Needle biopsies may be underused for breast cancer patients

NEW YORK (Reuters Health) - Most women should undergo a needle biopsy for breast cancer diagnosis, but some surgeons opt for a more invasive procedure instead, according to a new study.

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.

“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: Journal of Clinical Oncology, online June 9, 2014.