Study of Breast Biopsies Finds Surgery Used Too Extensively
By DENISE GRADY
Published: February 18, 2011
Too many women with abnormal mammograms or other breast problems are undergoing surgical biopsies when they should be having needle biopsies, which are safer, less invasive and cheaper, new research shows.
Kelly Jordan for The New York Times
A study by Dr. Stephen R. Grobmyer, the director of the breast cancer program at the University of Florida in Gainesville, has found that too many surgical biopsies are being performed.
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A study in Florida found that 30 percent of the breast biopsies there from 2003 to 2008 were surgical. The rate should be 10 percent or less, according to medical guidelines.
The figures in the rest of the country are likely to be similar to Florida’s, researchers say, which would translate to more than 300,000 women a year having unnecessary surgery, at a cost of hundreds of millions of dollars. Many of these women do not even have cancer: about 80 percent of breast biopsies are benign. For women who do have cancer, a surgical biopsy means two operations instead of one, and may make the cancer surgery more difficult than it would have been if a needle biopsy had been done.
Dr. Stephen R. Grobmyer, the senior author of the Florida study, said he and his colleagues started their research because they kept seeing patients referred from otherhospitals who had undergone surgical biopsies (also called open biopsies) when a needle should have been used.
“After a while you keep seeing this, you say something’s going on here,” said Dr. Grobmyer, who is director of the breast cancer program at the University of Florida in Gainesville.
The reason for the overuse of open biopsies is not known. Researchers say the problem may occur because not all doctors keep up with medical advances and guidelines. But they also say that some surgeons keep doing open biopsies because needle biopsies are usually performed by radiologists. The surgeon would have to refer the patient to a radiologist, and lose the biopsy fee.
A surgical biopsy requires an inchlong incision, stitches and sometimes sedation or general anesthesia. It leaves a scar. A needle biopsy requires only numbing with a local anesthetic, uses a tiny incision and no stitches and carries less risk of infection and scarring.
If the abnormality in the breast is too small to be felt and has been detected by a mammogram or other imaging method, the needle biopsy must also be guided by imaging — mammography, ultrasound or M.R.I. — and will often have to be performed by a radiologist. If a lump can be felt, imaging is not needed to guide the needle, and a surgeon can perform it.
“Surgeons really have to let go of the patient when they have an image abnormality,” said Dr. I. Michael Leitman, the chief of general surgery at Beth Israel Medical Center in Manhattan. “They are giving away a potential surgery. But the standards require it. And I’m a surgeon.”
Dr. Grobmyer’s study, published by The American Journal of Surgery, is based on 172,342 biopsies entered into a state database in Florida. It is the largest study of open biopsy rates in the United States, and the first to include patients with and without cancer.
About 1.6 million breast biopsies a year are performed in the United States. But in 2010, only about 261,000 found cancer (207,000 women had invasive breast cancer, and another 54,000 had a condition called ductal carcinoma in situ, in which cancer cells have not invaded the surrounding tissue).
Hospitals charge $5,000 to $6,000 for a needle biopsy, and double that for an open biopsy, according to Dr. Grobmyer’s article. Doctors’ fees for an open biopsy range from $1,500 to $2,500, he said, and $750 to $1,500 for a needle biopsy.
A surgeon who was not part of Dr. Grobmyer’s study said she often encountered patients referred from other hospitals whose open biopsies should have been done with a needle.
“I see it all the time,” said the surgeon, Dr. Elisa R. Port, the chief of breast surgery atMount Sinai Medical Center in Manhattan. “People are causing harm and should be held accountable.”
Dr. Melvin J. Silverstein, a breast cancer surgeon at Hoag Memorial Hospital Presbyterian in Newport Beach, Calif., and a clinical professor of surgery at the University of Southern California, said it was “outrageous” that 30 percent of breast biopsies were done by surgery.
He said some of the unnecessary procedures were being performed by surgeons who did not want to lose biopsy fees by sending patients to a radiologist.
“I hate to even say that,” Dr. Silverstein said. “But I don’t know how else to explain these numbers.”
A study at Beth Israel Medical Center in Manhattan (Dr. Leitman was an author), published in 2009, found that the rate of open breast biopsies in 2007 varied with the type of surgeon.
Breast surgeons employed by the hospital and involved in teaching had a 10 percent rate. Breast surgeons in private practice who operated at Beth Israel had a 35 percent rate. Among general surgeons, who do not specialize in breast surgery (some who were on staff at the hospital and some who were not), the rate was 37 percent. All the doctors earn biopsy fees, so they all had the same incentive.
The lead author of the study, Dr. Susan K. Boolbol, chief of breast surgery at Beth Israel, said the difference could be explained, in part, by training. She said the academic breast surgeons on the hospital staff were more likely than the others to keep up with new developments in the field and to work closely with radiologists. As for the idea that the motivation was money, she said, “A huge part of me doesn’t want to believe it’s true.”
She said that when she asked surgeons in the study why they were doing open biopsies, many said patients wanted them. “My comeback was, ‘Do you think you had an inherent bias in the way you explained it?’ ” In the past seven years, she said she had only one patient choose an open biopsy over a needle biopsy.
Dr. Boolbol says some patients fear that sticking a needle into a cancer will cause it to spread, and she spends a lot of time explaining that it is not true. She said that open biopsy rates declined among surgeons at Beth Israel who were told about her study’s findings, but newcomers still tended to have higher rates.
“This is a constant education process for surgeons,” she said.
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.”
Dr. Silverstein says that when he lectures and asks how many surgeons in the audience perform open biopsies, no hands go up. “Nobody will admit it,” he said.
He said there is more to be gained by taking his message straight to the patients. He and other doctors say that any woman who is told that she needs a surgical biopsy should ask why, and consider a second opinion.
“Maybe we have to get patients to say, ‘This guy took a big chunk out of me and I didn’t even have cancer, and now I’m deformed,’ ” Dr. Silverstein said. “Who just overthrew Mubarak? The people. This is exactly the same thing.”
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