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Surgeons Often Inappropriately Perform Open Breast Biopsies

Posted Feb 22 2011 12:00am

All women should keep this fact in mind. If they have a suspicious breast mass and they are referred to a breast surgeon, they will be more likely to have an unnecessary open biopsy as opposed to a needle biopsy, which is much less invasive. The background for this assertion was provided in a recent article (see: Study of Breast Biopsies Finds Surgery Used Too Extensively ), Below is an excerpt from it:

Too many women with abnormal mammograms or other breast problems are undergoing surgical biopsies when they should be having needle biopsies, which are safer, less invasive and cheaper, new research shows....A study in Florida found that 30 percent of the breast biopsies there from 2003 to 2008 were surgical. The rate should be 10 percent or less, according to medical guidelines....Many of these women do not even have cancer: about 80 percent of breast biopsies are benign. For women who do have cancer, a surgical biopsy means two operations instead of one, and may make the cancer surgery more difficult than it would have been if a needle biopsy had been done. Dr. Stephen R. Grobmyer, the senior author of the Florida study, said he and his colleagues started their research because they kept seeing patients referred from other hospitals who had undergone surgical biopsies (also called open biopsies) when a needle should have been used....The reason for the overuse of open biopsies is not known. Researchers say the problem may occur because not all doctors keep up with medical advances and guidelines. But they also say that some surgeons keep doing open biopsies because needle biopsies are usually performed by radiologists. The surgeon would have to refer the patient to a radiologist, and lose the biopsy fee....If the abnormality in the breast is too small to be felt and has been detected by a mammogram or other imaging method, the needle biopsy must also be guided by imaging — mammography, ultrasound or M.R.I. — and will often have to be performed by a radiologist. If a lump can be felt, imaging is not needed to guide the needle, and a surgeon can perform it....Hospitals charge $5,000 to $6,000 for a needle biopsy, and double that for an open biopsy, according to Dr. Grobmyer’s article. Doctors’ fees for an open biopsy range from $1,500 to $2,500, he said, and $750 to $1,500 for a needle biopsy....[A surgeon] said some of the unnecessary procedures were being performed by surgeons who did not want to lose biopsy fees by sending patients to a radiologist....A study at Beth Israel Medical Center in Manhattan...published in 2009 found that the rate of open breast biopsies in 2007 varied with the type of surgeon. Breast surgeons employed by the hospital and involved in teaching had a 10 percent rate. Breast surgeons in private practice who operated at Beth Israel had a 35 percent rate. Among general surgeons, who do not specialize in breast surgery ...the rate was 37 percent. All the doctors earn biopsy fees, so they all had the same incentive. 

Surgeons are predisposed to perform surgery on patients -- that is what they are trained to do and that is what they get paid for. A similar rule applies to oncologists and to radiation therapists. The former treat cancer with chemotherapy and the latter with high-energy radiation, as opposed to opting for no treatment. Take away the profit incentive for these specialists and embed them in one of the multi-disciplinary-teams (MDT) that are common in cancer hospitals and you have a better chance for optimal treatment. The treatment biases of individual specialists get submerged into the consensus team decisions.

Surgeons who continue to perform open biopsies when a needle biopsy of a breast mass is indicated are usually well able to rationalize their decisions (see: Most Oncologic Surgeons Do Not Adhere to Cancer Care Standards ). They will also probably deny that they are motivated by the procedure fees. They will often state that the patient favored the open biopsy but they may have been subtlety influencing this decision. It's also difficult for a patient to contravene the recommendation of their surgeon (see: Some Tips for Selecting a "Good" Doctor and a "Good" Hospital ). To put the point bluntly, patients need to take more control over their medical referral path, become more knowledgeable about their condition, and seek second opinions (see: Seeking A Second Opinion as a Partial Solution to the DCIS Controversy ).

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