Image-guided needle breast biopsy best, but underused
Image-guided breast biopsy improves the quality of breast cancer surgery and outcomes, and reduces costs, according to a study published in the October issue of the Journal of American College of Surgeons.

Image-guided breast biopsy provides several advantages compared with open biopsy, including improved patient comfort, fewer complications, shorter recovery times and lower positive margin and re-excision rates. Several national societies recommend image-guided breast biopsy rather than open biopsy as the primary method of breast cancer diagnosis. However, utilization of the open procedure remains uneven.

Ted A. James, MD, from the department of surgery at University of Vermont College of Medicine in Burlington, and colleagues designed a study to assess diagnostic biopsy methods in Vermont and to evaluate the impact of biopsy method on the quality of surgery.

James and colleagues mined data from the Vermont Breast Cancer Surveillance System, the Vermont Cancer Registry and the Centers for Medicare & Medicaid Services to identify the study cohort. The analysis focused on 1,135 cases of breast cancer diagnosed between 1998 and 2006 in Vermont in women ages 65 and older.

The initial biopsy method was percutaneous needle biopsy in 62.8 percent of cases and open biopsy in 37.2 percent. The use of percutaneous biopsy increased over the study period, rising from 48.7 percent in 1998 to 2000, to 73.6 percent in 2004 to 2006.

The researchers found that positive margins were less common with the percutaneous approach than with open biopsy at 20.1 percent and 37.4 percent, respectively. The mean number of surgical operations for women undergoing open biopsy was 1.63 compared with 1.26 for women undergoing percutaneous needle biopsy.

“Re-excision for inadequate margins can be a source of psychological and emotional stress for patients, requires additional time from both the patient and the surgeon, and increases health care costs,” wrote James et al.

In addition, in a press release, James noted the significance of the findings for national healthcare policy, which has shifted toward declining reimbursement if patients are readmitted 30-days later for the same condition: "It's really about quality, and trying to find ways to deliver better outcomes to our patients. It's also only a matter of time before Medicare and Medicaid start looking at why patients at hospital A are going back for more re-excisions than patients at hospital B."

The analysis revealed that women in urban settings were more likely to undergo percutaneous needle biopsy than those in rural areas. The researchers offered several potential solutions to address the underutilization of needle biopsy in rural areas. These include: increased training and recruitment of clinicians experienced in percutaneous needle biopsy, establishing stronger referral patterns to tertiary facilities and greater outreach by comprehensive breast centers into the rural community.

“The observation of increasing rates of percutaneous needle biopsy over the time period of the study is certainly promising, and consistent with other reports; however, widespread incorporation remains less than ideal,” concluded James and colleagues. They suggested several strategies to improve adoption of needle biopsy: inclusion of percutaneous needle biopsy as a requirement for breast center certification, provision of training opportunities for clinicians and greater public awareness of the benefits of percutaneous needle biopsy.