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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