Preoperative Needle Biopsy Improves the Quality of Breast Cancer Surgery

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.

Multilevel predictors of guideline concordant needle biopsy use for non-metastatic breast cancer

PURPOSE

Persistent breast cancer disparities, particularly geographic disparities, may be explained by diagnostic practice patterns such as utilization of needle biopsy, a National Quality Forum-endorsed quality metric for breast cancer diagnosis. Our objective was to assess the relationship between patient- and facility-level factors and needle biopsy receipt among women with non-metastatic breast cancer in the United States.

METHODS

We examined characteristics of women diagnosed with breast cancer between 2004 and 2015 in the National Cancer Database. We assessed the relationship between patient- (e.g., race/ethnicity, stage, age, rurality) and facility-level (e.g., facility type, breast cancer case volume) factors with needle biopsy utilization via a mixed effects logistic regression model controlling for clustering by facility.

RESULTS

In our cohort of 992,209 patients, 82.96% received needle biopsy. In adjusted models, the odds of needle biopsy receipt were higher for Hispanic (OR 1.04, Confidence Interval 1.01-1.08) and Medicaid patients (OR 1.04, CI 1.02-1.08), and for patients receiving care at Integrated Network Cancer Programs (OR 1.21, CI 1.02-1.43). Odds of needle biopsy receipt were lower for non-metropolitan patients (OR 0.93, CI 0.90-0.96), patients with cancer stage 0 or I (at least OR 0.89, CI 0.86-0.91), patients with comorbidities (OR 0.93, CI 0.91-0.94), and for patients receiving care at Community Cancer Programs (OR 0.84, CI 0.74-0.96).

CONCLUSION

This study suggests a need to account for sociodemographic factors including rurality as predictors of utilization of evidence-based diagnostic testing, such as needle biopsy. Addressing inequities in breast cancer diagnosis quality may help improve breast cancer outcomes in underserved patients.

Choosing Wisely Africa: Ten Low-Value or Harmful Practices That Should Be Avoided in Cancer Care

PURPOSE

Choosing Wisely Africa (CWA) builds on Choosing Wisely (CW) in the United States, Canada, and India and aims to identify low-value, unnecessary, or harmful cancer practices that are frequently used on the African continent. The aim of this work was to use physicians and patient advocates to identify a short list of low-value practices that are frequently used in African low- and middle-income countries.

METHODS

The CWA Task Force was convened by the African Organization for Research and Training in Cancer and included representatives from surgical, medical, and radiation oncology, the private and public sectors, and patient advocacy groups. Consensus was built through a modified Delphi process, shortening a long list of practices to a short list, and then to a final list. A voting threshold of ≥ 60% was used to include an individual practice on the short list. A consensus was reached after a series of teleconferences and voting processes.

RESULTS

Of the 10 practices on the final list, one is a new suggestion and 9 are revisions or adaptations of practices from previous CW campaign lists. One item relates to palliative care, 8 concern treatment, and one relates to surveillance.

CONCLUSION

The CWA initiative has identified 10 low-value, common interventions in Africa’s cancer practice. The success of this campaign will be measured by how the recommendations are implemented across sub-Saharan Africa and whether this improves the delivery of high-quality cancer care.

Minimally Invasive Breast Procedures: Practical Tips and Tricks

OBJECTIVE. The purpose of this article is to review the literature regarding image-guided breast procedures, including helpful tips and tricks to guide the practicing interventional breast radiologist. CONCLUSION. The successful diagnosis and treatment of breast cancer involves coordination of the multidisciplinary breast team. Optimal procedural skills for image-guided biopsy and preoperative lesion localization are paramount to the radiologists' success.

Dissemination of health technologies: Trends in the use of diagnostic test in breast cancer screening

OBJECTIVE

To analyse trends in the use of diagnostic test in breast cancer screening programs in Spain.

MATERIALS AND METHODS

Retrospective study of 542,695 women who had undergone at least one screening mammogram in any of the screening centres of three administrative regions in Spain, between 1996 and 2011. Process measures were: overall recall rate, overall invasive test rate, and rates of each type of invasive test (fine-needle aspiration biopsy, core-needle biopsy and surgical biopsy). As results measures were included detection of benign lesions rate, ductal in situ cancer rate and invasive cancer rate. Adjusted by age rates were estimated year by year for each measure and, also, the annual percent of change and its corresponding joint points.

