The unkindest cut of all

Surgical biopsy rather than needle biopsy is performed more often than it should be. About this I have no doubt. Anecdotal evidence of professional and financial bias in favor of surgery has been supported by surveys demonstrating that up to 80% of women undergoing biopsy see the edge of a scalpel rather than the tip of a needle. It is hard to believe that nearly a decade has passed since the first digital spot system for breast biopsy was commercialized.

It is easy to lament the low payment afforded minimally invasive biopsy compared with surgery. Medicare pays around $400 for surgical biopsy but only $128 if the job is done with a needle. Professional fees paid by private insurers are similarly unbalanced, but these do not begin to reflect the true costs. The additional requirements of surgery-general anesthesia, an OR, support staff, a recovery room-bump the total cost of surgery to $3000 or more. Then there are the personal costs to the patient: unnecessary discomfort and possible disfigurement.

Why is this happening? The fault, to paraphrase shamelessly, lies not in the stars but in ourselves. It is human nature to recommend what we know. Most ob/gyns have traditionally recommended patients to surgeons for biopsy. Surgeons do surgery.

If surgeons were given both the equipment and the financial incentive to use needle biopsy, the practice of medicine would almost certainly change. But that is a tall order. Surgeons must first want to buy the equipment, and insurers must want to change the reimbursement rate. The means to both ends might be found in a grassroots effort to educate patients about the advantages of needle biopsy.

Women’s health advocates are an influential segment of society. Some vendors have already sought the help of these groups to win support for full-field digital mammography. It makes at least as much sense to seek their help in educating women about the advantages of needle biopsy, while simultaneously pushing for changes in reimbursement rates that favor this procedure. Promoting this technology through a strategic effort coordinated by radiology vendors is not only the smart thing to do, it is the right thing to do.