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Tristán Associates Harrisburg, PA 17111
Margolin et al. [1] summarize their 5 years of experience (spanning the years 1994 through 1998) with minimally invasive breast biopsy in the September 2001 issue of the American Journal of Roentgenology, providing further evidence of the merit of these procedures. Regarding their selection of cases, they report with surprising candor that "To secure the cooperation of our breast surgeons, it was agreed that all patients with lesions that were highly suggestive of malignancy (Breast Imaging Reporting and Data System [BI-RADS] assessment category 5) [2] would be referred for surgical consultation," and "Such patients were seldom then referred for imaging-guided core biopsy." I know all too well the controversial political and turf issues that surrounded minimally invasive breast biopsy in its infancy, so I sympathize with the situation in which Margolin et al. apparently found themselves. However, there seems to be a growing dissatisfaction among the American public when patients are not presented with all options for breast biopsy but are simply sent off to surgery instead.
A Time magazine columnist [3] laments that she had not been offered a minimally invasive breast biopsy when suspicious calcifications were detected on her mammogram. Fortunately, she persevered and sought other opinions: "Luckily, getting those other opinions paid off. I discovered that I didn't need a local excisional biopsy after all. Instead, I was a candidate for a kind of minimally invasive breast biopsy called a Mammotome....Why hadn't anyone told me?"
The Wall Street Journal [4] focused on this issue not long ago, speculating that reimbursement may play a deciding role: "This cheaper, less traumatic alternative to surgery, called core needle biopsy, has been available for nearly a decade. Yet a majority of American women for years have been advised to have scarring surgical biopsies instead—in part because doctors get paid more to do surgery than nonsurgical procedures."
For many years, there has been abundant evidence of the efficacy and superiority of minimally invasive breast biopsy in general [5,6,7,8,9,10,11] and for highly suspicious masses [12] and calcifications [13] in particular. Furthermore, a survey conducted in July 1996 [14] indicated that (even at that time) more than 80% of radiologists were performing minimally invasive biopsies of highly suspicious masses and calcifications. Faced with such evidence, if a radiologist recommends a biopsy to a patient but does not include a discussion of minimally invasive options, what are the moral, ethical, and legal ramifications of remaining silent so as not to upset surgical colleagues? In particular, if a radiologist knows that silence will lead inevitably to a surgical biopsy but believes that a minimally invasive biopsy is a better choice, does he or she have a duty to speak up?
Margolin et al. [1] hint that they are no longer bound by those restrictions. In the discussion section of their article, they report, "More recently, we have performed core biopsies in more patients with suspicious (BI-RADS 5) lesions who would previously have been referred directly to surgeons." Have the restrictions been lifted, or are they simply being ignored? If neither, are Margolin's surgical colleagues required to provide objective evidence supporting their approach of surgical biopsy for BI-RADS 5 lesions? Does such evidence exist?
We started performing minimally invasive breast biopsy procedures in 1994, in the same year as Margolin and his colleagues. Fortunately, we were independent enough not to be forced to agree to the types of restrictions they faced. However, other radiology practices undoubtedly exist that are still bound by such agreements—to the detriment of their patients. If so, it is time for a change. The state of the art has moved on: minimally invasive breast biopsy has become the procedure of choice when a histologic diagnosis is indicated. Surgical biopsy should be reserved for those few instances in which minimally invasive biopsy either is technically not possible or has yielded unsatisfactory, discordant, or atypical results. And patients should be told so; otherwise, they are being deprived of the procedure of choice without their knowledge.
References
California Pacific Medical Center San Francisco, CA 94118
My colleagues and I appreciate the response of Dr. Guenin to the report of our first 5 years' experience with imaging-guided core breast biopsy [1]. It was particularly gratifying to receive a response from another radiologist in community practice. In 1993, our acquisition of stereotactic and sonography equipment for imaging-guided breast biopsy was perceived by our surgeons as a threatening encroachment on a traditional area of their practice. Among their most strenuous objections was the risk of needle-track seeding of malignant cells. Although this possibility was not a documented or established risk of core biopsy, we chose to address this concern by referring BI-RADS 5 (Breast Imaging Reporting and Data System [2]) cases for surgical consultation.
Our first 5 years of experience, therefore, largely excluded BI-RADS 5 [2] lesions. As Guenin correctly surmises, this is no longer true. Our own data and that published from other centers have now clearly established the appropriateness, efficacy, safety, cost-effectiveness, and patient acceptance of imaging-guided core breast biopsy.
In the past several years, we have encouraged all patients with breast abnormalities suitable for imaging-guided biopsy to make an appointment for this procedure at the time of their diagnostic visit. This recommendation has met with a favorable response from nearly all patients and managed-care providers and has achieved gradual acceptance by our surgeons.
My colleagues and I strongly encourage radiologists to collect and analyze imaging-guided biopsy data from their own practice. The appropriate dissemination of favorable results can not only effectively neutralize objections that may be politically or economically motivated, but also enhance and improve the care that radiologists can provide to their patients.
References
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