Robert C Wright, MD, PS – Puyallup, Washington
Informed Consent
Ultrasound Guided Core Needle Breast Biopsy
(right/ left/ both sides)
Your symptoms, physical exam and mammogram or breast ultrasound show an abnormality which needs further characterization by biopsy. A sample of tissue will need to be studied carefully under the microscope to provide us with a diagnosis. After careful consideration, an ultrasound guided core needle breast biopsy has been recommended.
Purpose and Alternatives for this Procedure
The usual purpose of a breast biopsy is to determine the nature of an abnormality. A needle biopsy will usually be all that is necessary for a diagnosis, but an open biopsy may still be indicated if this biopsy is not conclusive.
Description of the Procedure
An ultrasound guided core needle biopsy may be performed with you awake in the office. You will receive local anesthesia first, to numb up the area where the biopsy will take place. The ultrasound machine directs a needle into the breast toward the lump. The core biopsy apparatus is fired, obtaining a core of breast tissue within the needle. The needle is removed and the core is sent to the pathologist for examination and interpretation. You may go home soon after the procedure. It will take a day or two to determine the results of the breast biopsy.
Risks/Complications of Treatment
1. Bleeding – this is a problem that could happen any time the skin is entered.
2. Infection – we take special care to prevent infection, but it is always a possibility.
3. Spread of cancer – this is very unlikely.
4. Pain – some people will experience breast discomfort during and the evening after the procedure. This pain is usually minor and resolves in a day or two.
5. Missed lesion – although uncommon, it is possible to biopsy a suspicious lump in the breast and miss the cancerous portion. This might be a problem if your breasts are very lumpy.
6. Error in diagnosis – core biopsy has been demonstrated to be reliable and accurate. It is still important to depend on clinical suspicion rather than results of the biopsy for determination of proper treatment.
Anticipated Recovery/Expected Rehabilitation
You will be able to resume normal, unrestricted activities the next day following the biopsy.
If the biopsy shows a cancer is present, further treatment, including surgery, will be required.
(see other side)
Consent for Treatment
I understand my condition to be a breast lump and am aware of its risks if undiagnosed. I have read and understand the above explanation of the procedure being proposed. My surgeon has answered my questions, and I choose to proceed with the ultrasound guided core needle biopsy.
I also understand that the purpose of a breast biopsy is for diagnosis, and not for treatment. My condition may require further therapy.
HIPAA: Before and after surgery, unless otherwise requested in writing by you, visitors whom you invite to attend the surgery will be informed of the surgical finding, your surgical status, and anticipated recovery issues for effectiveness of communications. Because of the anesthetic, you may or may not remember these important details.
Print NamE______
Signature ______Date ______
Witness ______Date ______
Surgeon ______Date ______
Relationship to Patient if Signature of Legal Guardian ______
I waive the right to read this form, and do not want to be educated and informed of treatment risks; nonetheless I understand the need for this surgery and grant permission to the surgeon to proceed on my behalf.
Signature ______Date ______
rev 6-03/kab