RESULTS

Core-needle biopsy rates decreased between 1996 and 1999 and changed trends in 1999-2011 with an increase of 4.9% per year. Overall recall rate declined by 4.6% from 1999 to 2004, invasive test rate declined between 1996 and 2004 by 24.3%. Fine-needle aspiration biopsy rate changes were: a 22.4% declined per year (1996-1998), and 13.5% declined per year (1998-2005). Benign lesions rate decreased from 1996 to 2011, 21.4% per year (1996-2001) and 6.0% (2001-2011). Ductal carcinoma in situ and invasive cancer had no-statistically significant changes.

CONCLUSION

The introduction of core-needle biopsy was slow and not concurrent with the reduction in the use of other diagnostic tests, but also represented a reduction in the rate of overall diagnostic tests and in the detection rate of benigns lesions without affecting the cancer detection rates.

Breast cancer detection with short-interval follow-up compared with return to annual screening in patients with benign stereotactic or US-guided breast biopsy results

PURPOSE

To compare the cancer detection rate and stage after benign stereotactic or ultrasonography (US)-guided core breast biopsy between patients with short-interval follow-up (SIFU) and those who return to annual screening.

MATERIALS AND METHODS

The Breast Cancer Surveillance Consortium (BCSC) registry and the BCSC Statistical Coordinating Center received institutional review board approval for active and passive consent processes and a waiver of consent. All procedures were HIPAA compliant. BCSC data for 1994-2010 were used to compare ipsilateral breast cancer detection rates and tumor characteristics for diagnoses within 3 months after SIFU (3-8 months) versus return to annual screening (RTAS) mammography (9-18 months) after receiving a benign pathology result from image-guided breast biopsy.

RESULTS

In total, 17 631 biopsies with benign findings were identified with SIFU or RTAS imaging. In the SIFU group, 27 ipsilateral breast cancers were diagnosed in 10 715 mammographic examinations (2.5 cancers per 1000 examinations) compared with 16 cancers in 6916 mammographic examinations in the RTAS group (2.3 cancers per 1000 examinations) (P = .88). Sixteen cancers after SIFU (59%; 95% confidence interval [CI]: 39%, 78%) were invasive versus 12 after RTAS (75%; 95% CI: 48%, 93%). The invasive cancer rate was 1.5 per 1000 examinations after SIFU (95% CI: 0.9, 2.4) and 1.7 per 1000 examinations (95% CI: 0.9, 3.0) after RTAS (P = .70). Among invasive cancers, 25% were late stage (stage 2B, 3, or 4) in the SIFU group (95% CI: 7%, 52%) versus 27% in the RTAS group (95% CI: 6%, 61%). Positive lymph nodes were found in seven (44%; 95% CI: 20%, 70%) invasive cancers after SIFU and in three (25%; 95% CI: 5%, 57%) invasive cancers after RTAS.

CONCLUSION

Similar rates of cancer detection were found between SIFU and RTAS after benign breast biopsy with no significant differences in stage, tumor size, or nodal status, although the present study was limited by sample size. These findings suggest that patients with benign radiologic-pathologic-concordant percutaneous breast biopsy results could return to annual screening.

Trends in breast biopsies for abnormalities detected at screening mammography: a population-based study in the Netherlands

Background:

Diagnostic surgical breast biopsies have several disadvantages, therefore, they should be used with hesitation. We determined time trends in types of breast biopsies for the workup of abnormalities detected at screening mammography. We also examined diagnostic delays.

Methods:

In a Dutch breast cancer screening region 6230 women were referred for an abnormal screening mammogram between 1 January 1997 and 1 January 2011. During two year follow-up clinical data, breast imaging-, biopsy-, surgery- and pathology-reports were collected of these women. Furthermore, breast cancers diagnosed >3 months after referral (delays) were examined, this included review of mammograms and pathology specimens to determine the cause of the delays.

Results:

In 41.1% (1997–1998) and in 44.8% (2009–2010) of referred women imaging was sufficient for making the diagnosis (P<0.0001). Fine-needle aspiration cytology decreased from 12.7% (1997–1998) to 4.7% (2009–2010) (P<0.0001), percutaneous core-needle biopsies (CBs) increased from 8.0 to 49.1% (P<0.0001) and surgical biopsies decreased from 37.8 to 1.4% (P<0.0001). Delays in breast cancer diagnosis decreased from 6.7 to 1.8% (P=0.003).

Conclusion:

The use of diagnostic surgical breast biopsies has decreased substantially. They have mostly been replaced by percutaneous CBs and this replacement did not result in an increase of diagnostic delays.