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Letters, 4/18

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Let us bring back breast FNAB

The article “Standardized reporting for breast FNAB cytology” (January 2018) is a welcome account of some of the challenges associated with breast fine needle aspiration biopsy compared with core needle biopsy. The author expertly outlines the significance of a standardized approach to performance, interpretation, and reporting of the breast FNAB procedure. The article was a pleasant surprise because the topic of breast FNAB has not been the subject of much interest in our pathology community during the past several years. It appears that core needle biopsy has begun to replace breast FNAB in clinical practice. Even in institutions with expertise in breast cytopathology, breast FNAB is used now only on rare occasions by a pathologist as the initial sampling procedure.

The consequences of this change may be unintentional and are twofold. First, pathology residents and cytopathology fellows are given fewer opportunities than in the past to perform and interpret breast cytopathology. Second, if core biopsies are used in place of FNAB procedures, which are generally less costly than core biopsies, the financial burden for our patients increases.1 In cost-conscious environments, such as in developing countries, health maintenance organizations, and managed care practices, breast FNAB continues to thrive.

The International Academy of Cytology’s selection of a “Breast Group” to renew interest in excellence in breast FNAB cytology should be recognized and celebrated. It was encouraging to learn that breast FNAB is still regarded as a valid diagnostic test, especially in developing countries, and that measures should be in place to ensure that standard guidelines are followed and updated as evidence dictates.

The question that remains is: With an emphasis on cost containment in all health care systems, how can FNAB regain its value and become the procedure of choice in evaluating patients with palpable breast lesions worldwide? Achieving such would be difficult and require pathologists/cytopathologists to end the silence and freely demonstrate the value of breast FNAB in breast cancer diagnosis, research, and education. We must take advantage of the changing trends in medicine and exert our role within the multidisciplinary team to educate our colleagues on the advantages of breast FNAB. We have to educate them on the sampling and diagnostic issues of FNAB that are similar to those reported for core needle biopsies.2 Furthermore, we must remain flexible in working with radiologists and surgeons in the selection of an appropriate sampling procedure based on clinical presentation and imaging.

Raising awareness of the utility of rapid assessment breast clinics, or RABCs, is another challenge. These specialized facilities are designed to assess symptomatic women with a prompt diagnosis and treatment of malignancy or to assure those with a benign condition. Educating health care leaders about raising patient satisfaction and improving processes in providing care may be effective in obtaining sufficient support to build the infrastructure for those clinics. Eighty-five percent of patients assessed at RABCs do not have cancer. Therefore, they provide a critically important service in identifying patients who do not need further therapy.3,4

Departure from the practice of breast FNAB has a major impact on the required training for pathology residents and cytopathology fellows. With suboptimal training in breast cytopathology, the risk is a false sense of proficiency, which could ultimately result in poor performance of the FNAB procedure and misdiagnosis. We as a profession have to find opportunities to provide real-time training in breast cytopathology.

Other contributions of breast cytopathology include diagnosis by imprint cytopathology, assessment of biomarkers, and prediction of risk factors in breast cancer research and prevention.5

Having spent many years in the practice of breast pathology/cytopathology, I urge our scientific leaders in clinical practice, breast cancer research, and education to consider the current demise of breast FNAB in developed countries to be a serious problem and to work together to bring this important procedure back to life.

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