Needle biopsy, the standard of care for diagnosing breast cancer, is underused in the United States, and patients are often influenced by surgeons to undergo unnecessary excisional biopsy, which may have a negative impact on diagnosis and treatment. That is the conclusion of a study now online ahead of print in the Journal of Clinical Oncology (DOI.10.1200/JCO.2013.52.8257).
Reflecting these findings, the senior author, Benjamin Smith, MD, Associate Professor in the Departments of Radiation Oncology and Health Services Research at MD Anderson Cancer Center, said that MD Anderson sees a number of patients who have undergone excisional biopsy when a needle biopsy would have been appropriate. And while patient characteristics such as geographic location tend to influence needle biopsy use, so do provider characteristics, he said.
“I was shocked to see the percentage of people who did not have a core biopsy,” said William Farrar, MD, Director of Ohio State's Stefanie Spielman Comprehensive Breast Center, who was asked to comment for this article. About 95 percent of patients undergo a core needle biopsy for diagnosis at his facility, he said. “We do see a small number of patients coming to us each year who have already undergone an excisional biopsy, and these individuals are often from rural parts of the state.”
Overall, the study is a “wake-up call,” said Maureen Chung, MD, Director of the Margie and Robert E. Petersen Breast Cancer Research Program at John Wayne Cancer Institute in Santa Monica, CA. Chung, a breast surgical oncologist, said she hopes the rate of needle biopsy has improved since the years 2003 to 2007, the time period the researchers evaluated.
Smith and his colleagues—first author is Jan M. Eberth, PhD—retrospectively reviewed the Medicare claims of 89,712 patients diagnosed with breast cancer from 2003 to 2007 who received breast-conserving surgery and radiation therapy. The study also identified 11,279 diagnosing surgeons and 12,405 treating surgeons.
Of the patients, 68.4 percent underwent a needle biopsy, with 92.8 percent undergoing a core biopsy. The rate of individuals undergoing needle biopsy increased from 60.8 percent in 2003 to 76.5 percent in 2007.
Of the total cohort, 68.4 percent of the patients consulted with a surgeon before biopsy and 31.6 percent saw a surgeon afterward. Of the patients who saw a surgeon upfront, 53.7 percent had a needle biopsy, with 38.4 percent having the procedure performed by their surgeon, and 15.4 percent undergoing needle biopsy by a radiologist. All women who saw a surgeon post-biopsy had received a needle biopsy.
Multivariate analysis indicated that the patient characteristics most significantly associated with consultation with a surgeon before biopsy and leading to a lower rate of needle biopsy were older age, black race, Medicaid coverage, co-morbid illness, earlier year of diagnosis, rural residence, longer distance to the nearest radiological facility, no mammogram in the 60 days before consultation, and a visit with a primary care physician in the 60 days before consultation.
Notably, while the procedure was less common in rural areas, even some locations within reasonably sized cities are commonly using excisional instead of needle biopsy, Smith noted.
Underuse of needle biopsy is often dependent on what provider the patient sees, he said. With multivariate analysis, the investigators found that the surgeon characteristics associated with excisional biopsy included lack of board certification, training outside of the United States, medical school graduation before 1980, low case volume, and specialization in general surgery.
The researchers also found that the risk of multiple surgeries was 33.7 percent in patients who underwent needle biopsy compared with 69.6 percent in those who underwent excisional biopsy.
Benefits of Needle Biopsy
“While you might think that using a surgical biopsy might simplify things and make treatment a single step, additional procedures and studies for staging are often required after the fact,” noted Heather Richardson, MD, FACS, a breast surgeon at Piedmont Hospital in Atlanta. For this reason, she said, she does not recommend excisional biopsies as a primary option for lesions that could be malignant.
Additionally, needle biopsy results help surgeons go into the operating room knowing they are going to excise a cancer and that they should pay close attention to obtaining clear margins, Chung said. In contrast, patients who undergo excisional biopsy are at risk of having to return for another surgery to obtain these clear margins.
