The case for and against two-step procedure for the surgical treatment of breast cancer

In recent years there have been numerous suggestions that malignant breast tumors are best handled by a two-step procedure. The bases for these suggestions evolve from two factors. There is a perceived desire on the part of the patient to know the exact diagnosis prior to having a general anesthetic so that all treatment options can be thoroughly explored and a mutually acceptable operative procedure decided on. The interval between the biopsy and the definitive operation can be used to study those conditions that would modify treatment decisions. A contrary view holds that a one-stage procedure eliminates the need for a biopsy as a separate operation, is more acceptable to some patients who do not wish to worry during the 1-day or 2-day interval between the two stages, and routine testing in the asymptomatic patient with Stage I or Stage II breast carcinoma will yield positive results in only 1% to 2% of the cases and is probably not worthwhile. In recent years, the increasing acceptance of aspiration biopsy has eliminated the need for a formal excisional biopsy in most cases. For the patient who prefers a one-stage procedure, an aspiration biopsy in the office is probably not worthwhile. Fine-needle aspiration biopsy with cytology is less painful and more accurate than core needle biopsy. A negative result on an aspiration biopsy should not be accepted as definitive where there are other clinical indications that the lesion may be malignant. Women with large breasts who have a small lesion located near the chest wall or who have a nonpalpable lesion detected by mammography are not good candidates for aspiration biopsy; neither are they good candidates for excisional biopsy under local anesthesia as an outpatient.