Authors Stacy McClelland RN BSN Tampa General Hospital, Cancer

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Stacy McClelland RN BSN
Tampa General Hospital, Cancer Center
University of South Florida, College of Nursing, Masters of Nursing Education student
Patricia Weiss RN MSN OCN CCRP
Cleveland Clinic
Special thanks
A special thanks to Dr. John Kiluk for his gracious gift of expertise and time through which his
suggestions further improved this article. You are a truly wonderful mentor, colleague, and
Patient Fears of Tumor Cell Dissemination Secondary to Surgical Interventions
Patient fears are an ever present factor of patient care. Addressing these concerns as a
healthcare provider is part of our responsibility to provide the best care possible. When a breast
biopsy is indicated, fears will certainly surface. One such fear may be of tumor cell
dissemination secondary to surgical interventions. Current research supports needle biopsies
over incisional or excisional biopsies in most situations and that tumor cell dissemination is a
very rare occurrence. Post biopsy breast excision, radiation, or hormonal therapy are additional
methods that depending on the type of breast cancer will hopefully either locally or systemically
address the cancer from developing into further advancement (Foxson, Lattimer, & Felder,
2011). Preparing for such discussions will allow a healthcare provider to speak with authority on
the topic of a breast biopsy or surgery, even in a situation where a patient has underlying fears.
Fears exist
Personal beliefs help to form the direction of our life in many ways. When personal or
cultural beliefs conflict with mainstream medicine, this can translate to delays in achieving
standard care. Foundations of current practice must be discussed in medical decision making to
help patients make an educated decision for their healthcare along with recognizing and
accepting their viewpoint. Ultimately if concerns and fears have been discussed in relation to
pros and cons then the healthcare provider should be supportive of the patient’s choices even if
the caregiver’s personal beliefs conflict with those of the patient. As technology and medicine
have advanced, so has the way patients interpret their health. The internet has become an
accepted and influential source of healthcare information. However, not all sites are of equal
quality and may be based on opinion versus medical fact, evidence based-care or current
research. People naturally gravitate to sites supporting their own preconceived beliefs in order
to validate what they believe to be true. Many websites exist for the purpose of interpreting
symptoms or even alternative choices to mainstream medicine. Combined with personal cultural
or personal beliefs this information may translate into or support fears about medical decisions
such as a biopsy for determination of cancer presence.
Fears of cancer and its metastasis can be multifactorial. Patients may believe that
disturbing or penetrating the malignancy will cause or hasten the spread of their cancer. There
may also be a belief that exposure of the tumor cells to ambient air with oxygen will result in
further spread of their cancer. Culture, educational level or life exposures may also influence
opinions. Patient fears may be based on generalized fears such as death or deformity,
unanswered questions, and they may seek comfort in spirituality (Demir, Donmez, Ozsaker, &
Diramali, 2008). In their article Chapple et all discussed how a group of patients verbalized fears
of their prostate biopsy spreading their cancer and transmitting cancer cells to partners during
intercourse post biopsy (Chapple, Ziebland, Brewster, & McPherson, 2007). Patients surveyed
about air exposure during lung surgery revealed that some believed that exposure of cancer cells
to ambient oxygen would spread their cancer. Some even were so firm in their belief that they
would elect to not have surgery and disbelieve physician statements to the contrary. Of the
participants studied, African Americans were about three and a half times more likely to believe
air exposure spread their tumors. This belief was so strong that nineteen percent of studied
African Americans would decline surgery whereas only five percent of studied Caucasians
would decline surgery. Additionally, fourteen percent of African Americans and five percent of
Caucasians would not change their beliefs regardless of their doctor’s advice (Margolis et al.,
2003). Where fears are based may not be thoroughly understood, but their presence should be
acknowledged and addressed. It would be safe to assume that all patients have fears of cancer
metastasis and this topic should be addressed in discussions of cancer treatment and course of
care. Patients may be hesitant to disclose fears, but once discussed these fears can be addressed
and hopefully overcome.
