The evaluation of national time trends, quality of care, and factors affecting the use of minimally invasive breast biopsy and open biopsy for diagnosis of breast lesions

Quality and Value in Rural Cancer Care

Nearly 60 million people reside in rural America with only 10% of US general surgeons providing for their surgical care. Rural cancer care has been maligned in the literature due to a lack of understanding of local resource limitations and to the difficulties involved in documenting the quality of local cancer care in small and rural communities. A majority of US cancer patients are diagnosed and treated in community cancer programs, many of which are Commission on Cancer Accredited and deliver care that is of high quality and value. The article discusses the components of high quality health care and offers suggestions for solo or small group rural surgeons to assist in collection of their own quality data and comparison to national benchmarks. One small rural program in Appalachian Ohio is used for a best-case example.

Gradual adoption of needle biopsy for breast lesions in a rural state

Background

Minimally invasive breast biopsy (MIBB) is the standard of care for the diagnosis of breast cancer, with consensus guidelines suggesting MIBB goals of 90% of total biopsies. In a previous study of patients in the rural state of Vermont, USA (population size of 640,000), rural breast cancer patients had open biopsies 42% of the time compared to 29% of urban breast cancer patients. The aim of this study was to assess overall population‐based biopsy trends in Vermont.

Methods

The Vermont Breast Cancer Surveillance System (VBCSS) was used to identify women receiving MIBB and excisional breast biopsies in Vermont. Patient zip code at the time of initial biopsy was used to determine the patient residence rurality by rural–urban commuting area codes (RUCA 2.0™).

Results

There were 9122 diagnostic episodes from 1999 to 2018. MIBB was the initial biopsy method in 7524 (82.5%) cases, while surgical excision was the initial biopsy method in 1598 (17.5%) cases. A linear trend fit estimated an increase of 1.3% per year (p < 0.001, 95% CI 1.1%–1.5%) in the fraction of patients undergoing MIBB. Patients living in rural areas were less likely to receive MIBB (78.5%) than those living in urban areas (94.9%), p < 0.001. Multivariate analysis showed that urban patients and those patients in the years 2014–2018 were more likely to receive MIBB (OR 5.00, 95% CI 4.13–6.05 [p < 0.05] and OR 4.41, 95%CI 3.68–5.28 [p < 0.05], respectively). The rate of MIBB for rural patients increased and met the 90% quality standard in 2013 and ultimately matched urban patient rates of MIBB in 2018.

Conclusions

For the first time, we show that MIBB usage is above 90% in the state of Vermont and that there no longer exist disparities in breast biopsies between urban and rural patients or rural/urban facilities in the state, overall.

Identifying key barriers to effective breast cancer control in rural settings

Breast cancer is the most common cancer and the second most common cause of cancer mortality among women in the United States. Efforts to promote breast cancer control in rural settings face specific challenges. Access to breast cancer screening, diagnosis, and treatment services is impaired by shortages of primary care and specialist providers, and geographic distance from medical facilities. Women in rural areas have comparable breast cancer mortality rates compared to women in urban settings, but this is due in large part to lower incidence rates and masks a substantial rural/urban disparity in breast cancer survival among women diagnosed with breast cancer. Mammography screening utilization rates are slightly lower among rural women than their urban counterparts, with a corresponding increase in late stage breast cancer. Differences in breast cancer survival persist after controlling for stage at diagnosis, largely due to disparities in access to treatment. Travel distance to treatment centers is the most substantial barrier to improved breast cancer outcomes in rural areas. While numerous interventions have been demonstrated in controlled studies to be effective in promoting treatment access and adherence, widespread dissemination in public health and clinical practice remains lacking. Efforts to improve breast cancer control in rural areas should focus on implementation strategies for improving access to breast cancer treatments.

Rural Standards and the Quality Equation

The article describes the barriers rural surgeons face when attempting to measure, analyze, and benchmark the quality and value of the care they provide for their patients. Examples of suboptimal care are presented as well as special geographic and resource-related circumstances for many of these disparities of care. The article includes in-depth descriptions of the American College of Surgeons (ACS) Optimal Resources for Surgical Quality and Safety Program and the ACS Rural Hospital Surgical Verification and Quality Improvement Program. The article concludes by discussing several documented clinical, economic, and social advantages of keeping surgical care local.

Diagnostic Performance of Ultrasound-Guided Fine-Needle Aspiration of Nonpalpable Breast Lesions in a Multidisciplinary Setting: The Institut Curie's Experience

OBJECTIVES

To assess the diagnostic performance of ultrasound-guided fine-needle aspiration (USFNA) in nonpalpable breast lesions (NPBLs) in a multidisciplinary setting.

METHODS

In total, 2,601 NPBLs underwent USFNA by a radiologist-pathologist team. Gold-standard diagnosis was based on surgery, core-needle biopsy, or 1-year imaging follow-up. USFNA's diagnostic performance was analyzed in different clinical and imaging subgroups.

