Skip to main content

Advertisement

SpringerLink
Log in

Underutilization of Needle Biopsy Before Breast Surgery: A Measure of Low-Value Care

  • Health Services Research and Global Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Breast core needle biopsy (CNB) can obviate the need for breast surgery in patients with an unknown breast lesion; however, variation in compliance with this guideline may represent a disparity in health care and a surrogate measure of unnecessary surgery. We evaluated variation in breast CNB rates prior to initial breast cancer surgery.

Methods

We performed a retrospective analysis using Medicare claims from 2015 to 2017 to evaluate the proportion of patients who received a CNB within 6 months prior to initial breast cancer surgery. Outlier practice pattern was defined as a preoperative CNB rate ≤ 70%. Logistic regression was used to evaluate surgeon characteristics associated with outlier practice pattern.

Results

We identified 108,935 female patients who underwent initial breast cancer surgery performed by 3229 surgeons from July 2015 to June 2017. The mean CNB rate was 86.7%. A total of 7.7% of surgeons had a CNB performed prior to initial breast surgery ≤ 70% of the time, and 2.0% had a CNB performed ≤ 50% of the time. Outlier breast surgeons were associated with practicing in a micropolitan area (odds ratio [OR] 1.88, 95% confidence interval [CI] 1.29–2.73), in the South (OR 1.84, 95% CI 1.20–2.84) or West region (OR 1.78, 95% CI 1.11–2.86), > 20 years in practice (OR 1.52, 95% CI 1.09–2.11), and low breast cancer surgery volume (< 30 cases in the study period; OR 4.03, 95% CI 2.75–5.90).

Conclusions

Marked variation exists in whether a breast core biopsy is performed prior to initial breast surgery, which may represent unnecessary surgery on individual patients. Providing surgeon-specific feedback on guideline compliance may reduce unwarranted variation.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Bevers TB, Anderson BO, Bonaccio E, et al. Breast cancer screening and diagnosis: Clinical practice guidelines in oncology. J Natl Compr Cancer Netw. 2009;7(10):1060–96. https://doi.org/10.6004/jnccn.2009.0070.

    Article  Google Scholar 

  2. Silverstein MJ, Lagios MD, Recht A, et al. Image-Detected Breast Cancer: State of the Art Diagnosis and Treatment. J Am Coll Surg. 2005;201(4):586-597. https://doi.org/10.1016/j.jamcollsurg.2005.05.032.

    Article  PubMed  Google Scholar 

  3. nBx – Breast measure: Image or palpation-guided needle biopsy to the primary site is performed to establish diagnosis of breast cancer. 2019. Available at: https://www.facs.org/~/media/files/quality programs/cancer/ncdb/measure specs breast.ashx. Accessed 9 Jul 2020.

  4. NAPBC Standards Manual 2014 Edition. Available at: https://www.facs.org/~/media/files/quality%20programs/napbc/2014%20napbc%20standards%20manual.ashx. Accessed 12 Jul 2018.

  5. Commission on Cancer: Five Things Physicians and Patients Should Question. Choosing Wisely. Available at: https://www.choosingwisely.org/societies/commission-on-cancer/. Published 2013. Accessed 9 Jul 2020.

  6. Centers for Medicare and Medicaid Services. Physician compare national downloadable file. https://data.medicare.gov/Physician-Compare/Physician-Compare-National-Downloadable-File/mj5m-pzi6. Updated 2018. Accessed 7 Nov 2018.

  7. Centers for Medicare and Medicaid Services. Medicare data on provider practice and specialty (MD-PPAS) user documentation version 2.2. Updated 2017. Available at: https://resdac.umn.edu/sites/resdac.umn.edu/files/MD-PPAS%20User%20Documentation%20-%20Version%202.2.docx.

  8. United States Census Bureau. Geographic Terms and Concepts-Core Based Statistical Areas and Related Statistical Areas. Available at: https://www.census.gov/geo/reference/gtc/gtc_cbsa.html.

  9. Society of Surgical Oncology. SSO-Approved Breast Oncology Fellowship Training Programs. Rosemont, IL: Society of Surgical Oncology.

