Diagnosis Methods Underused
An international panel of cancer specialists declared last week that doctors are not making full use of their most effective methods of diagnosing breast cancer--particularly when it comes to taking biopsies, which are performed on more than a million women a year.
In recent years, specialists have refined several quick, accurate needle biopsy techniques that are much easier on the patient than the traditional, surgical biopsy, in which doctors open the breast and cut out the mass to check for cancer, the panel said. According to industry estimates, most of the 1.3 million women who had biopsies of abnormal-looking mammogram spots last year got the surgical operation, leaving an incision scar on the breast.
“We know that about 80% of those biopsies find no cancer at all, and we ought to be able to spare those women” a surgical biopsy, said Dr. Melvin Silverstein, a professor of surgery at USC’s Keck School of Medicine, who headed the panel of 22 radiologists, pathologist and other specialists. At a meeting of cancer surgeons earlier last week, the panel urged colleagues to adopt newer techniques of diagnosis as quickly as possible. A switch to needle biopsy by itself “would represent an instant and enormous improvement in the diagnosis and treatment of breast cancer,” for most patients, Silverstein said.
Breast tumors are the No. 2 cancer killer of women, with some 200,000 new cases of invasive disease diagnosed each year. To screen for it, most doctors recommend that women get annual mammograms starting at age 40, and no later than age 50. When an unusual spot shows up, the next step is a biopsy, and the standard, cut-it-out procedure is highly accurate: If cancer is there, doctors almost always find it. Unfortunately, the operation often does not remove all the cancerous tissue, so doctors have to go in again. “Now you’re talking about multiple surgeries on the same breast, when with a needle biopsy we know what we’ve got before going in, and we can do it all in one shot,” Silverstein said.
Most doctors who diagnose and treat cancer see the advantages of needle biopsy for their patients. It can be performed in a doctor’s office, after all, with local anesthetic, and leaves no visible scar.
But biopsy reimbursement rates to doctors tend to favor the surgical over the needle procedure, the panel reported. In addition, reliable needle biopsies require close coordination between surgeons, radiologists and pathologists that many practitioners find time-consuming and difficult. Finally, many doctors simply do not have enough experience doing the newer biopsies to feel confident with the results.
“Training is a very big issue, we believe,” says Barbara Brenner, executive director of Breast Cancer Action, a national patient advocacy organization based in San Francisco. “In skilled hands, these techniques may be the best for patients. But you really need to ask your doctor: Does he or she know how to do it; how many of these procedures has he or she done, and how many false positives has he or she had?” when the biopsy comes back negative but it turns out the woman actually does have cancer. If the doctor has only limited experience with the newer biopsy, she says, then patients are much better off getting the traditional surgical procedure--or finding a specialist who has a track record doing the needle method. “If you have the privilege or the money to be able to do that; many of us have no choice,” she said.
It is also worthwhile for patients to ask how much experience the lab analysts who study the biopsy--the pathologists--have with needle biopsy, according to Dr. Michael Laigos, an associate professor of pathology at Stanford University and another member of the panel. “You could have a good surgeon, and a good radiologist, but if some klutz is looking at the slides, you’re not going anywhere,” he says. “I think it’s going to take an educated patient population to ask for these procedures and make sure they get done right.”
As a rule, Brenner said, people living in rural areas are less likely to find doctors skilled in performing needle biopsies. But even in big cities full of skilled specialists, many women are getting the surgical procedure unnecessarily. “I see about 50 of these women a year, and I’m just one guy,’ Silverstein said.
One of those women is Jean Sartorius, 74, of La Quinta, who recently discovered a lump in her breast. After a mammogram confirmed there was a mass, her doctor removed the lump and found that it was cancerous. But he didn’t get all the cancer out, Sartorius said. “I had to go in and have a second operation. My advice is: Find a doctor who can do the [needle] biopsy so, if you have cancer, you only have to go through one operation.”
The panel’s statement, published in the current issue of the Journal of the American College of Surgeons, was unusual because it was based not on rigorous published evidence but on the specialists’ “own experience, their knowledge of completed and ongoing research.” Yet the combined reputations of the 22 members gave the statement added weight. Among the panel’s other recommendations:
* Increase reimbursement rates for mammography and needle biopsy. “Some radiologists have stopped doing mammograms altogether because they can’t cover costs, and they’re worried about liability,” Laigos said.
* Improve cooperation between pathologists, radiologists and others involved in diagnosis. Even when done expertly, needle biopsies can miss cancers 5% to 10% of the time, Silverstein said. But by working together, radiologists and pathologists can usually spot those mistakes, he said.
* Further refinement of a diagnostic technique called sentinel lymph node biopsy, in which doctors inject dye around the tumor and watch to see whether it spreads--and where. Cancer cells often spread from the breast to a cluster of lymph nodes located near the armpit. The dye enables doctors to pinpoint exactly which lymph nodes (if any) have become cancerous, and to remove only those, instead of removing all the underarm nodes.