Purpose and types of biopsy or surgical intervention
In order to properly diagnose and treat cancer, a tissue sample obtained either through a
biopsy or a surgical intervention is an integral part of the process. Microscopic evaluation via
histologic analysis guides treatment, especially in the initial presentation of the disease (Vogel,
2011). Although there are multiple types of biopsies, which type is used can be determined by
the type and location of the lesion. Certain medical criteria can exclude a patient from having
certain types of biopsies or from having biopsy at all. For example a stereotactic needle biopsy
is contraindicated in patients that are obese, using anticoagulant therapy, or unable to lay prone
(Vogel, 2011).
Types of biopsies
Some of the factors influencing biopsy type are risk to the patient, patient willingness to
consent to a procedure, or the ability to obtain a sufficient sample due to tumor size or location.
Furthermore, cost has become of consideration when selecting which type of biopsy is indicated.
Individual cancer types may have multiple possible biopsy techniques dependent on these
factors. Types of biopsies that may be used in diagnosing breast cancer can include fine-needle
aspiration biopsy, core-needle biopsy, excisional biopsy, or incisional biopsy (Vogel, 2011).
National Comprehensive Cancer Network (NCCN) guidelines for breast biopsy indicate coreneedle biopsy as the preferred method of biopsy.
Exceptions to biopsy
Certain tumor types have a greater risk than benefit when considering biopsy. However,
patients may not differentiate that different cancer types have varied biopsy and treatment
protocols. When a patient hears that a biopsy is contraindicated or causes risk of metastasis they
can easily transfer fears to their own cancer type even if it is much different situation. Knowing
which types of cancers do have limitations on when biopsy is indicated can be helpful in
understanding and explaining differences to a patient faced with a breast cancer biopsy.
Examples of biopsy exceptions are with Wilms tumors, ocular melanoma, testicular carcinoma,
or hepatic metastasis from colon cancer (American Cancer Society, 2012) (Eide & Walaas,
2009) (Lewis & Martin, 2006).
Patient Barriers
Patients can have personal barriers to having a biopsy even if it is indicated by medical
standards. Factors influencing personal opinions can be multifactorial. Examples of such
sources are the internet, family and friends, cultural heritage and economic limitations. Searches
on cancer therapy and plan of care bring about many different viewpoints of treatment. Some
are traditional medicine and some are alterative therapy. Traditional and alternative medicines
do not necessarily coexist perfectly, but both should be understood by the healthcare provider in
order to answer patient questions and concerns. Many alternative medicine opinions voice
concerns in regard to breast biopsies spreading breast cancer secondary to seeding post tumor
biopsy (Hibbard, 2004). When discussing a topic such as a biopsy, all viewpoints must be
studied to knowledgeably address the situation with the patient. Family or friends may deter
someone from a biopsy stating they knew of someone who had a biopsy and “it spread the
cancer.” Family and friends already have a relationship and trust built with the patient.
Healthcare practitioners need to strive to build a trusting relationship as well and to help guide a
patient in their choices based on the most current evidence-based research. This trust can also
help the patient overcome what may be another obstacle in agreeing to a biopsy, a fear of
confirming a cancer is present. Some cultures such as African Americans there may be a higher
rate of belief that tumor biopsy will spread their cancer (Margolis et al., 2003). Another factor
that has become ever more prevalent in recent times is a patient’s economic situation. For
instance, a patient may not financially be able to take time off of work for a biopsy. Also if a
patient does not have health insurance the cost of the biopsy may be unaffordable. According to
the article “How much does a biopsy cost?” breast biopsy costs without insurance range from
$1,000 to $5,000 depending on the type of biopsy performed (2009). Assistance provided varies
from state to state and the American Cancer Society is a great resource to guide access to care.
In realizing the potential patient barriers to a breast biopsy, a healthcare provider is then better
prepared to serve as a resource and more understanding to the possible concerns that exist.
Education for clinicians to become better prepared for these discussions will obviously lead to
better outcomes for the provider and patient alike.
Review of Literature
Several studies have focused on if tumor cell dissemination was in fact an occurrence.
