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 The difference may be a matter of surgeon experience, researchers
say, so many women could benefit if surgeons were trained and
encouraged to opt for the needle method more often.
“Needle biopsy really is the standard of care,” said senior study
author Dr. Benjamin D. Smith of The University of Texas MD Anderson
Cancer Center in Houston.
“Having a three or four centimeter (surgical) incision in the skin
is going to hurt more and take longer to heal than inserting a
needle,” Smith told Reuters Health by phone. “Excisional biopsy has
more complications than needle biopsy.”
When a woman has a suspicious lump in her breast, usually detected
by a mammogram, the way to determine if it is cancer is to take a
sample of tissue from the lump and test it.
Diagnostic radiologists are trained to use ultrasound or mammography
to guide a large needle through the breast to take the sample, and
surgeons can also use a needle, albeit without the extra guidance
equipment.
The surgical approach, is sometimes called an “open biopsy” because
it requires an incision to access the lump. The procedure is also
known as excisional biopsy.
If the lump is cancerous, valuable information about its nature can
be gleaned from a biopsy, the study authors point out. But rather
than having two surgeries, one to diagnose the cancer and another to
remove it, a needle biopsy can provide that initial information in
most cases.
To see how often women were getting needle biopsies versus the
surgical kind, and what factors predicted the type of biopsy a woman
got, Smith and his coauthors looked at the diagnostic histories of
almost 90,000 women with breast cancer using Medicare data for the
years 2003 to 2006.
The women were at least 66 years old and had undergone both
breast-conserving surgery and radiation to treat their cancers.
About two-thirds of the women had a needle biopsy, including those
who had a related technique, known as a core biopsy.
Of the women who had consulted with a surgeon before the biopsy,
only 54 percent subsequently had a needle biopsy.
Surgeons without board certification, who were trained outside the
United States or who were not specialized in surgical oncology were
less likely to have patients undergo a needle biopsy, according to
the study results in the Journal of Clinical Oncology.
The surgeon’s disposition was more important in predicting needle
biopsies than other factors like rural location, the authors write.
“This paper is an interesting example of how important it is for
cancer patients to be treated by experienced surgeons and in higher
volume institutions,” said Dr. Dawn L. Hershman, leader of the
Breast Cancer Program at the Herbert Irving Comprehensive Cancer
Center of Columbia University Medical Center in New York. Hershman
was not a part of the new study.
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“Both a needle biopsy and an excisional biopsy can diagnose the
cancer, however, the attention to margins, the evaluation of the
lymph nodes and the evaluation for other possible abnormalities in
the breast prior to going to the operating room can save the patient
needing multiple surgeries,” she told Reuters Health by email.
It may seem like a waste of time to test a lump of tissue that’s
bound to be removed anyway, but the results of the test have
important implications for treating the cancer, said Dr. Katharine
A. Yao, a breast surgery specialist at NorthShore Medical Group in
Evanston, Illinois.
“Some patients will ask if their mammogram or breast mass is so
suspicious on imaging and on exam and it is going to come out
anyway, why do a biopsy?” Yao told Reuters Health by email. “It is
important to do the biopsy so that if the mass or abnormality on
mammogram is cancer, there can be a full discussion of the treatment
plan including different types of surgery, adjuvant treatments and
the use of neoadjuvant therapy.”
Women who did not have a needle biopsy were twice as likely to
undergo multiple surgeries for their cancers than women who did.
“I think part of it is that in our medical system physicians are
incentivized to do more,” Smith said. “Surgeons get paid by the
procedure more or less, and it’s hard to change those patterns.”
An excisional biopsy, because it is more invasive, itself counts as
a “surgical procedure,” whereas needle biopsy does not, he said.
The best option is to have a radiologist perform the biopsy, said
Smith, himself a radiation oncologist. But in some areas of the
country, a general surgeon may be the only available option, and the
surgeon may be inexperienced with the needle technique, he said.
“I think there’s an opportunity for professional societies to define
quality benchmarks to emphasize needle biopsy as an important
measure of quality,” Smith said.
Not all women with a mass in the breast should have a biopsy, and in
some cases a needle biopsy may not be technically possible, Hershman
noted.
“Since the experience of the surgeon – case volume, board
certification, surgical oncology training, training in the U.S. – is
associated with needle biopsy rates, primary care doctors should
encourage their patients to see surgeons who are experienced in
breast disease or cancer and who have devoted some part if not all
of their practice to breast disease if they have a breast mass or an
abnormal mammogram,” Yao said.
SOURCE: http://bit.ly/1oePGTK Journal of Clinical Oncology, online
June 9, 2014.
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