Why private practice surgeons perform more open breast biopsies

A Florida study assessed the rate of needle versus surgical breast biopsies over a period of five years.

What we’re talking about here are non-palpable abnormalities that are identified on screening mammography. A mammogram report will come back that assesses the relative risk of an abnormal collection of calcifications harboring an invasive or pre-invasive cancer (staged on a scale from I-V). With such data, one is obligated, as the patient’s advocate, to prove whether or not the mammogram represents true or false positive findings. This means doing a biopsy.

Two ways to go about clarifying the cancer/no cancer conundrum: A needle biopsy is scheduled in the department of radiology. The interventional radiologist uses the stereotactic images to advance a specialized needle into the midst of the concerning area and subsequently vacuum aspirate several “cores” of tissue. The technique is not without complications, but is generally very well tolerated without the complications seen from surgical biopsies (bleeding, infection, unsightly scars, etc). The sensitivity approaches 97-99%. A negative needle biopsy, although reassuring, still demands that close follow up is necessary, i.e. re-imaging of the breast within 3-6 months.

The open biopsy is a surgical procedure. And it involves two phases. One, a woman has to go to the radiology suite for directed placement of a wire such that the tip resides in the hot zone of concern. She then is wheeled to the surgical area where she is sedated and anesthetized. The surgeon then makes a 2-5 cm incision in the skin and excises a lump of breast tissue containing the area of concern, using the pre-placed wire as a guide. She goes home the same day. Bleeding and infection complicate 1-3% of these procedures. Sensitivity is 100% and, if a cancer is confirmed, phase one of treatment has already been accomplished (excision of tumor).

This is the conversation, along with the options presented, that surgeons across the country have with patients who are referred to us with an abnormal mammogram. According to the paper cited above, 70% of women opt for the needle biopsy approach, while 30% are undergoing open surgical excision. My personal feeling is that it’s always better to start small/less invasive and expand the armamentarium as needed. According to the authors of the paper, and other leading light Breast Surgeons, the idea that 30% of breast biopsies in this country are being done via the open approach is a miscarriage of justice akin to the 30 year torture/dictatorial regime of Mubarak in Egypt.

The study found that the open biopsy rate of academic breast surgeons was about 10%. Private practice general surgeons conversely performed open biopsies 37% of the time. The discrepancy was attributed to several factors — lack of knowledge by podunk non-academic surgeons, and pure greed being the main ones. Because, you know, if a surgeon refers a woman to a radiologist for biopsy of a suspicious lesion, then s/he loses the cost opportunity for an open excision. Only the holy white tower of academia prepares one for a surgical career free from financial incentive, didn’t you know?

I love this passage from the New York Times article, again from breast cancer surgeon Dr. Melvin Silverstein:

One way for hospitals to stop excess open biopsies is to ban them, Dr. Silverstein said, unless they are truly necessary, as in uncommon cases in which a needle cannot reach the spot.

“We made a rule,” he said. “If it can be done with a needle, it has to be. We embarrass you if you do an open biopsy. We bring you before a tumor board to explain.”

Hey Dr. Silverstein guess what? Not every surgeon who takes care of patients with abnormal mammograms lives within two seconds of a giant tertiary care center with experienced, reliable interventional radiologists and pathologists available at all times. We don’t all spend our Tues and Thurs morning sipping coffee for three hours in multidisciplinarian breast oncology conferences. Some Americans actually live in the rural Midwest and sparsely populated western plains. Furthermore, surgeons who do fewer breast biopsies per year than a dedicated breast oncologist will have inflated stats if a few patients opt for the open approach. Also, some women actually prefer the option of surgical removal. Even if the needle biopsy is negative, the lesion may still show up on a subsequent follow-up mammogram. The report may call it “suspicious” or maybe it will be downgraded to “close follow up recommended”. Either way, she must continue to live with it, knowing she harbors something “not quite right,” albeit almost assuredly benign, in one of her breasts. Some women, believe it or not, just don’t like to have to carry around that secret knowledge. Some women stop you short when you get to discussing the minimally invasive options: “just take it out,” they say.

Again, I am a strong proponent of stereotactic needle biopsies for the initial assessment of a concerning mammographic lesion. But this pompous posturing by some in the field of academic breast surgery is simply intolerable. Non-fellowship trained surgeons who perform lumpectomies and mastectomies are fully capable of staying up on the medical literature. We are adept at following best treatment guidelines. You don’t need a special little framed fellowship certificate on your wall to have an informed, back and forth conversation with with a patient in a very vulnerable position.

Jeffrey Parks is a general surgeon who blogs at Buckeye Surgeon.

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  • Sue Smith

    I have read many similar articles. Does anyone consider what the woman wants? I have spoken to many women who were shocked when they went for biopsy when they realized what the procedure entailed. Every physician reading this should wake up to the fact that a human being is not just a breast or a whatever part…..most women I’ve spoken to who have had these biopsy procedures had no idea what they were getting into…and described alot of pain and shock, and were traumatized by it. If a woman chooses a surgical procedure while sedated, that is up to her. Stop treating women like children.

