The Quality Gap

Since 2006 the American Society of Breast Surgeons has recommended that “A major goal of modern breast medicine is to minimize the number of patients with benign lesions who undergo open surgical breast biopsies for diagnosis. Image-guided percutaneous needle biopsy is the diagnostic procedure of choice for image-detected breast abnormalities. It should be readily available to all patients with image-detected lesions. There are relatively few patients (<5%) for whom excisional biopsy should be the initial procedure for diagnosis. For patients with a diagnosis of breast cancer, the goal is to make the diagnosis with a needle and to go to the operating room one time for definitive treatment. A definitive diagnosis of breast cancer made using a minimally invasive needle biopsy permits optimal preoperative work-up, patient counseling, and surgical planning.” 

Yet data still show that 35-40 percent of women under go an open excisional biopsy as the initial diagnostic procedure.  This necessitates two surgical procedures of the breast, one for diagnosis and at least one for treatment. For women with benign biopsy results, this means they may have undergone a surgical procedure when a less invasive and far less costly procedure could have been done – and for most, surgery avoided.

A critical step in diagnosing or ruling out cancer in a breast abnormality is examination of tissue by a qualified pathologist (a physician specializing in detecting disease). A quality gap also exists in how the tissue extracted in a breast biopsy is examined by a pathologist, leading to unacceptably high rates of missed diagnosis or misdiagnosis.  This can occur with any type of biopsy. Susan G. Komen for the Cure® in 2006 issued a white paper outlining problems ranging from tissue sampling problems to reimbursement inadequacies for pathologists. Studies document problems in the way physicians present tissue to pathologists, as well as in lack of standardization for interpreting and reporting pathology findings. These problems can be reduced by having the biopsy and pathology examination performed at a breast center of excellence with physicians who specialize in breast care. 

PPOs, patients and providers all have a role in assuring that women with breast abnormalities are cared for by experienced physicians in specialized breast care settings to minimize errors or gaps in care.