RESULTS

USFNA's sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were, respectively, 92.6% (95% confidence interval [CI], 90.8%-94.2%), 96.8% (95% CI, 95.8%-97.6%), 94.8% (95% CI, 93.2%-96.1%), and 95.4% (95% CI, 94.3%-96.4%). The best PPV was achieved in Breast-Imaging Reporting and Data System (BI-RADS) categories 4C and 5 and the best NPV in BI-RADS categories 2, 3, and 4A and in patients younger than 50 years. The mitotic count, BI-RADS categories, associated palpable cancer, and age (<50 or ≥50 years) were statistically independent factors ( P  < .05) between USFNA's false-negative and true-positive results.

CONCLUSIONS

USFNA is a robust diagnostic procedure in NPBLs. Age and the BI-RADS category of the lesion are important factors determining its performance.

Ultrasound Guided Therapeutic Excisional Vacuum Assisted Biopsy in Breast Fibroadenomas

OBJECTIVE

The aim of this study was to evaluate the performance of ultrasound (US) guided Vacuum Assisted Biopsy (VAB) in the therapeutic excision of breast fibroadenomas.

MATERIALS AND METHODS

Patients who underwent excisional US guided VAB of their fibroadenomas between December 1999-May 2001 were retrospectively evaluated. Seventy-eight patients with BI-RADS category 3 and 4a lesions (one lesion per patient) with a maximum diameter smaller than 3 cm were enrolled in the study. Fifty-one of those were diagnosed with fibroadenoma. Biopsies were performed with a 11G needle using the Mammotome (Johnson & Johnson, New Jersey, USA) vacuum biopsy device. Patients were followed up with US for three years. Follow-ups were done semiannually in the first year and annually afterwards.

RESULTS

Ten patients (19%) were found to have residual lesions in the first week after the biopsy. Additional eight patients (15%) were found to have residual-recurrent lesions in their annual follow up. However, none of these eight lesions demonstrated growth during the three year follow-up. The initial size of the FA was not found to be significantly different between the lesions which were completely excised with no residue or recurrence and those which were not (p>0.05).

CONCLUSION

The VAB method for the therapeutic excision of small FAs or other benign lesions is practical and easily tolerated by patients. Lesions smaller than 3 cm should be preferred for VAB. A multidisciplinary clinical environment is necessary for each step of the treatment.

Improving Quality Metric Adherence to Minimally Invasive Breast Biopsy among Surgeons Within a Multihospital Health Care System

BACKGROUND

Minimally invasive breast biopsy (MIBB) is the procedure of choice for diagnosing breast lesions indeterminate for malignancy. Multihospital health care systems face challenges achieving systemwide adherence to standardized guidelines among surgeons with varying practice patterns. This study tested whether providing individual feedback about surgeons' use of MIBB to diagnose breast malignancies improved quality metric adherence across a large health care organization.

STUDY DESIGN

We conducted a prospective matched-pairs study to test differences (or lack of agreement) between periods before and after intervention. All analytical cases of primary breast cancer diagnosed during 2011 (period 1) and from July 2012 to June 2013 (period 2) across a multihospital health care system were reviewed for initial diagnosis by MIBB or open surgical biopsy. Open surgical biopsy was considered appropriate care only if MIBB could not be performed for reasons listed in the American Society of Breast Surgeons' quality measure for preoperative diagnosis of breast cancer. Individual and systemwide results of adherence to the MIBB metric during period 1 were sent to each surgeon in June 2012 and were later compared with period 2 results using McNemar's test of marginal homogeneity for matched binary responses.

RESULTS

Forty-six surgeons were evaluated on use of MIBB to diagnose breast cancer. In period 1, metric adherence for 100% of cases was achieved by 37 surgeons, for a systemwide 100% compliance rate of 80.4%. After notification of individual performance, 44 of 46 surgeons used MIBB solely or otherwise appropriate care to diagnose breast cancer, which improved systemwide compliance to 95.7%.

CONCLUSIONS

Providing individual and systemwide performance results to surgeons can increase self-awareness of practice patterns when diagnosing breast cancer, leading to standardized best-practice care across a large health care organization.

At what age should screening mammography be recommended for Asian women?

Although regular screening mammography has been suggested to be associated with improvements in the relative survival of breast cancer in recent years, the appropriate age to start screening mammography remains controversial. In November 2009, the United States Preventive Service Task Force published updated guidelines for breast cancer, which no longer support routine screening mammography for women aged 40–49 years, but instead, defer the choice of screening in that age group to the patient and physician. The age to begin screening differs between guidelines, including those from the Task Force, the American Cancer Society and the World Health Organization. It remains unclear how this discrepancy impacts patient survival, especially among certain subpopulations. Although the biological characteristics of breast cancer and peak age of incidence differ among different ethnic populations, there have been few reports that evaluate the starting age for screening mammography based on ethnicity. Here, we discuss the benefits and harm of screening mammography in the fifth decade, and re-evaluate the starting age for screening mammography taking ethnicity into account, focusing on the Asian population. Breast cancer incidence peaked in the fifth decade in Asian women, which has been thought to be due to a combination of biological and environmental factors. Previous reports suggest that Asian women in their 40s may receive more benefit and less harm from screening mammography than the age-matched non-Asian US population. Therefore, starting screening mammography at age 40 may be beneficial for women of Asian ethnicity in well-resourced countries, such as Japanese women who reside in Japan.