Jun 09, 2014
This study found that the strongest factor influencing whether a patient being treated for breast cancer received surgical or needle biopsy was the professional and academic characteristics of the individual surgeon caring for the patient.
By Shira Klapper, Senior Writer/Editor
In the 1990s, organizations such as the Joint Task Force of the American College of Radiology (ACR) and the American College of Surgeons (ACS) issued guidelines reflecting the new consensus on preferred modality for breast biopsies. The reports stated that needle biopsy, compared to open surgical biopsy of the breast, is the safer and less costly option and should be performed in no less than 90% of patients. Since the release of these reports, the rates of needle biopsies have shot up, from past rates of 24% to the current rates of between 68-88%. But as these numbers show, a good number of patients still receive open surgical biopsy.
Now, a new study in the June 9th edition of the Journal of Clinical Oncology (JCO), ahead of print, finds more evidence that among women being treated for breast cancer, the rate of needle biopsies is less than ideal. The study, “Surgeon Influence on Use of Needle Biopsy in Breast Cancer Patients: A National Medicare Study,” found that out of 89,712 Medicare patients, 68% had received needle biopsy, and 32% had received open, surgical biopsy. Statistical analysis revealed that several factors influenced the receipt of one modality over the other, but that the strongest factor of all was the professional and academic characteristics of the individual surgeon caring for the patient.
The merits of needle versus open biopsy
|Benjamin Smith, MD|
“Needle biopsy is much less invasive than open biopsy,” said Dr. Smith. “A small amount of topical anesthetic is injected into the skin of the breast, after which, a spring-loaded needle is inserted into the breast, deployed, and pulls out a core of tissue to be sent off to pathology. Excisional biopsy, by contrast, involves using a scalpel to cut an opening in the breast and taking out part or all of the tumor. From the patient’s perspective, it’s not much different than having a lumpectomy.”
In addition to being more invasive, most patients who undergo open biopsy still need to undergo additional breast and lymph node surgery to actually treat their cancer.
Disparities in populations
Dr. Smith’s interest in rates of needle biopsy arose after observing differences between patients at his former and current practices.
“I was stationed in San Antonio for four years as a radiation oncologist in the Air Force,” said Dr. Smith. “And to be honest, I cannot recall ever seeing a patient in our practice who had an excisional biopsy.”
Upon coming to MD Anderson, he noticed that, similar to the Air Force, the breast surgeons at MD Anderson did not use excisional biopsy. However, patients whose breast cancers were diagnosed at other facilities prior to coming to MD Anderson frequently underwent open, excisional biopsy instead of needle biopsy. These open biopsies occasionally led to complications, and often complicated the patients’ overall care plan.
A novel hypothesis
The JCO study was designed to help Dr. Smith and his colleagues understand the sequence of events that led some patients to receive open biopsy and others to receive needle biopsy. The researchers had the great benefit of access to 2003-2007 nationwide Medicare data, allowing them to look back at a wide swath of patients.
The researchers based the study on a novel hypothesis: The order in which patients saw either a radiologist or surgeon was the key factor in determining the use of needle biopsy.
In explaining the hypothesis, Dr. Smith stated, “Ideally, the treatment algorithm is that patients found to have suspicious growths would first see a radiologist, who would perform the needle biopsy. Then, if necessary, the patient would be referred to a surgeon, who would remove the tumor.”
But if that order is reversed, and patients go first to the surgeon, they stand a much higher chance of having open surgical biopsy.
The researchers also hypothesized that the individual characteristics of the surgeon—such as years in practice and caseload—would have an impact on whether patients received needle or open biopsy.
Surgeon: the most important factor
Ultimately, the researchers were able to look at 89,712 patients with breast cancer and 12,405 surgeons. When the MD Anderson team analyzed this enormous amount of data, they found that 68.4% of patients had undergone needle biopsy. But when the patients were divided by the order in which they saw the surgeon and radiologist, an interesting pattern emerged: among patients who saw a surgeon first, only 53.7% had a needle biopsy. Patients who went to surgeons first were also more likely to share certain characteristics, such as living in rural areas, living more than 8.1 miles from a radiologic facility, and not having had a mammogram within 60 days before consultation.
The big finding, however, was that while individual patient-factors were found to have an impact on biopsy modality, a more significant 30% of the variation was explained by another factor: the treating surgeon and his/her characteristics. Patients seeing surgeons with lower case volume, earlier decade of medical school education, non-U.S. training, and absence of board certification were more likely to have open biopsy.
Improvements in practice
Dr. Smith is hopeful that the Affordable Care Act and the new emphasis on “value” from our health care dollars might encourage surgeons to change their practices—surgeons might increasingly refer patients directly to radiologists, or they might perform more needle biopsies themselves.
“Right now there’s some financial incentive for surgeons to do an excisional biopsy,” said Dr. Smith. “But it’s possible that over time that may change because of physician ‘report cards,’ which might include information on biopsy type as a measure worth noting.”“This might be one of the important policy changes in the future.”
Dr. Benjamin Smith is an Associate Professor of Radiation Oncology at The University of Texas MD Anderson Cancer Center. He is currently Chair of the American Society for Radiation Oncology (ASTRO) Guidelines Subcommittee. He has been a member of ASCO since 2003.
Click here to read the abstract.
Click here to read the PDF.
Eberth, JM, Xu, Y, Smith, GL, et al. Surgeon influence on use of needle biopsy in breast cancer patients: a national medicare study. J Clin Oncol. 2014; Published online ahead of print 6.9.2014.
The Exclusive Coverage series on ASCO.org highlights selected research from JCO with additional perspective provided by the lead or corresponding author.
@ 2014 American Society of Clinical Oncology