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In 2001–2, 89% of cancers detected by the UK National Health Service Breast Screening Programme (NHSBSP) were diagnosed preoperatively.1 In 1996–7, the figure was 63%. Year on year increases in the preoperative diagnosis rate have parallelled the increasing use of needle core biopsy (NCB). There has been a threefold increase (from 17% to 66%) in the proportion of cancers diagnosed by a B5 NCB over this period. The proportion of cases diagnosed by fine needle aspiration cytology (FNAC) alone fell from 19% in 2000–1 to 13% in 2001–2.
Although in appropriate circumstances FNAC may be a sensitive and cost effective technique in the diagnosis of breast cancer,2 its use in the NHSBSP is increasingly limited. In the Leeds Breast Screening Assessment Unit in the year 2001–2 we performed 124 FNACs and 487 NCBs. This contrasts with 243 FNACs and 92 NCBs in 1995–6. Our preoperative diagnosis rate has increased from 59% to 92% over the same period.
Better characterisation of malignant lesions and the ability to perform ancillary investigations, such as hormone receptors and biomarker studies (for example, HER-2 analysis), are major advantages of the technique, given the wide range of immediate therapeutic choices now available. The decision to use neoadjuvant chemotherapy or offer immediate reconstruction may be influenced by information only reliably obtained by NCB.
Comparing FNAC sensitivities, specificities, and inadequate rates between different units is now complicated by NCB use. Different units vary in the extent and manner in which FNAC is used. In our unit, FNAC is now almost confined to the investigation of small masses where cystic/solid differentiation with ultrasound is uncertain and lesions that are difficult to biopsy because of their small size and/or location in the breast. A higher proportion of “non-diagnostic” samples (that is, “C1” without epithelium) is to be expected. Despite National Institute for Clinical Excellence recommendations that pathologists should maintain FNAC skills, there will be an inevitable diminishing exposure to the “subtleties” of FNAC diagnosis, which will further reduce its usefulness.
Lets face it. Except for in a limited range of circumstances, FNAC has had its day. Pathologists, radiologists, surgeons, and oncologists all need a little bit more on the slide.