love, you can do so from our website, www.cancerdecisions.com, or by

calling Diane at 1-800-980-1234 (814-238-3367 from outside the US).

 

We look forward to helping you.

 

 

 

ARE NEEDLE BIOPSIES SAFE?

 

 

A June 2004 report from the John Wayne Cancer Institute in California

has rekindled a long-standing debate over whether or not needle biopsies

are safe. The paper set out to examine whether this technique, widely

used to obtain specimens in cases of suspected cancer, might itself

allow malignant cells to spread from an isolated tumor to nearby lymph

nodes. The authors reluctantly conclude that a needle biopsy may indeed

increase the spread of the disease by 50 percent compared to patients who

receive the more traditional excisional biopsies (or " lumpectomies " ).

 

This is a rigorous study, and it comes with an excellent pedigree. The

lead author, Nora M. Hansen, MD, was chief surgical resident at the

University of Chicago (1994-1995) before coming to the John Wayne Cancer

Institute in Santa Monica, Calif., in 1997. She is currently Assistant of the Joyce Eisenberg Keefer Breast Center, Saint John's

Hospital and Health Center, Santa Monica.

 

John Wayne Cancer Institute, a division of Saint John's Hospital, is

the institution that pioneered the procedure known as sentinel node

biopsy. This is a technique for identifying the first lymph node to

which a

tumor is likely to spread. By removing that node and examining it at

the time of surgery, it is possible to predict with great accuracy

whether the cancer has indeed spread. This enables the surgeon to remove

only those lymph nodes that have become involved with cancer, instead of

resorting to wholesale lymph node dissection, a procedure which can

leave a patient with long-term pain, edema, disfigurement and impairment

of limb mobility.

 

The report was published in a prestigious journal, the American Medical

Association's Archives of Surgery, which has been published

continuously since 1885. The study was conducted by a team of John Wayne

scientists which, in addition to Dr. Hansen, included Armando G.

Giuliano, MD,

chairman of the American College of Surgeons Breast Oncology Committee

and the author of over 200 scientific articles on breast cancer. I

emphasize the credentials of the study's authors in order to make the

point

that this is a group of well-respected clinicians and assuredly not a

group of mavericks.

 

Hansen and her colleagues wanted to discover whether the common method

used to obtain specimens from a breast tumor influenced the subsequent

spread of disease to the sentinel node (SN). She and her colleagues

therefore studied 663 women who were known to have breast cancer. Of

these, about half had been biopsied with a needle — either a fine needle

aspiration (FNA) or a large-gauge needle core biopsy. The other half had

undergone the physical removal of their tumor (i.e., an excisional

biopsy or lumpectomy). The study found that women who had had either

kind of

needle biopsy were fifty percent more likely to have cancer in their

sentinel nodes than women who underwent the surgical removal of the whole

tumor with excisional biopsy.

 

The report's authors state: " Manipulation of an intact tumor by FNA or

large-gauge needle core biopsy is associated with an increase in the

incidence of SN metastases, perhaps due in part to the mechanical

disruption of the tumor by the needle. " This is a discreet way of

saying that

needle biopsy, an increasingly common procedure, was itself responsible

for spreading the cancer, although the authors take pains to qualify

this disturbing conclusion by suggesting that not every cluster of cancer

cells found in the regional lymph nodes will inevitably end up

developing into clinically apparent cancer.

 

The implications of this study are vast, since patients who are found

to have cancer in their lymph nodes are automatically classified at a

higher stage and therefore face much more extensive treatment than those

who have small tumors that are limited to the breast.

 

Instead of being told that they have stage I cancer and that surgery

" got it all, " they are now delivered the frightening news that the cancer

has spread outside its capsule and gotten into the lymphatic system.

They then face the possible dissection of the affected chain of lymph

nodes and aggressive chemotherapy, radiation and/or hormonal therapy to

wipe out the stray cancer cells (Chu 1999).

 

The report also potentially throws a monkey wrench into the smooth

running early detection 'machine' that every year identifies and treats

hundreds of thousands of Americans with cancer. Indeed, over the last few

decades the needle biopsy has become an essential element in the

detection not only of breast cancer, but also of many other kinds of

cancer.

The advantages of the technique are many: needle biopsies are nearly

painless and bloodless in-office procedures, and much less expensive and

time-consuming than surgical biopsies. The procedure consists of a

hollow needle being inserted into a suspected tumor in order to retrieve

samples for microscopic examination. In certain cases the tumor may have

to be punctured four to six separate times in the process of obtaining

adequate tissue for diagnostic purposes.

