Unnecessary Invasive Breast Biopsies

In case you missed it, CBS News recently aired a story regarding a study which showed that approximately 600,000 women each year receive invasive breast biopsies performed by surgeons when referring them to a radiologist for a needle/stereotactic biopsy would be just as effective at confirming or ruling out cancer, would be less costly, less invasive, and would leave the patient with a far smaller scar.

If you are having trouble viewing the video below, it can also be viewed on the CBS Web site (a short commercial will air before the segment begins).

I am not a breast imager by subspecialty, but would be interested to know whether this is a pattern of referral behavior that you are seeing in your market (without mentioning specific names).

If so — what do you think radiologists can and/or should do to counter this trend?

What would you recommend that patients ask their referring physicians regarding this process?

I look forward to hearing from you.

Comments

[Phan Huynh MD]

The radiologist should discuss options of percutaneous vs surgical biopsy along with risks/benefits with the patient when a recommendation for biopsy based on clinical and/or imaging findings is rendered, typically at the diagnostic mammogram/ultrasound procedures. The patients are often not aware of their options. The radiologist can reinforce the notion that s(he)is the patient' physician and that s(he)is well trained to perform breast biopsies.

[Sally Herschorn]

I am a breast imager at an academic institution. When our breast imaging patients need a biopsy, we discuss this with them and schedule them for a biopsy. I see many patients from elsewhere being referred to surgeons because of an abnormal mammogram or ultrasound. Once the radiologist has referred the patient to a surgeon, it is likely a surgical biopsy may result; unless the surgeon is clued in to current practice and requests an image guided core or vacuum assisted biopsy. We, as radiologists, can go a long way to alleviating this problem by not referring category 4 or 5 lesions to surgeons but doing the biopsies ourselves or referring the patient to a radiology practice that performs biopsies if we happen to work where biopsies are not performed.

I have seen a few botched surgical biopsies and needle localizations for benign disease. I am more concerned about the surgical biopsies done for malignant disease. We see this frequently in patients from outlying rural hopsitals who get a surgical biopsy to make the diagnsosis but still have considerable residual disease. These women need at least one if not two more surgical procedures. If they had received an ultrasound or stereo biopsy to make the diagnosis, a cancer operation could then have been performed by a breast surgical oncologist and hopefully be successful in fewer procedures.

[Craig Hanson]

This is not an issue in the greater Seattle market, which has a large and strong community of breast imagers, many of whom are fellowship trained and do 100% breast imaging or a large percentage of their practice is dedicated to breast imaging. From talking to colleagues around the country over the years, it seems that this is more of a problem in markets where there is not a significant degree of subspecialization in breast imaging and/or breast imagers are not supported well by their groups. At our breast center we take complete charge of the patient and interface directly with the primary care providers so that the patient rarely sees a surgeon until there is a cancer diagnosis established by image-guided needle biopsy. We also have a great working relationship with our surgeons who see us as an asset and not a competitor. This relationship has been fostered by a weekly multidisciplinary breast conference we implemented 15 years ago.

[Mark Guenin, MD]

The ACR shares at least part of the blame here. For years, I've been trying without success to get the ACR to change the wording of their stereotactic and ultrasound-guided breast biopsy Practice Guidelines to reflect the fact that the tide has turned - that image-guided biopsy is now the procedure of choice when a tissue diagnosis is required.

The sentence

"Image-guided core needle biopsy (CNB) is an alternative to needle localization and surgical excisional biopsy for many image-detected breast lesions requiring tissue diagnosis"

is an historical throwback, recalling the days in the mid-90s when radiologists were reluctant to tread on the turf formerly occupied by surgeons, so we used namby-pamby language to make sure we didn't anger them. As written, that sentence gives the impression that "Surgery is the procedure of choice, but, under certain circumstances, well, I suppose you could get away with an image-guided procedure."

This news segment on CBS, and the article and editorial in this month's edition of the Journal of the American College of Surgeons that prompted the CBS piece, should erase any doubt in anyone's mind. Image-guided breast biopsy, not surgical excision, is now the procedure of choice.

As far back as 2001, in the Annals of Surgery, Monica Morrow (a breast surgeon, fer cryin' out loud) was concluding, "Stereotactic core needle biopsy is the diagnostic procedure of choice for most mammographic abnormalities" [Ann Surg. 2001 April; 233(4): 537-541].

I have proposed that the wording in the ACR Guidelines be changed to:

"Image-guided core needle biopsy (CNB) has become the procedure of choice for most image-depicted breast lesions requiring tissue diagnosis."

But I'm not holding my breath.

[David R. Pennes, M.D.]

Part of the problem of surgeons doing inappropriate surgical biopsies when a needle biopsy would suffice lies with the radiologist.

I have 'face time' with almost every diagnostic mammography patient I see, brief as it may be, even if all we did was compress out a summation shadow.

In the case of a BIRADS 4, I take a few minutes and actually show the patient her images, and point out the advantages of a needle biopsy. The statement "We think a needle stick is better than cutting" gets the point across. We have the advantage of nurses at our place who then explain a stereo or ultrasound guided needle biopsy in much greater detail.

The patient leaves the department knowing the options and if she inappropriately gets sent to a surgeon at that point, then the surgeon has to talk her out of it.

Since we started doing this, the number of inappropriate surgical biopsies has dropped to near zero.

[Phillip Shaffer, MD]

The questions are - is this the pattern we are seeing in our practice and what should we do to counter the trend.

I am a breast imager in a large metropolitan area. We have a very busy breast center and work beautifully with our surgeons.

We also staff smaller hospitals in rural areas. It is in these places that some of the surgeons are doing open biopsies still. The reason is clear - their reimbursements have been cut so severely that they are simply trying to survive. If they have to leave the community, the community will be the poorer for it.

What should we do to counter the trend? The above suggestions to immediately tell the patient that she can have a needle biopsy instead of the open surgical procedure - essentially pre-empting the surgeons discussion with the patient - is an interesting one and obviously somewhat risky for professional relations.

I think that this news report actually points the way. When women are aware that they don't have to have an open biopsy but can have a needle biopsy, of course they choose the needle biopsy. This transition can be facilitated by radiologists (orchestrated by the ACR in our push to get radiologists more credit?). More television and media exposure. A radiologist commenting on this research in every media market is important

When surgeons who recommend open biopsies lose their patients, they will change.

I am concerned, though, that we will see more surgeons trying to become amateur breast imagers to skim the cream from the top. This is the real threat to us. I think more media exposure for radiologists is important to pre-empt this move. How many in the general population understand that breast biopsies are done almost exclusively by radiologists? I bet the answer is very very few.

[catherine everett md]

I practice at one regional and two smaller county hospitals and do primarily breast and MSK imaging. Essentially no inappropriate open breast biopsies are performed, but more than half of the stereotactic or ultrasound guided biopsies are done by the surgeons themselves. They have poor quality us units in their offices, and send us only the "difficult" cases. Similarly with stereotactic biopsies, we get referrals from surgeons for the implant patients. The referral pattern from primary care/ob-gyn to surgeon is very difficult to break, even though we have made inroads primarily because our patients refer their friends. How are the surgeons trained? You must have been to an equipment manufacturer sponsored course, even out of curiosity. At most of these, well over half of the attendees are surgeons. How is the quality? At one location in a hospital-based facility, the standard of care is largely met, although we have been unable to get hospital administration to apply for ACR accreditation. At another location, the stereotactics are done at the surgeon-owned outpatient surgery center with outdated equipment, no specimen radiographs, and no post procedure mammograms.