Surgical Biopsies for Breast Cancer are Overused in the United States

Ebert et al in an article published by JCO report their findings from a review of Medicare data from 89,712 patients with breast cancer and 12,405 surgeons, regarding three outcomes: surgeon consultation before versus after biopsy, use of needle biopsy, and number of surgeries for cancer treatment.

Surgical biopsy was the standard for breast diagnosis before the 1990s, when most patients with breast cancer presented with clinical symptoms. The growth of mammographic screening in the 1980s significantly increased the number of non-palpable lesions found that required diagnostic work-up with either needle biopsy or surgical biopsy following needle localization. In their analysis the  authors looked at factors associated with surgeon consultation before biopsy, Medicaid coverage, rural residence, residence more than 8 miles from a radiologic facility performing needle biopsy, and no mammogram within 60 days before consultation. Among patients with surgeon consultation before biopsy, factors such as absence of board certification, training outside the United States, low case volume, earlier decade of medical school graduation, and lack of specialization in surgical oncology were negatively correlated with receipt of needle biopsy.

Overall, 68.4 percent had a needle biopsy and 31.6 had a surgical biopsy. If the patient's initial appointment was with a surgeon instead of a radiologist, the surgical biopsy rate grew to nearly 50 percent.  Surgeons less likely to refer patients for a needle biopsy were those without board certification, trained outside the U.S., graduated from medical school before 1980 or not specialized in surgical oncology.

The study found that 70 percent of patients who had an excisional biopsy required multiple surgeries while only 33 percent of patients who had needle biopsies did.

As in some countries like the United Kingdom diagnosis for breast cancers is now made with needle biopsy in 95% of the cases, the authors conclude that surgical biopsy is overused in the United States, and is having a negative impact on breast cancer diagnosis and treatment.