UF COM researchers find surgical breast biopsies overused in Florida

Thousands of women receive unnecessary surgical breast biopsies in Florida each year, UF researchers state in an article published online this week by the American Journal of Surgery.

These surgeries carry greater health risks and are more expensive than a less invasive, equally effective procedure called a needle biopsy.

“Open surgical biopsy is not accounting for 10 percent or 5 percent of initial breast biopsies, which is what’s recommended,” said Luke Gutwein, M.D., a surgical resident in UF’s department of surgery. “It’s accounting for 30 percent of initial breast biopsies, so open biopsy is incredibly over-utilized.”

Gutwein and six other UF researchers analyzed state public health data for the years 2003 to 2008 and found that about 30 percent of breast biopsies were performed through open surgery. The study reflects conditions outside Florida, too, said David P. Winchester, M.D., a professor of surgery at NorthShore University HealthSystem in Evanston, Ill., and a former chairman of the National Accreditation Program for Breast Centers.

“This is an important message and should be generalizable to other parts of the country, in terms of the desirability of using minimally invasive biopsy techniques,” he said.

Needle biopsies are usually more appropriate when the suspicious area can be seen clearly through imaging techniques, according to reports written by panels of breast health specialists. The procedure, typically performed by radiologists, requires inserting a needle through a tiny incision into the suspicious area and extracting tissue samples through the needle. The radiologist monitors the procedure via ultrasound or mammography as it takes place.

A needle biopsy leaves only a tiny dot of a scar and carries significantly less risk of infection than an open surgical biopsy. In addition, it is less painful and does not require any recovery time. Most breast biopsies show the area in question to be benign.

The latest report, published in the Journal of the American College of Surgery in 2009, stated that open breast biopsies, which require a full surgical procedure and general anesthesia, should be used to initially diagnose a lesion in less than 5 percent to 10 percent of cases.

Though use of needle biopsies increased significantly during the five years studied, the researchers found that overuse of open breast biopsies in Florida leads to $37.2 million in charges each year. The study did not take providers’ charges into account, meaning the actual amount wasted is much greater. The researchers did not analyze possible reasons for over-utilization of open breast biopsies.

“The article has clearly defined the problems with doing an open biopsy,” Winchester said. “The most compelling reason is that this may be a benign lesion. If it’s benign and needle biopsy confirms that, then surgery isn’t necessary.”

Some patients, such as those with very small breasts or whose lesions are located close to the chest wall or an implant, are not candidates for a needle biopsy.

In cases where a needle biopsy reveals cancer, physicians can begin treatment before surgery and can plan better for removal of the cancer, increasing the likelihood of extracting it entirely in a single surgery.

But Stephen Grobmyer, M.D., an associate professor of surgery, a member of the UF Shands Cancer Center and medical director of the UF Breast Center, said he regularly sees patients who have undergone an open breast biopsy when a needle biopsy would have sufficed. He said this can make multidisciplinary therapy and additional surgeries more difficult to plan and administer.

“It makes determining how big a lesion is, or if there’s any residual cancer, difficult,” Grobmyer said. “It often makes the surgery that is required more extensive. It often will mean that patients, where they could have had one operation, end up with more than one operation.”

Other researchers involved in the project include UF’s Darwin Ang, M.D., Ph.D., an assistant professor of acute care surgery; Huazhi Liu, M.S., a statistical coordinator in the department of surgery; Julia Marshall, M.D., a clinical assistant professor in the department of radiology; Steven Hochwald, M.D., an associate professor and chief of surgical oncology; and Edward Copeland III, M.D., a distinguished professor of surgery.

Grobmyer said educating health-care providers and patients alike about the issue should be a higher priority.

“We spend a lot of time talking about a lot of other things,” he said. “This is a major area in breast cancer care which is cost-inefficient. It’s bad for patients. It’s just bad for the whole system.”