Minimally invasive breast biopsy lags in Texas
AT THE ANNUAL MEETING OF THE SOUTHERN SURGICAL ASSOCIATION
Major Finding: During 2008, 79% of Texas women aged 66 years or older undergoing breast biopsy had a minimally-invasive procedure.
Data Source: A review of Texas Medicare claims data for 67,582 women who underwent a breast mass biopsy during 2001-2008.
Disclosures: Dr. Riall and Dr. Grobmyer had no disclosures.
PALM BEACH, FLA. – More than a fifth of women in Texas with image-detected breast abnormalities failed to undergo minimally invasive breast biopsy as recently as 2008, according to a review of statewide Medicare data, even though in 2005 a U.S. consensus panel declared the minimally invasive approach the procedure of choice and that few patients should have excisional biopsy as their initial procedure.
The analysis also revealed substantial disparities in use of minimally-invasive breast biopsy (MIBB) relative to open-surgical biopsy. In several rural health service areas (HSA) of Texas during 2005-2008, fewer than 40% of women undergoing biopsy of an image-detected breast abnormality had MIBB, Dr. Taylor S. Riall said at the annual meeting of the Southern Surgical Association. During 2005-2008, 5% of Texas HSAs had MIBB rates greater than 90%, the target set by U.S. cancer organizations. The researchers also identified low levels of MIBB use for Hispanic women, and women of low socioeconomic status.
"Our studies identify targets for interventions to improve MIBB rates, such as the Hispanic disparity and geographic variations in practice pattern," she said. "Our findings highlight that the strategies for intervention need to vary by geographic region and the underlying etiology of the failure to adopt this cost-effective practice," said Dr. Riall, a cancer surgeon at the University of Texas Medical Branch in Galveston.
"This is by far the most detailed study of MIBB [practice patterns] performed to date," commented Dr. Stephen Grobmyer, a surgical oncologist and director of breast services at the Cleveland Clinic.
The data documented that surgeons were an important contributor to MIBB underuse. Throughout the 9 years of data studied by Dr. Riall and her associates during 2001-2008, 70% of MIBB were performed by radiologists, while 26% were performed by surgeons. In contrast, surgeons performed 94% of open, excisional biopsies. When a woman’s breast mass was first identified by a surgeon, 44% of the women had MIBB; when first identified by a primary care physician, 58% had MIBB; when first identified by an oncologist, 59% had MIBB; and when first identified by a gynecologist, 67% had MIBB.
The low levels of MIBB use occurred despite increasingly strong recommendations during the period studied to move MIBB to the forefront of breast-abnormality assessment. In 2001, the first international consensus conference on image-detected breast cancer, organized by the University of Southern California, said that "percutaneous biopsy is the preferred initial diagnostic procedure in most patients with mammographically detected abnormalities"(J. Amer. Coll. Surg. 2001;193:297-302).
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All patients need minimally-invasive biopsy access
Current guidelines strongly endorse minimally-invasive breast biopsy as the standard for establishing the histologic diagnosis of a breast mass before interventional treatment. Minimally-invasive breast biopsy reduces the interval between diagnosis and starting therapy, and reduces cost compared with an open technique.
The report by Dr. Riall and her associates also touches on a legal aspect that demands our attention. Currently, about 20% of U.S. medical litigation centers on cases involving breast cancer and delayed diagnosis of these cancers. The demographic disparities in care that they identified in their study mean that it is essential for us to identify and resolve the specific barriers to performing minimally-invasive breast biopsy in certain regions and among certain groups of patients. In doing this, we could better achieve the goal of using the minimally-invasive approach in greater than 90% of patients, both in Texas and throughout the United States.
The principle reason why these barriers exist is possibly related to improper insurance coverage and inadequate access to the necessary technology. It is not surprising to me that 70% of the minimally-invasive biopsies were performed by radiologists, while only 26% were done by surgeons. Our goal should be to make access to this contemporary technology available to the entire U.S. population.
Dr. Kirby I. Bland is a surgical oncologist and professor and chairman of surgery at the University of Alabama, Birmingham. He made these comments as a designated discussant of the report. He had no disclosures.