Needle biopsy for the initial evaluation of breast abnormalities has downstream consequences for breast cancer care so superior to those of open surgical biopsy that the needle biopsy rate at a medical Center or in a surgeon's practice may be a useful quality of care benchmark, Dr. Stephen B. Edge, a fellow of the College, said at a breast cancer symposium sponsored by the Cancer Therapy and Research Center. "The use of (open) surgical biopsy for initial evaluation of breast abnormalities should be strongly discouraged," said Dr. Edge of the Roswell Park Cancer Institute, Buffalo, New York.

      This was the key conclusion of the National Comprehensive Cancer Network (NCCN) study he presented. The study demonstrated that breast cancers initially addressed by needle biopsy -- that is, fine-needle aspiration, vacuum-assisted biopsy, and needle-core biopsy -- ultimately entailed fewer operations on the breast, fewer total trips to surgery, and less time to completion of the diagnostic and surgical phases of cancer care. In addition, needle biopsy omits the need for surgery in most instances, since the majority of breast lesions prove benign.

      The primary study end-point was the need for reexcision to complete the surgical phase of treatment, with reexcision being defined as more than one surgical operation on the breast performed on separate days. In addition to using more resources, reexcision involves greater patient morbidity, greater inconvenience, and poorer cosmetic results.

      Reexcision rates varied substantially among the cancer centers. Only two institutions had reexcision rates below 50% following (open) surgical biopsy. The rate of reexcision after needle biopsy ranged from as low as 10% to as high as 40%. These observations indicate that the quality of care in breast cancer varies widely across the country, Doctor Edge said.

      A British audience member rose to note that preoperative needle biopsy is standard practice in his country. "I'm surprised that in the States there is still so much open surgical biopsy," he said. Doctor Edge replied that he, too, was "quite surprised" at the 42% surgical biopsy rate at NCCN institutions, which are reputed to be among the world's leading surgical centers for breast cancer.

      Doctor Walker adds: The Breast Cancer Surgery Center has one of the highest needle biopsy rates in the community, currently being over 75% of cancers diagnosed. A benchmark of 50% has been suggested, as noted above. Other surgeons in our community have needle biopsy rates as low as 0%. One reason for this difference is that the Federal government has chosen to reimburse surgeons at less than one-third of the rate of an open biopsy for an image-guided core needle biopsy, which is equally as difficult and time-consuming. Some surgeons, therefore, simply refuse to perform stereotactic or ultrasound-guided breast biopsy.