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Dear Dr. Roach: Three years ago, during a routine mammogram, I was diagnosed with what has been deemed a benign (most likely) breast mass. Since then I have had mammograms every six months with ultrasounds to monitor it. Last summer my doctor wanted an MRI done of the breast, but my insurance company denied the request and said a breast biopsy should be done. Because of my intense dislike of anything to do with needles, I declined.

This summer, my best friend was diagnosed with breast cancer and underwent THREE biopsies before undergoing a double mastectomy. She told me the biopsies were extremely painful, and she is no slouch to when it comes to pain, so I believe her.

My question is not on why an insurance firm would want a person to undergo a more-invasive procedure before a less-invasive one; my question is why, in this day and age of anesthesia for procedures like dental cleaning and the like, women are required to undergo the torture of having a large, horse-size (my friend’s words) needle driven deeply into probably one of the most sensitive areas of their body with only the application of a topical or local injection? This was the main reason for my refusal to have one done. It seems to be an inhumane way of diagnosis.

I have asked several of my doctors, but none seems to be able to give me an idea about why this is done. Hopefully, you can shed some light on this subject.

L.Z.

Dear L.Z.: I haven’t had a breast biopsy, so I can’t comment on how painful they are, but I certainly agree that women (and a very few men) who get breast biopsies should be kept more pain-free than your friend was. Few patients I have had who underwent the procedure told me about pain as intense as your friend describes.

As far as biopsy versus MRI, I can’t defend the insurance company’s position. I suspect that they look at the cost of getting a (often or usually) definitive answer from a biopsy versus the less-certain MRI result and decide that, as a rule, biopsies are more cost-effective than MRIs.

However, in a world where the optimal management of breast tumors is changing on a daily basis, I think that the patient’s own physician ought to be the one making the decisions, not the insurance companies. I often have said that any guideline, no matter how well-researched and evidence-based, has to allow for individual variation.

All that being said, there is absolutely a time when a biopsy becomes the only reasonable choice. The only person who definitively diagnoses cancer is the pathologist, and I have seen many cases where additional imaging leads to delay in making the diagnosis and beginning treatment. I don’t have enough information to form an opinion in your case and so defer to your doctor (and think your insurance company should, too).

Email questions to ToYourGoodHealth@med.cornell.edu.

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