Breast Cancer Needle Biopsy in 'Granular' Detail

Nick Mulcahy

October 05, 2012

October 5, 2012 — There are now even more reasons to use less invasive, more efficient needle biopsy in the diagnosis of breast cancer.

In a study of 1135 breast cancer patients in Vermont, needle biopsy — and the related preoperative diagnosis of cancer — improved surgical outcomes, compared with open biopsy.

"Having a preoperative diagnosis of breast cancer improved initial margin status, decreased the total number of operations, and was associated with more use of axillary node evaluation and adjuvant radiation after breast-conserving surgery," write the authors, led by Ted A. James, MD, associate professor of surgery at the University of Vermont College of Medicine in Burlington.

This study provides more evidence of the advantages of needle biopsies, which have been recommended by national medical societies for some time, the authors note.

The study appears in the October issue of the Journal of the American College of Surgeons.

Somebody needs to send a memo to surgeons in Vermont where, from 1998 to 2006, 37% of all breast cancer biopsies performed were open surgical.

The message is clear.

"The message is clear: Women are better off having a needle biopsy," said Stephen Edge, MD, chief of breast surgery at the Roswell Park Cancer Institute in Buffalo, New York, who was not involved with the study.

This study provides "more granular detail" than previous studies that have compared the 2 biopsy methods, he said, referring to the variety of performance metrics used in the analysis.

"This is not news," Dr. Edge said about the overall message that surgical outcomes are better with needle biopsy. Image-guided percutaneous needle biopsy has been widely used since the mid-1990s, and a lot of research has established its advantages in outcomes, he noted.

How to improve the uptake of needle biopsy is an ongoing issue in breast cancer surgery, Dr. Edge explained.

He believes that surgeons should be "obligated" to record in the case record why open surgical biopsy was performed. "Then the surgeon would have to indicate why the lesion is not amenable to needle biopsy," he said.

In a press statement, Dr. James speculated that "some physicians are still doing open biopsy perhaps because of limited resources or lack of awareness. Needle biopsies require special instruments, techniques, and skills that may not be available at all treatment sites."

The Vermont study provides some good news about biopsy choice. The use of needle biopsy there increased during the 9-year study period. In the early years of the study, 63.0% of all patients were biopsied with needles; in the last 3 years (2004 to 2006), that jumped to 73.6%.

How Often Is Too Often?

Dr. James and colleagues used a variety of data sources for their study: the Vermont Breast Cancer Surveillance System, the Vermont Cancer Registry, and the Centers for Medicare and Medicaid Services enrollment and claims data.

Of the 1135 breast cancer patients in the study, 713 (62.8%) underwent percutaneous needle biopsy for initial diagnosis and 422 (37.2%) underwent open biopsy.

Urban patients were more likely to have a needle biopsy than rural patients (70.6% vs 57.5%; P < .0001).

Patients who had an open biopsy were more likely to have positive margins than those who had a needle biopsy (37.4% vs 20.1%; P < .0001).

As a consequence of positive margins, open biopsy led to more reexcisions and to additional operations to assess lymph nodes, when indicated. The mean number of surgeries was lower in the needle biopsy patients than in the open biopsy patients (1.26 vs 1.63; P < .0001). A single operation was needed for 76.4% of the needle biopsy patients, but for only 44.0% of the open biopsy patients.

One of the hallmark benefits of needle biopsy is multidisciplinary presurgical planning. Among other things, this allows radiation oncologists to assess the need for their services. In this study, perhaps predictably, adjuvant breast radiation therapy was used after breast-conserving surgery more often in patients diagnosed with needle biopsy than in those diagnosed with open biopsy (65.8% vs 50.3%; P < .0001).

Overall, open biopsy was used too much in Vermont during the study period, Dr. James noted in a press statement. "The open approach should only be used in about 10% of cases," he explained.

We don't really know what the right proportion should be.

That's "shooting from the hip," Dr. Edge said about the 10% estimate.

"We don't really know what the right proportion should be," he acknowledged. With an eye toward clarifying that confusion, Dr. Edge and his colleagues at Roswell Park are planning a 5-year study of open biopsies to get a sense of the proportions and the reasons for performing them. In general, the reasons for using open biopsy include the location of the mass and when a suspicious lesion turns out not to be cancer.

The study authors and Dr. Edge have disclosed no relevant financial relationships.

J Am Coll Surg. 2012;215:562-568. Abstract