Jacky Luiten

Utility of diagnostic breast excision biopsies during two decades of screening mammography | 35 3 Introduction In the Netherlands, all women aged 50‐75 years are invited to attend the nation‐ wide biennial screening mammography program, which was implemented between 1989 and 1996. In 1998 the upper age limit of the program was extended to 75 years of age and during 2009‐2010 screen‐film mammography was replaced by full‐field digital mammography. 1‐3 Adequate biopsy of a suspicious abnormality detected at screening mammography is required to obtain a definitive pathology result. A simple biopsy technique that can be used is fine needle aspiration (FNA). FNA was first described in 1847 for head and neck cancers. 4 During the 1960s FNA became more widely used and was considered as the gold standard for the pre‐operative diagnosis of breast cancer. 5 However, due the fact that FNA only collects cells, core biopsy evolved as an alternative to harvest tissue. Core biopsy enabled pathologists to make a more reliable diagnosis as it delivers full tissue structure instead of separate cells only. In addition, more reliable testing of hormone receptor and HER2 status is hereby feasible. 6,7 Considering the fact that nowadays most breast lesions are non‐palpable at the time of initial diagnosis, biopsies are usually performed under guidance of ultrasound or mammography. The core biopsy technique was first described in 1977 and in the 1990s large core biopsies gradually replaced FNA. 8 Core biopsy was also an adequate alternative for surgical excision biopsy. Surgical excision biopsy is an invasive technique and used to be the most reliable method to obtain a conclusive diagnosis of a potentially malignant breast lesion, with a diagnostic accuracy of 94%‐99%. 9 However, surgical excision biopsies are maximal invasive procedures, are usually performed under general anesthesia and have been found to hamper the assessment of future screening mammography. 10,11 Therefore, the use of excision biopsy, next to fine needle aspiration and core biopsy, has become a matter of debate. In a systematic review, published in 2002, Crowe et al . already reported a decline in the use of excisional biopsies between 1995 and 2002. 12 Later, a population‐based study by van Breest Smallenburg et al ., in 2013 reported a decline in the use of excision biopsy between 1997 and 2010 and showed that it was gradually replaced by large percutaneous core biopsy. 13 However, percutaneous core biopsies do not always provide a definite histopathological diagnosis, especially in the current era of digital mammography, which is characterized by the detection of many small lesions. This persistent uncertainty may cause physicians at the multidisciplinary board meetings to opt for an excision biopsy. Furthermore, we distinguished between excision biopsies performed as first biopsy method (primary excision biopsies) and excision biopsies