Surgical biopsy is overused. Because many women with breast problems would need a needle biopsy, which is safe, less invasive and cheaper.
Research in Florida shows that 30 percent. the biopsies performed in this state in 2003-2008 were of a surgical nature. Meanwhile, according to medical directives, the percentage should be 10 percent. lower. The results from the rest of the US are similar to those from Florida. This means that over 300 American women undergo unnecessary surgery every year, at a cost of hundreds of millions of dollars. Many of these women don’t even have cancer: around 80 percent. the biopsy results show no problems. However, for those women who have been diagnosed with cancer, a surgical biopsy means two operations instead of one, and a greater likelihood of complications than if a needle biopsy were used.
Dr.Stephen R. Grobmyer, lead author of the Florida study, said he and his colleagues chose to conduct the study because each of them had been in contact with patients who had had a surgical biopsy (also called open biopsy) from other hospitals, although in their In the case of this, a needle biopsy was sufficient. “As you meet more and more of these patients, you find that something is wrong,” says Grobmyer, who is also the director of the breast cancer research program at the University of Florida at Gainesville. The reason why open biopsies are used too often is unknown. Florida researchers say this problem may occur because not all physicians follow the latest research results and changing medical directives. They also suspect that some surgeons perform open biopsies because needle biopsies are the domain of radiologists, so the surgeon would have to refer the patient to a radiologist, thus depriving himself of the money for the procedure.
A surgical biopsy requires an incision of more than two centimeters, suturing, and sometimes a dose of sedatives or general anesthesia. It also leaves a scar. And with a needle biopsy, only local anesthesia is used and the tiny incision requires no stitches. Needle biopsy also means less risk of infection and scarring. If the anomaly in the breast is too small to be felt, but has been shown by mammography, a needle biopsy should also be supported by a visual method such as mammography, ultrasound or magnetic resonance imaging. This type of examination is often performed by a radiologist. If the tumor can be felt by touch, visual methods are not needed to guide the needle to the correct location. In such cases, the surgery may also be performed by a surgeon. “The surgeon should let the patient go if her anomaly is only visible on the mammogram,” says Dr. I. Michael Leitman, head of the general surgery department at the Beth Israel Medical Center in Manhattan. – The presence of such anomalies creates the possibility of surgical intervention, but the standards do not allow it.
Dr. Grobmyer based the study on the results of 172 patients from the Florida database. The results were published in The American Journal of Surgery. This is the largest open biopsy study ever conducted in the US. About 342 million biopsies are performed annually in America. However, in 1,6, such treatments detected cancer in only about 2010. women (261 had invasive breast cancer and 207 had its non-invasive form called ductal carcinoma in situ). Grobmyer reports in the article that hospitals charge fees of 54-5 thousand. dollars for a needle biopsy and twice that amount for an open biopsy. Doctors’ rates are $ 6-1500 for an open biopsy, and $ 2500-750 for a needle biopsy.
Dr. Elisa R. Port, head of the thoracic surgery unit at Mount Sinai Medical Center in Manhattan, who did not participate in the Grobmyer study, also admits that she often deals with patients who underwent an open biopsy instead of a needle biopsy. – I meet such patients all the time – says Dr. Port. – Surgeons hurt people and should be held accountable. Dr. Melvin J. Silverstein, a breast cancer surgeon at Hoag Memorial Hospital Presbyterian in Newport Beach, California, calls the 30 percent “outrageous” rate. surgical breast biopsy. In his opinion, some of these procedures are performed by surgeons who do not want to lose their remuneration for performing an open biopsy. “I’m sorry to make that assumption,” says Dr. Silverstein. “But I don’t know how else to explain these numbers.”
A 2009 study from the Beth Israel Medical Center in Manhattan, co-authored by Dr. Leitman, found that the 2007 breast biopsy rate varied depending on the type of surgeon. Among breast surgeons employed in hospitals and teaching at universities, this percentage was 10%. However, private breast surgeons who also operated in Beth Israel performed as much as 35%. this type of treatment. Among general surgeons who did not specialize in breast surgery (some of them worked in this hospital and some did not), the percentage rose to 37%. All doctors charge for the biopsy, so the financial incentive was the same in all cases.
Dr. Susan K. Boolbol, lead author of the study and head of the Beth Israel thoracic surgery unit, says the difference may be explained in part by the professional background of doctors. In her opinion, surgeons involved in academic activities are up to date with the latest developments in their field and work closely with radiologists. What about financial incentives? “I don’t want that to be true,” says Boolbol.
But when she asked participating surgeons why they were performing open biopsies, many replied that they wanted it. Meanwhile, she herself admits that in the last seven years only one of her patients has preferred open biopsy to needle biopsy. Dr. Boolbol reports that open biopsy rates have decreased among doctors who are familiar with the results of the new research. However, it still remains high among newly recruited surgeons. “Surgeons need to learn all the time,” says Boolbol.
Dr. Silverstein says hospitals may prohibit open biopsy except when absolutely necessary, such as in the rare instances where the needle cannot reach the area being examined. – In our hospital, we have adopted the following rule: if you can perform a biopsy with a needle, it must be done this way – says Dr. Silverstein. – If any surgeon behaves differently, he will have to explain himself to a special committee. When Silverstein asks surgeons in lectures how many open biopsies he is taking, he fails to notice a single raised hand. “Nobody wants to admit it,” he says. “Maybe we should educate our patients more to say,“ This guy removed a big chunk of my body even though I didn’t even have cancer. And now I’m deformed. Who overthrew Mubarak? Ordinary people. Maybe surgeons can also handle it.
Denise Grady, Los Angeles Times, 03.02.2011