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Breast CancerMonday's with Jean Campbell

Needle or Surgical Breast Biopsies

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biopsyI  read the following article about breast biopsies, written by Denise Grady, in  Blue Cross and Blue Shield Association’s (BCBSA) newsletter in February 18, 2011. I was especially interested, as I had both procedures following abnormal mammograms on a few occasions.  The needle biopsies, when conclusive, saved me surgery. Unfortunately, they were not always conclusive and I required surgical biopsies to confirm that I was breast-cancer free.

Article: Breast Research Urges Needle, Not Surgical, Biopsies.

Too many women with abnormal mammograms or other breast problems are undergoing surgical biopsies when they should be having needle biopsies, which are safer, less invasive and cheaper, researchers are reporting.

A study in Florida found that 30 percent of the breast biopsies there from 2003 to 2008 were surgical. The rate should be 10 percent or less, according to medical guidelines. The figures from Florida probably apply to the rest of the country, researchers say, which would translate into more than 300,000 women a year having unnecessary surgery, and cost hundreds of millions of dollars. Many of those women do not even have cancer: most breast biopsies, about 80 percent, are benign. For women who do have cancer, a surgical biopsy means two operations instead of one, and may make the cancer surgery more difficult than it would have been if a needle biopsy had been done.

Dr. Stephen R. Grobmyer, the senior author of the Florida study, said he and his colleagues did the research because they kept seeing patients referred from other hospitals who had undergone surgical biopsies (also called open biopsies) when a needle should have been used. “After a while you keep seeing this, you say something’s going on here,” said Dr. Grobmyer, who is director of the breast cancer program at the University of Florida in Gainesville. “You try to define the problem so you can do something about it.”

The reason for the overuse of open biopsies is not known. Researchers say it may occur because not all doctors keep up with medical advances and guidelines. But they also say that some surgeons keep doing open biopsies because needle biopsies are usually performed by radiologists, so the surgeon would have to refer the patient to a radiologist, and lose the biopsy fee.

A surgical biopsy requires an inch long incision, stitches and sometimes sedation or general anesthesia. It leaves a scar. Needle biopsy requires only numbing with a local anesthetic, uses a tiny incision and no stitches, and carries less risk of infection and scarring.

If the abnormality in the breast is too small to be felt and was detected by a mammogram or other imaging, then the needle biopsy must also be guided by imaging — mammography, ultrasound or M.R.I. — and will often have to be performed by a radiologist. If there is a lump large enough to be felt, then imaging is not needed to guide the needle, and a surgeon can perform it.

“Surgeons really have to let go of the patient when they have an image abnormality,” said Dr. I. Michael Leitman, the chief of general surgery at Beth Israel Medical Center in Manhattan. “They are giving away a potential surgery. But the standards require it. And I’m a surgeon.”

Dr. Grobmyer’s study, being published in The American Journal of Surgery, is based on 172,342 biopsies entered into a state database in Florida. It is the largest study of open biopsy rates in the United States, and the first to include patients with and without cancer.

About 1.6 million breast biopsies a year are performed in the United States. But in 2010 only about 261,000 found cancer (207,000 women had invasive breast cancer, and another 54,000 had ductal carcinoma in situ, in which cancer cells have not invaded surrounding tissue).

Hospital charges for a needle biopsy are about $5,000 to $6,000, and double that for an open biopsy, according to Dr. Grobmyer’s article. Doctors’ fees for an open biopsy range from $1,500 to $2,500, he said, and for a needle biopsy, $750 to $1,500.

A surgeon who was not part of Dr. Grobmyer’s study said she often encountered patients referred from other hospitals who had open biopsies that should have been done with a needle. “I see it all the time,” said Dr. Elisa R. Port, the chief of breast surgery at the Mount Sinai Medical Center in Manhattan. “People are causing harm and should be held accountable.”

Dr. Melvin J. Silverstein, a breast cancer surgeon at Hoag Memorial Hospital Presbyterian in Newport Beach, Calif., and a clinical professor of surgery at the University of Southern California, called a 30 percent rate of surgical breast biopsies “outrageous.” He said some of the unnecessary procedures were being done by surgeons who did not want to lose the biopsy fee by sending the patient to a radiologist. “I hate to even say that,” Dr. Silverstein said. “It breaks my heart. Most doctors do the right thing. They work really hard and try to do the right thing. But I don’t know how else to explain these numbers.”

A study at Beth Israel Medical Center in Manhattan (Dr. Leitman was an author), published in 2009, found that the rate of open breast biopsies in 2007 varied with the type of surgeon. Breast surgeons employed by the hospital and involved in teaching had a 10 percent rate. Breast surgeons in private practice who operated at Beth Israel had a 35 percent rate. Among general surgeons, who do not specialize in breast surgery (some on staff at the hospital and some not), the rate was 37 percent. All the doctors earned biopsy fees, so they all had the same financial incentive.

The lead author of the study, Dr. Susan K. Boolbol, chief of breast surgery at Beth Israel, said she thought part of the difference could be explained by training. She said the academic breast surgeons on the hospital staff were more likely than the others to keep up with new developments in the field and to work closely with radiologists. As for the idea that the motivation was money, she said, “A huge part of me doesn’t want to believe it’s true.”

She said that when she asked surgeons in the study why they were doing open biopsies, many said patients wanted them.“My comeback was, ‘Do you think you had an inherent bias in the way you explained it?’ ” Dr. Boolbol said, adding that as a surgeon, she explains the options to patients. In the past seven years, she said she has had only one patient choose an open biopsy over a needle biopsy.

Dr. Boolbol said some patients feared sticking a needle into a cancer would cause it to spread, and that she spent a lot of time explaining that it was not true. She said that open biopsy rates declined among surgeons at Beth Israel who were told about the findings, but newcomers still tended to have higher rates. “This is a constant education process for surgeons,” she said.

One way for hospitals to stop excess open biopsies is to ban them, Dr. Silverstein said, unless they are truly necessary, as in uncommon cases in which a needle cannot reach the spot or the patient cannot lie in the required position. “We made a rule,” he said. “If it can be done with a needle, it has to be. We embarrass you if you do an open biopsy. We bring you before a tumor board to explain.” Dr. Silverstein said that when he lectures at hospitals and medical schools and asks how many surgeons in the audience perform open breast biopsies, no hands go up.

“Nobody will admit it,” he said. Nor do they seem interested, he added, in making rules to minimize it.

He thinks there is more to be gained by taking his message straight to the female patients. He and other doctors say that any woman told she needs a surgical biopsy should ask why, and consider seeking a second opinion. “Maybe we have to get patients to say, ‘This guy took a big chunk out of me and I didn’t even have cancer, and now I’m deformed,’ ” Dr. Silverstein said. “Who just overthrew Mubarak? The people. This is exactly the same thing.”

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