The Anxiety of the Biopsy from NY Times Health Blog

| February 25, 2009

Came across this post from NY Times Health blog this week.  Couple of thoughts:

Biopsies required to fix for certain time should need for certain IHC (i.e. HER2) required.  Formal guidelines coming on ER/PR as well just as we know have ASCO/CAP guidelines for HER2 testing.  Despite the time requirement, processing can and often occurs in 1 day and can be signed out the following day.  I would gather most laboratories will complete majority of sign-outs in one day.  We do it routinely here otherwise get calls from clinicians by mid-day asking for results.  Of course some require additional levels, review, consultation and/or IHC but the exception, not the rule.  2.5 day turn around time seems excessive.  5 days for 73 of 126 women not to have a result seems protracted. I would have hoped the patients' clinician explained reason for delay but this did not seem to occur either. 

Nonetheless, in the laboratory industry the goals are to have high diagnostic accuracy, rapid turnaround time and cost control; said another way, you can have it right, fast or cheap, pick any two.  If given a choice, I gather all of us would choose the right answer in a timely fashion at a reasonable cost. Nonetheless, it sometimes takes a little longer to ensure the right answer & may involve more tests increasing costs.  Having been on both sides of this equation I would rather have the right answer even if it costs more and takes longer.  I wonder what happens to cortisol levels with misdiagnoses and inappropriate, unnecessary or unindicated therapy…

Post and abstract from paper published below.

Waiting days for the results of a breast biopsy appears to affect stress hormone levels just as much as finding out you have cancer does, a new study shows.

Harvard researchers tracked 126 women who were undergoing breast biopsy, monitoring their levels of the stress hormone cortisol while they waited.

One of the most surprising findings, researchers said, was how long many women had to wait before receiving their results. While the average wait time was 2.5 days, many women had to wait five days or longer. By the fifth day, 37 women learned their biopsy was benign, 16 learned they had cancer and 73 still did not have a result, according to the report, which appeared in the medical journal Radiology. Most of the women who did not have a diagnosis had not received any information or explanation for the delay.

Women who were still uncertain about their diagnosis had abnormal cortisol levels that were “essentially indistinguishable’’ from the cortisol profiles of the women who were told they had cancer. And women without a diagnosis had significantly worse cortisol profiles compared to women who had received benign test results.

“If you talk to any woman who has had a biopsy who has had to wait for results, she will tell you it’s a horrible roller coaster,’’ said Dr. Elvira V. Lang, associate professor of radiology at Harvard Medical School and Beth Israel Deaconess Medical Center. “Even when patients hear they have a cancer, they can start doing something. But if you hang in there for five days and you still don’t know what direction it goes, it’s just very stressful.’’

The concern, Dr. Lang said, is that cortisol levels can influence wound healing and immune response, raising a woman’s potential health risks if she ultimately needs to be treated for cancer. And the stress and anxiety of waiting also affects the quality of life of a woman, her family and her ability to function well at work, she said.

Dr. Lang said the research should spur hospitals to focus not only on speeding up test results, but on improving communication and possibly offering psychological services to women who are waiting for a diagnosis. The study was funded by the Department of Defense breast cancer research program. Dr. Lang has a financial interest in a consulting firm that trains medical personnel how to improve communication with patients.

“We have to work much faster to get results to women,’’ Dr. Lang said. “You want to keep stressors as profound as this as short as possible.’’

Large-Core Breast Biopsy: Abnormal Salivary Cortisol Profiles Associated with Uncertainty of Diagnosis

Elvira V. Lang, MD, FSIR, FSCEH, Kevin S. Berbaum, PhD, and Susan K. Lutgendorf, PhD

From the Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA 02115 (E.V.L.); and Departments of Radiology (K.S.B.) and Psychology (S.K.L.), University of Iowa, Iowa City, Iowa. Received June 19, 2008; revision requested July 22; revision received July 31; accepted August 27; final version accepted September 16. Supported by the U.S. Army Research and Materiel Command DAMD 17-01-01. E-mail:

Purpose: To determine whether uncertainty of the diagnosis after large-core breast biopsy (LCBB) adversely affects biochemical stress levels.

Materials and Methods: This study was institutional review board approved and HIPAA compliant, and all patients gave written informed consent. One hundred fifty women aged 18–86 years collected four salivary cortisol samples per day for 5 days after LCBB. t Tests were used to compare diurnal cortisol slopes among three groups: patients who did not have a final diagnosis (uncertain group), patients who knew they had cancer (known malignant group), and patients who knew they had benign disease (known benign group).

Results: Women learned their diagnosis on days 1–6 (mean, day 2.4) after LCBB. Analysis was truncated at day 5, when the data from a sufficient number of patients from each group were available for meaningful analysis: 16 patients from the known malignant group, 37 from the known benign group, and 73 from the uncertain group, which totaled 126 patients. The mean cortisol slope for the women with an uncertain diagnosis (–0.092 ln [µg/dL]/hr; 95% confidence interval [CI]: –0.113 ln [µg/dL]/hr, –0.072 ln [µg/dL]/hr) was significantly flatter (less desirable) than that for the women who learned that they had benign disease (–0.154 ln [µg/dL]/hr; 95% CI: –0.197 ln [µg/dL]/hr, –0.111 ln [µg/dL]/hr; P = .014) but not significantly different from that for the women who learned that they had malignant disease (–0.110 ln [µg/dL]/hr; 95% CI: –0.147 ln [µg/dL]/hr, –0.073 ln [µg/dL]/hr; P = .421).

Conclusion: Uncertainty about the final diagnosis after LCBB is associated with substantial biochemical distress, which may have adverse effects on immune defense and wound healing. Results indicate the need for more rapid communication of biopsy results.

© RSNA, 2009

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  1. EM says:

    “I wonder what happens to cortisol levels with misdiagnoses and inappropriate, unnecessary or unindicated therapy…”
    Totally agree. I also wonder about the pathologist’s cortisol level if the diagnosis was to be wrong.