Michalpoulos et al. prospectively studied breast biopsies with two of thirty-one participants
having benign cells disseminated (2008). Even when tumor cell dissemination was found to
occur, these disturbed cells lacked viability. Of the various types of biopsies, the authors noted
vacuum-assisted biopsies as being the least associated with tumor seeding (Loughran & Keeling,
2011). In a case review of 15 patients that had either excisional or needle biopsy, all had
disrupted cells noted and eleven with carcinoma cells. Researchers noted that even if disrupted
and dissemination occurs, tumor cells were not found to be seeded or proliferating after
disturbance (Carter, Jensen, Simpson, & Page, 2000). Three specific cases of tumor cell seeding
resulting in localized recurrence were examined from stereotactic core breast biopsies (Chao et
al., 2001). Again confirmation exists for tumor dissemination post biopsy, but risk appears to be
very low. In a 2006 study by Uriburu et al., the authors note that even though needle tract
seeding exists the incidence is approximately 0.005%. In a review of literature that examined 15
other studies, it was noted that displacement of epithelial cells could occur in a core needle
biopsy but this did not translate into an increase in morbidity. Radiation for some and follow-up
for all will continue to be needed as a part of therapy for patients with breast cancer (Liebens et
al., 2009). This can also be confirmed by a 2006 study that concluded that core needle biopsy
was not found to change recurrence or survival of patients, especially if followed by surgery and
radiation. Furthermore, a biopsy would allow options such as neoadjuvant chemotherapy that
might otherwise be lost if a biopsy was not performed (Fitzal, et al., 2006). Micro-Metastasis in
areas such as the axilla can exist and can go undetected at the time of core biopsy (Filippakis &
Zografos, 2007). This makes findings of dissemination to areas such as the axilla hard to
interpret as initial time of tumor spreading cannot be determined.
Authors have theorized reasons for tumor cell dissemination. Length of the breast biopsy
procedure is one possible theorized issue (Michalopoulos et al., 2008). One study evaluated
breast tumor seeding post biopsy in relation to type of breast cancer. Of the cases studied,
papillary Ductal Carcinoma In Situ (DCIS) lesions were the cancer type most frequently noted to
when seeding was present (Nagi, Bleiweiss, & Jaffer, 2005). It should be noted that ductal
carcinomas are one of the most frequent occurring breast cancers at around seventy percent of all
breast cancers (Foxson, Lattimer, & Felder, 2011). As the study by Nagi, Bleiweiss, and Jaffer
was fifty-three cases of epithelial displacement from a total of 13,334 biopsies it should be noted
that it is indeed a rare occurrence and difficult to study. However, further study is needed to
examine breast cancer type in relation to seeding post biopsy. If this is a case of a cancer type
that is of higher incidence or a type that is more prone to seeding is not yet determined.
However, since cancer type is not known until after biopsy implications would be limited to
follow up therapy and patient recurrence risk. Biopsy needle gauge and biopsy type were
another study’s focus, to investigate the size of the needle gauge in relation to breast biopsy
seeding. This theory was disproven as the largest needle type with vacuum-assisted biopsy, 11
to 14 gauge, had the least amount of tumor dissemination. Authors also noted the percentages
associated with an automated gun and palpation was statistically insignificant. They theorized
that tumor seeding was more related to time between breast biopsy and excision, which will need
further study (Diaz, Wiley, & Venta, 1999). In a 2004 study, technique used in a breast biopsy
was determined to influence displacement of cells, but the significance of this displacement was
not found to be negative to a patient’s future health.
Even though fine-needle aspiration
biopsies were found to be more associated with sentinel metastasis, this portion of the study
group also had the largest primary tumors which could also relate to incidence of metastasis as
well (Hansen, Ye, Grube, & Giuliano, 2004).
Various methods have been examined as ways to reduce the possibility of tumor cell
dissemination due to biopsy. One such experimental study is with a specialized biopsy needle
device that was able to take a preserved sample, but denatured disseminated cells using
radiofrequency pulsations (Wiksell et al., 2010). Another study examined the use of a coaxial
cutting needle instead of a fine-needle for biopsy. No evidence of tumor seeding were found
post biopsy as far as 410 days post biopsy, as opposed to the small risk reported to be found with
fine-needle biopsy for liver carcinoma (Maturen et al., 2006). This deems further study to
confirm the findings which hold potential to greatly reduce the already small risk that exists for
tumor dissemination into the needle tract from biopsy.