 

 

Get a Band-Aid and Go Home

 

 

Is it really safe to puncture a tumor in this way, especially when the

tumor is anatomically walled off or encapsulated from the rest of the

body? Isn't this running the risk of spreading the disease, either into

the track formed by the needle, or, worse, by spilling cells directly

into the lymphatic system or bloodstream? Has this procedure really been

carefully thought out and researched before being implemented on such a

massive scale?

 

To read the mainstream media, you would think that the medical

profession is uniformly in favor of this procedure. For example:

 

• A 1999 report in the Journal of American Medical Association

enthusiastically endorsed the use of needle biopsies.

 

• " A painful surgical biopsy of breast tissue may no longer be

necessary, " a CNN website enthused, in interpreting the study. Needle

biopsies

are " just as reliable, less expensive, and more comfortable " than the

surgical alternative for diagnosing breast cancer " (Salvatore 1999).

 

• Jack E. Meyer and colleagues at Boston's Brigham and Women's Hospital

reviewed 1,836 cases of breast cancer diagnosed with the aid of a

needle. They found large-core needle biopsies " accurate, safe and well

accepted by patients and referring physicians. " Instead of an operation,

with local or general anesthesia, and possible deformation of the breast,

patients experienced a one-hour in-office procedure.

 

" When the procedure's over you get a Band-Aid and you go home, " said

Meyer (Salvatore 1999).

 

 

Win-Win

 

 

To summarize: in principle the needle biopsy seems like a win-win

situation. It is a simple office procedure, convenient, bloodless and

virtually pain-free for patients. One would certainly not dispense with a

test like this for trivial reasons. Currently, 1.2 million US women a

year undergo breast biopsies. Between 20 and 25 percent of these tests

show cancer, according to Dr. Neil Gorrin, assistant chief of surgery at

Kaiser Permanente Medical Center in South San Francisco (Viddya 2001).

That means that virtually all the women in the US who were diagnosed

with breast cancer (215,990 this year) went through this procedure.

 

Yet concerns have been raised about the safety of invasive biopsies

since they were first introduced more than a century ago.

 

The surgical biopsy first came to prominence in the 1870s, through the

work of Carl Ruge and Johan Veit of the University of Berlin, who

showed that only 10 out of 23 women who had undergone surgery for

cervical

cancer actually turned out to have the disease. At that time, surgeons

in their arrogance simply assumed that they could recognize cancer when

they saw it: they viewed the suggestion that tumors should be biopsied

before excision as a direct challenge to their diagnostic and clinical

acumen. But the work of Ruge and Veit effectively changed the

prevailing tide of opinion.

 

Remarkably, fine needle biopsies - described as " a new instrument for

the diagnosis of tumors " - were first reported for head-and-neck cancer

by M. Kun in 1847. They were soon forgotten, but were subsequently

revived by Hayes E. Martin, MD, and Edward B. Ellis, MD, of Memorial

Sloan-Kettering, in the 1920s (Martin 1930). Needle biopsies were

performed

on a large scale at Memorial in the 1930s; however, the technique did

not gain many adherents in the US during that time. Needle biopsies later

underwent a resurgence in Scandinavia during the 1950s and 1960s, and

it was from there that the trend spread to the rest of the world,

including back to the United States (Das 2003).

 

By the time of World War I biopsy became routine practice in the US,

endorsed by both the American Cancer Society and the American Medical

Association.

 

However, by no means everyone in the medical establishment was

convinced that biopsy was an unqualified good. James Ewing, the dean of

American cancer pathologists, explicitly condemned puncturing unbroken

skin

for the purpose of sampling deeper lesions. He wrote: " It is especially

to be avoided with...tumors of the breast, and all growths in which

incisions of the skin involve also incisions through the tumor capsule "

(Pack 1940: 43).

 

That would of course preclude most of the situations in which needle

biopsies are currently done.

 

Ewing was not alone. The editor of the influential New York Medical

Record had this to say on the subject:

 

" [O]ne who harpoons or excises a piece of tissue from a tumor with

unbroken cutaneous or mucous surface, especially an encapsulated

tumor, and

then waits a day or two while the specimen is being examined, will

almost inevitably destroy his patient's chance of recovery by

operation....To resort to indiscriminate digging into all tumors on

the chance of

thereby reaching a diagnosis, which can usually be made by safer

measures, and which moreover is not absolutely necessary, is positively

wicked.... " (Pack 1940).

 

Strong words! The author ends on a peculiarly modern note: " [A]

physician acting on this advice would have no defense whatever if the

heirs of

his patient should bring a malpractice suit " (cited in Pack 1940:44).

 

 

To be concluded, with references, next week.

 

 

 

--Ralph W. Moss, PhD

 

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