  • AnnR

    A needle biopsy isn’t pleasant. You lie face down, fully awake, while your Radiology team gets your breast in a mammogram-type vice, and then shoots a needle-gun into it.

    My experience included re-booting the PC that displayed the image twice, and wondering whether if there was a fire drill they’d get me out of the nasty vice thing before fleeing the room.

    I wasn’t ever offered a choice, but I will note that it had a $20 co-pay verses $100 to go to a surgery center.

    • Sue Smith

      AnnR, thanks for posting. In my experience, women are not TOLD what they are in for before they go for the procedure, and as you stated, you were not offered any options. And although sedation poses risks, again, it should be the woman’s choice. We are sedated for colonoscopies. Why not have that choice when having one’s breast compressed to the width of a pancake, and then have needles shot into it? It is shocking to me that in this day and age, women are expected to tolerate this. The procedure you described above, with no sedation, is akin to torture. It is hard to have one’s breast in the “vice” (good term) even for the short period of time it takes to do a mammo. It is claustrophobic and uncomfortable. Women have to start asking about options available to them and advocate for themselves. I have not had this procedure, but I once endured a cervical biopsy, (with no local, nothing) when I was very young and did not advocate for myself. It was incredibly painful and shocking, as I was not told what to expect. Several years later I married a surgeon, and he told me that I could have had a local for it. Always ask for options!

      • Patient

        Speak for yourself. I’d much rather remain aware of my surroundings, even if what’s happening is unpleasant or even painful. I plan to have unsedated colonoscopy, which is currently offered (and advertised) by one of the GI docs in my area. There is no way I’d agree to general anesthesia or even sedation for a biopsy that could be done under local anesthesia, either.

        I agree having options is important. Just remember others’ choices may be different than yours.

  • http://www.mdwrites.com MD

    I am a radiologist who has practiced mammography in the past. Many breast surgeons in the community are extremely protective of any breast cases and will much prefer to do anything themselves, including biopsies. A surgeon told me that he is more than capable of managing breast cases, when I recommended an ultrasound guided biopsy. The way medicine is set up right now, finances often dominate what is best for the patient. A general surgeon has to eat. With all the cuts in reimbursement, I guess it must be tough making a good living only doing gallbladders all day? There is an easy way to fix this problem. Take the financial incentives out of doing procedures which are not necessary and you have a quick fix.

  • Sue Smith

    To “patient” above. I am speaking for myself, as well as sharing the opinions of many women who have undergone this procedure. I have used the words “options” and “choices” in my posts. I respect whatever option you choose for yourself. I have had three screening colonoscopies, and my choice has been sedation. I am speaking up on this issue because I have listened to several women who were literally traumatized by this experience, had no medical knowledge going in, and have actually found it so difficult to tolerate that they do not pursue further treatment. In my opinion, it is wise for a patient to be fully informed about procedures and options, and allow them to choose what it right for them, or at the very least mentally prepare themselves when armed with the information they need. The less trauma they suffer, the more likely they are to have these life saving procedures. I fully respect your choices.

    • SueCz

      Thank you for your post. My 82 yr old 1st generation Italian Aunt was in this position. Radiologist just said she had a lump, a possible cancer, and set up the appointment and told her NOTHING! Nor did he look @ her history. She is riddled with Arthritis. She has had 2 total knee replacements, hypertension, balance issues with dizziness. Her knees do not bend. She has a language barrier and is terrified to arrive @ this point in life and have this happen. She was @ the appointment alone, her husband drove her but this was all discussed in the mammogram room, no men allowed! I encouraged her to get a 2nd opinion from a breast specialist with her daughter accompanying her. Turns out the area in question is a micro-calcification that the radiologist (when the specialist called him directly) admitted is so small that he most likely would have difficulty getting the needle to or enough tissue for a bite. Repeat mammogram in 3 mos x 2 shows no change. Now though she is constantly worrying about the thing in her breast and that she did not do what a doctor said.

    • Patient

      My experiences have been just the opposite of yours: I’ve had physicians who pushed the most invasive, most medicated option every time. As MD said, look at the financial incentives for “doing more”, and all the better if patients are brainwashed into believing more is better, because that keeps them coming back willingly.

      Additionally, screening mammograms are hardly life-saving procedures. Colonoscopy? A different story, though you may not be aware they’re done without sedation much more frequently in Europe.

      SueCz: Your aunt’s primary care physician is to blame here, and I really hope she was having a diagnostic, not a screening mammogram. Screening mammograms aren’t recommended for women >75 yo, so double shame on the PCP if that’s how the “lump” was discovered.

      • SueCz

        Patient: Thanks for the reply. Good point ! Her mammogram was a screening mammogram. This is said to be a tiny barely to be seen micro-calcification, yet now she is on tract for follow up mammogram every 6 months. I do recall that screening is not recommended over 75 yrs of age. This is most likely a good example why, the incidence of normal micro-calcifications is probably higher. But once a woman is told she has a significant risk of this being a cancer, she wants it proven she does not. I am sure there will be ongoing conversations when I will bring this up. I will suggest her daughter go to her PCP visit with her next time.

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