In addition to fewer surgeries, needle biopsies help oncologists develop individualized treatment plans for patients, said Ossama Tawfik, MD, PhD, FASCP, Vice Chairman for Education and Outreach, Director of Anatomical and Surgical Pathology, and Professor of Pathology and Laboratory Medicine and Obstetrics and Gynecology at the University of Kansas Medical Center. “Whether patients need to come back in six months or two years to repeat a study or be taken to the operating room right away, these are all options.”
A core needle biopsy can obtain all the relevant information needed to decide whether patients can benefit from preoperative medical therapies such as targeted and hormone agents and allows for genomic testing to better tailor treatment, commented Dennis Citrin, MB, ChB, PhD, a medical oncologist at the Cancer Treatment Centers of America Midwestern Regional Medical Center, where he specializes in breast disease.
Needle biopsy also allows patients to know their diagnosis in 24 to 48 hours and enables them to sit down with their physician to discuss the surgical treatment options quickly, said Alison Estabrook, MD, Chief of the Division of Breast Surgery at Mount Sinai St. Luke's and Mount Sinai Roosevelt.
An interesting downside to excisional biopsy is that it decreases the accuracy of sentinel lymph node staging, said Smith, citing prior research. Excision may alter lymphatic flow, making the identification of the sentinel node more difficult, he theorized. Additionally, an open procedure increases the risk of infection and bleeding compared with needle biopsy.
Breast needle biopsy needs to be a collaborative effort among pathologists and radiologists, with the goal of improving patient outcomes, Tawfik said. “Our surgeons have decided to leave breast needle biopsies to the expertise of our radiologists who have experience with image guidance.”
Integrating breast needle biopsies throughout clinical practice and not performing the test in silos is also important, he added. The primary care physician, radiologists, pathologists, and surgeons all need to be communicating with each other.
To increase the use of needle biopsy requires “a push on the professional side and an understanding of the importance of the procedure,” Chung said.
Encouraging the American College of Surgeons (ACoS) to use needle biopsy certification as a quality issue for those general surgeons who treat breast cancer would be valuable, Farrar said.
Also, Smith noted, as part of the Choosing Widely campaign, the ACoS is advocating that women with abnormal imaging tests undergo a needle biopsy.
Additionally, physicians who aren't comfortable performing needle biopsy need to refer patients to medical centers with radiology departments where they can undergo the procedure, Farrar said.
Improvement in use may also occur in time as mobile radiology and telemedicine become increasingly available and as surgeons become more comfortable with needle biopsy, Richardson said.
In addition, Chung said, to further physician involvement, patients need to be their own advocates and should not be afraid to question why they are being scheduled to undergo a surgical excision rather than a needle biopsy.
Exceptions to Use
There are exceptions to using needle biopsy, she noted—for example, not being able to access growths with a needle. Some patients have calcifications, which require undergoing a stereotactic biopsy, but sometimes the breast tissue is not thick enough for the procedure and surgical excision becomes necessary.
In an accompanying editorial (DOI:10.1200/JCO.2014.55.6324), Kristine E. Calhoun, MD, and Benjamin O. Anderson, MD, of the University of Washington, note that some patients are unable to lie flat, or have medical issues making needle biopsy challenging. “In these cases, surgical biopsy may be necessary to make an accurate diagnosis,” they wrote. “Thus, the goal is not for 100 percent of cancers to be diagnosed by [percutaneous needle biopsy], although a rate exceeding 90 percent is a realistic goal.”
Evolution of Care
“We've gone through an evolution of how we treat breast cancer patients,” Chung noted. Twenty years ago, physicians used excisional biopsy, and now the standard of care is to use needle biopsy with image guidance before making the decision to go into an operating room.
Farrar added that the rates of needle biopsy have been increasing since the 1990s and are highest at larger institutions with breast centers.
The traditional approach of sending a patient with suspected breast cancer, either because of a palpable lump or an abnormal mammogram, for initial surgical treatment is outmoded, Citrin said. The diagnosis of breast cancer, with all of the relevant biological information that will determine systemic treatment, can be easily obtained from a simple core needle biopsy.
Surgery followed by chemotherapy or radiation is not the only way to care for women with breast cancer, he said. “The new paradigm is no longer ‘one size fits all.’”