Study: Surgical breast biopsies persistently overused

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CT scan shows a biopsy needle (arrow) advanced between the lateral edge of the sternum and the internal mammary vessels for biopsy
Image source: Radiographics

Despite clear advantages of percutaneous needle biopsy, open surgical breast biopsies remained common in Florida from 2003 to 2008, according to study published online Feb. 8 in The American Journal of Surgery. Reducing the number of open biopsies from 30 percent of the total volume to 10 percent could have produced a charge reduction of $37.2 million in the state in 2008.

Multiple current consensus statements support needle biopsy, typically performed by radiologists using mammographic or ultrasound guidance, for suspicious breast lesions. “Advantages of minimally invasive breast biopsy (MIBB) have been clearly outlined and include less scarring, less postprocedural morbidity and reduced costs,” according to Luke G. Gutwein, MD, of the department of surgery at University of Florida in Gainesville, and colleagues.

Gutwein noted that the rate of hematoma requiring treatment has been estimated to be 20 to 100 times more common in patients undergoing open biopsy, and infection rates have been estimated to be 38 to 63 times more common in patients undergoing open biopsy. “Patients with diagnoses of cancer on MIBB are less likely to require second operations for margin management and/or sentinel node biopsy,” continued the authors, who added that percutaneous biopsy may facilitate multidisciplinary planning.

Percutaneous biopsy is appropriate for 90 to 95 percent of breast lesions. Remaining lesions, such as those located in an unfavorable position near the chest wall or lesions not visible on imaging studies, require an open approach.

Gutwein and colleagues surmised wide and excessive application of open surgical biopsy in Florida. The researchers designed a population-based retrospective cohort study to analyze trends in breast biopsy performance from 2003 to 2008, relying on data gathered from the Florida Agency for Health Care Administration statewide outpatient surgery and database. They also calculated excess charges related to overuse of open biopsies.

During the study period 172,342 breast biopsies were performed in Florida. Despite a slight drop in open biopsy utilization by 2008, the rate of open surgical biopsy stood at approximately 30 percent in 2008. “This finding suggests that open biopsy is being overused in Florida,” affirmed the authors.

The researchers also observed a cost differential. In 2008, $112.7 million was charged for open surgical biopsy (approximately 30 percent of procedures) compared with $134 for MIBB. The authors estimated that reducing the open biopsy rate by 20 percent would have produced a charge reduction of $37.2 million. Extrapolating to the national level, they surmised “reducing the use of open surgical biopsy could be associated with a charge reduction into the hundreds of millions per year.”

Gutwein and colleagues did find MIBB more commonly performed at academic medical centers, and hazarded that the high rate of open biopsy utilization might be tied to a lack of resources for performing MIBB, lack of education about MIBB among practitioners or financial factors associated with open biopsy performance.

The authors concluded that the study “provides a clear demonstration of the potential to improve quality and reduce charges in modern healthcare through modification of practice patterns.” They also pointed to the need for provider and patient educational efforts focused on the advantages of MIBB.