  10. ACGME. Complex General Surgical Oncology Programs Academic Year 2017–2018 United States. Available at: https://www.surgonc.org/fellows/surgical-oncology-fellowships/program-list/. Accessed 8 Jan 2017.

  11. The New York Times. Breast Biopsies Leave Room for Doubt, Study Finds. Available at: https://www.nytimes.com/2015/03/18/health/breast-biopsies-dcis-atypia-diagnosis-leave-room-for-doubt.html. Accessed 4 Oct 2018.

  12. Healthcare Bluebook. Available at: https://www.healthcarebluebook.com/ui/consumerfront. Accessed 4 Jun 2017.

  13. Dahabreh IJ, Wieland LS, Adam GP, Halladay C, Lau J TT. Core Needle and Open Surgical Biopsy for Diagnosis of Breast Lesions: An Update to the 2009 Report. Comp Eff Rev No. 139. 2014: AHRQ Publication No. 14-EHC040-EF. Available at: https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/breast-biopsy-update_research.pdf.

  14. Holloway CMB, Saskin R, Paszat L. Geographic variation and physician specialization in the use of percutaneous biopsy for breast cancer diagnosis. Can J Surg. 2008;51(6):453–463.

    PubMed  PubMed Central  Google Scholar 

  15. Williams RT, Yao K, Stewart AK, et al. Needle versus excisional biopsy for noninvasive and invasive breast cancer: report from the national cancer data base, 2003–2008. Ann Surg Oncol. 2011;18(13):3802–3810. https://doi.org/10.1245/s10434-011-1808-y.

    Article  PubMed  Google Scholar 

  16. Medicare.gov Part B costs. Available at: https://www.medicare.gov/your-medicare-costs/part-b-costs/part-b-costs.html.

  17. Breslin TM, Caughran J, Pettinga J, et al. Improving breast cancer care through a regional quality collaborative. Surgery. 2011;150(4):635–642. http://dx.doi.org/10.1016/j.surg.2011.07.071.

    Article  PubMed  Google Scholar 

  18. Navathe AS, Emanuel EJ. Physician peer comparisons as a nonfinancial strategy to improve the value of care. JAMA. 2016;316(17):1759–1760. https://doi.org/10.1001/jama.2016.13739.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

None.

Funding

Funding for this work was provided by the Division of Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA, and the Robert Wood Johnson Foundation at Johns Hopkins University.

Author information

Authors and Affiliations

  1. Division of Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Richard C. Gilmore MD, Peiqi Wang MD, MPH, Katerina Kaczmarski MD, Susan Hutfless PhD, David M. Euhus MD, FACS, Lisa K. Jacobs MD, Mehran Habibi MD, Julie Lange MD, FACS, Melissa Camp MD, FACS & Martin A. Makary MD, MPH, FACS

  2. Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

    Martin A. Makary MD, MPH, FACS

Authors
  1. Richard C. Gilmore MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Peiqi Wang MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Katerina Kaczmarski MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Susan Hutfless PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. David M. Euhus MD, FACS
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Lisa K. Jacobs MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Mehran Habibi MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Julie Lange MD, FACS
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Melissa Camp MD, FACS
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Martin A. Makary MD, MPH, FACS
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Study conception and design: RCG, KK, MAM, DME. Acquisition of data: PW, SH, KK. Analysis and interpretation of data: PW, SH, RCG, MAM, DME. Drafting of the manuscript: RCG, PW. Critical revision: MAM, DME, LKJ, MH, JL, MC.

Corresponding author

Correspondence to Martin A. Makary MD, MPH, FACS.

Ethics declarations

The authors declare that they have no conflicts of interest to disclose.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Gilmore, R.C., Wang, P., Kaczmarski, K. et al. Underutilization of Needle Biopsy Before Breast Surgery: A Measure of Low-Value Care. Ann Surg Oncol 28, 2485–2492 (2021). https://doi.org/10.1245/s10434-020-09340-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1245/s10434-020-09340-6

Search

Navigation