The quality of breast cancer surgery improved when percutaneous needle biopsy (PNB) was performed preoperatively, and the potential impact of this procedure on the quality of patient care as well as on health care costs is substantial, according to the results of a recent study.
“Emphasis should be placed on understanding the barriers to the use of preoperative PNB and developing strategies to expand its use in the management of breast cancer,” wrote surgeon Ted A. James, MD, of the University of Vermont College of Medicine in Burlington, and colleagues, describing their findings in Journal of the American College of Surgeons (2012;215:562-568).
Both open surgical biopsy and PNB can confirm whether a suspicious breast lesion is actually malignant. Unlike an open surgical biopsy, however, PNB can be used to locate the lesion without having to open the breast. Because imaging techniques are used to extract a sample of the tissue causing concern, PNB can be performed using a topical anesthetic in an office setting or a radiology suite. The procedure is associated with less discomfort and quicker recovery time than that seen with open surgical biopsies.
Although PNB can help the patient avoid the risks and discomfort of an open surgical procedure and has the potential to provide a preoperative diagnosis of breast cancer, which helps to optimize surgical planning, the use of this technique remains an area of unexplained clinical variation, noted the investigators in their report. To perform a statewide assessment of diagnostic biopsy methods for women with breast cancer and to evaluate the impact of biopsy method on the quality of breast cancer surgery, James’s team combined data from Vermont cancer registries and Medicare to identify women diagnosed with the disease for the first time between 1998 and 2006.
The data showed that PNB was the initial biopsy method in 713 of 1,135 patients (62.8%), and that use of this method increased significantly over the course of the study, rising from 48.7% in the 1998-to-2000 period to 73.6% in the 2004-to-2006 time frame. Patients in urban settings were more likely to receive PNB than were patients living in rural areas (70.6% vs 57.5%).
The quality of breast cancer surgery as measured by initial margin status, total number of operations, and axillary evaluation improved with preoperative PNB compared with traditional open surgical biopsy. Reoperation to take out additional cancerous cells after removal of the lesion was needed in 37.4% of the patients undergoing open surgical biopsy, compared with 20.1% of patients diagnosed by needle biopsy. The open approach also led to more re-excisions to remove additional tissue for assessment of lymph nodes or other reasons: Needle-biopsy patients underwent a single operation 76.4% of the time, compared with only 44% of the time among open surgical biopsy patients.
However, PNB use varied considerably. “There are certainly some legitimate reasons to do an open biopsy, such as when the lesion is in a difficult position for the needle to reach,” acknowledged James in a statement issued by the American College of Surgeons. “But the open approach should only be used for about 10% of cases.”