Needle Biopsy Underused in the United States, Adversely Affecting Breast Cancer Treatment
In a study reported in the Journal of Clinical Oncology, Eberth et al found that needle biopsy is underused in diagnosis and treatment of breast cancer, with a number of surgeon factors contributing to underuse.
The study involved Medicare data from 89,712 patients with breast cancer seen between 2003 and 2007 and 12,405 surgeons. Factors analyzed included surgeon consultation before vs after biopsy, use of needle biopsy, and number of surgeries for cancer treatment.
Needle Biopsy Rates
Needle biopsy was used in 68% of all patients, but in only 54% of patients seen by a surgeon before biopsy. A total of 68% of patients had surgeon consultation before biopsy. Among the 54% of patients with surgeon consultation before biopsy, 38% underwent biopsy by their surgeon and 15% underwent biopsy by a nonsurgeon, typically a radiologist.
The proportion of patients undergoing biopsy increased from 61% in 2003 to 77% in 2007. Rates ranged geographically from a low of 24% (Bismarck, North Dakota) to a high of 97% (Lynchburg, Virginia).
Factors in Consultation Before Biopsy
On multivariate analysis, patient characteristics significantly associated with surgeon consultation before biopsy (all P < .001) included older age, black race, Medicaid coverage, higher Charlson comorbidity score, earlier year of diagnosis, longer distance to the nearest radiologic facility performing needle biopsy, no mammogram in the 60 days before consultation, and visit with a primary care provider within 60 days before consultation.
Patient Factors for Biopsy
On multivariate analysis, patient factors significantly associated with increased risk of not receiving needle biopsy for patients with surgeon consultation before biopsy (all P < .05) were Medicaid coverage (relative risk [RR] = 1.06 vs no Medicaid), earlier year of diagnosis (RRs = 1.15–1.34 for 2003–2005 vs 2007), Charlson comorbidity score (RRs = 1.04 and 1.08 for ≥ 3 and 2 vs ≤ 1), no chemotherapy (RR = 1.15), rural residence (RR = 1.07), distance to nearest radiologic facility performing biopsy (RR = 1.04 for ≥ 8.2 vs ≤ 0.6 miles), and mammography before consultation or biopsy (RR = 1.26).
Surgeon Factors for Biopsy
On multivariate analysis, surgeon factors significantly associated with increased risk of not receiving needle biopsy for patients with consultation before biopsy (all P < .05) were lack of board certification (needle biopsy rate of 39% vs 55% for board-certified surgeons, RR = 1.32), training outside the United States (44% vs 55%, RR = 1.17), earlier decade of medical school graduation (51% vs 64% for before 1980 vs 2000s, RR = 1.49), low case volume (40% vs 64% for 1–5 vs > 20 patients in cohort, RR = 1.66), and specialization in general surgery (52% vs 63% for surgical oncologists, RR =1.11).
Risk for Multiple Surgeries
Multiple breast cancer surgeries were performed in 34% of women who underwent needle biopsy vs 70% of those who did not (adjusted RR = 2.08, P < .001, for no biopsy vs biopsy) Among women undergoing biopsy, multiple surgeries were performed in 33% when biopsy was performed by a nonsurgeon vs 35% when biopsy was performed by a surgeon (adjusted RR = 1.03, P = .005, for surgeon vs nonsurgeon).
The investigators concluded, “Needle biopsy is underused in the United States, resulting in a negative impact on breast cancer diagnosis and treatment. Surgeon-level interventions may improve needle biopsy rates and, accordingly, quality of care.”
Benjamin D. Smith, MD, of The University of Texas MD Anderson Cancer Center, is the corresponding author for the Journal of Clinical Oncology article.
The study was supported by the Cancer Prevention and Research Institute of Texas, The University of Texas MD Anderson Cancer Center, American Cancer Society, Department of Defense, National Cancer Institute, and Ann and Clarence Cazalot. For full disclosures of the study authors, visit jco.ascopubs.org.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