Excision of the breast biopsy tract or radiation if the breast biopsy is found to be positive,
are recommendations presented by one group of researchers (Chao et al., 2001). Similar
recommendations were discussed by Uriburu et al., which included removal of biopsy tract after
confirmation of breast cancer (2006). Current guidelines from NCCN for most breast cancers
involve excision of remaining tumor and sometimes radiation. Radiation after excision is
recommended if the tumor is five centimeter or larger, the margins were either close or positive,
or positive nodal involvement (National Comprehensive Cancer Network, 2012).
Studies regarding patients’ fears of biopsy or surgery spreading their cancer show this is a
fear in existence for patients. In a study regarding patients expressed experiences after their
excisional breast biopsy, there was a desire for information and education, various fears, and
spiritual needs. Fears were founded in a positive cancer diagnosis, of having surgery in general,
and the loss of their breasts or femininity. Fear of their biopsy appeared to be one the greatest
fears mentioned (Demir, Donmez, Ozsaker, & Diramali, 2008). In another population of cancer
biopsies, men undergoing prostate biopsies were interviewed regarding their experiences and
perceptions. Tumor cell dissemination fears were reported as well as fears of spreading cancer
cells to their sexual partner. One patient stated the doctor mentioned tumor spreading was a
possibility of the biopsy which caused him to fear metastasis post biopsy (Chapple, Ziebland,
Brewster, & McPherson, 2007). Cultural and racial differences also factor into patient
perceptions and thus fears regarding their biopsy. In a prospective questionnaire following lung
surgery, of the patients surveyed African Americans had a significantly higher prevalence of the
belief that air exposure would spread their lung cancer compared to Caucasians. Additionally
nineteen percent of the African Americans studied would decline surgery versus five percent of
the Caucasians studied. (Margolis et al., 2003). In the studies presently published regarding
patients’ fears of tumor biopsies, post biopsy formatting may under represent the incidence as
these patients with the greatest fear may elect to not undergo biopsy.
Implications for practice
Many of the studies noted with seeding present post biopsy were not noted as having had
breast radiation. If a core breast biopsy and excisional breast biopsy can yield the same results
and the core biopsy does not pose significant risk of tumor cell dissemination, a core biopsy is a
far better overall choice compared to an excisional biopsy. Furthermore, patients may fear
seeding of their tumor post biopsy, but this has not been clearly shown to spread their breast
cancer. Tumor cells found in lymphatic tissue could have been there either before or after a
breast biopsy and if prior to biopsy may not have been detectable by palpation. Even though a
small risk exists for tumor cell dissemination, whether these displaced cells will amount to
anything further is not known (Uematsu & Kasami, 2008).
Recommendations for practice
Risk is a factor of all areas in medicine. It is more readily accepted in other areas such as
with medications. However, a patient is not likely to refuse their antibiotic due to the possibility
of side effects. These medications are prescribed because the benefit outweighs the risk for most
and the risks are discussed and known. Likewise the benefit of information from a minimally
invasive breast tumor biopsy outweighs the risk of treating an unknown situation. Carcinoma
identification is an important and critical initial step in the treatment of cancer.
Based on the current research and NCCN guidelines, it remains good practice to use
various biopsy methods and selection of the type based on the individual patient. Less emphasis
should be placed on excisional or incisional biopsies for most patients, as there exists the
increased risks associated with general surgery and the opportunity to have additional medical
interventions such as neoadjuvant chemotherapy are lost. It remains with the surgeon to obtain
consent and inform the patient of potential risks and complications. They may find it appropriate
to discuss that tumor dissemination is possible from a biopsy, but an extremely rare occurrence.
Unless a nursing role is tied to consenting and informing a patient for surgery, such as with a
mid-level provider, questions about their surgery or biopsy should be differed to the surgeon.
There could be legal implications from working outside the scope of your practice. So if a
patient has concerns about this possibility it should not be dismissed, but rather acknowledged
and discussed with their surgeon.
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