Surgeon-level decisions may impact needle biopsy use in breast cancer

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1. Fine needle aspiration or core biopsy for the initial diagnosis of breast cancer was underused.

2. Interventions for provider-level behavior may have a more significant impact on health care quality control than broader interventions.

Evidence Rating Level: 3 (Average)

Study Rundown: For women with limited breast cancer who are eligible for breast conserving surgery followed by radiation therapy, needle biopsy is the preferred method for initial diagnosis. With the relatively new availability of nationwide patient databases such as those from Medicare, evaluating the use of needle biopsies and other quality control measures in oncology is now possible. At the conclusion of this study, the authors found that needle biopsies were underused and that several factors, such as lack of board certification, training outside the US, low case volume, early medical school graduation, and lack of oncologic specialization had a significant impact on needle biopsy use following surgical consultation. Furthermore, patients undergoing needle biopsies were at significantly decreased risk for multiple cancer surgeries later on. Based on these results, the authors suggested that interventions at the provider level may have a more meaningful impact on quality control in oncology than previously reported. It should be noted that these findings may be limited to low-income women on Medicare with cancer treatable by breast conserving surgery and radiation.

Click to read the study in JCO

Relevant Reading: Improving the quality of cancer care: crossroads or convergence?

In-Depth [retrospective cohort]: For this retrospective analysis, a total of 89712 patients from a nationwide Medicare database spanning 2003 to 2007 were evaluated. All had confirmed breast cancer treated with breast conserving surgery and irradiation. Logistic regression was then performed to evaluate three primary outcomes: surgeon consultation before versus after biopsy, the use of needle (fine needle or core) biopsy, and the number of subsequent surgeries for cancer treatment. The authors found that needle biopsy was used in 68.4% of all patients, and of those, 53.7% had seen a surgeon prior to biopsy. Patients on Medicaid, rural residence, residence more than 8.1 miles from a radiologic facility, and no mammogram within 60 days prior to consultation were more likely to see early consultation. Following early consultation, absence of surgeon board certification, training outside the United States, low case volume, earlier medical school graduation, and lack of specialization in oncology decreased the use of needle biopsy. Patients undergoing needle biopsy were less likely to undergo multiple cancer surgeries than those without biopsy (33.7% versus 69.6%, P < 0.001).

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