乳腺癌手术前粗针活检未被充分利用
乳房粗针活检可尽量避免对乳房病灶性质未知的患者进行乳房手术。不过，对该指南依从性的差异，可能代表了医疗卫生水平的差异，并可作为不必要手术的替代衡量指标。
2021年1月29日，美国肿瘤外科学会和美国乳腺外科医师学会《肿瘤外科学报》在线发表霍普金斯大学的研究报告，对全国乳腺癌初次手术前乳房粗针活检率的差异进行了调查分析。
该研究对2015年7月～2017年6月联邦医疗保险索赔数据进行回顾分析，统计初次乳腺癌术前6个月内接受粗针活检的患者比例。将术前粗针活检率≤70%定义为异常执业模式。采用逻辑回归模型对异常执业模式相关外科医师特征进行分析。
结果，2015年7月～2017年6月，3229位外科医师进行对10万8935例女性患者进行了初次乳腺癌手术，术前粗针活检率平均86.7%。
同期，初次乳房手术前粗针活检率≤70%的医师占7.7%，≤50%的医师占2.0%。
异常执业模式显著相关乳腺外科医师特征：
小城市区（比值比：1.88，95%置信区间：1.29～2.73）
南部地区（比值比：1.84，95%置信区间：1.20～2.84）
西部地区（比值比：1.78，95%置信区间：1.11～2.86）
执业>20年（比值比：1.52，95%置信区间：1.09～2.11）
乳腺癌手术量低（研究期间<30例与≥30例相比，比值比：4.03，95%置信区间：2.75～5.90）
因此，该研究结果表明，初次乳房手术前是否进行乳房粗针活检存在显著差异，这可能代表对个别患者进行了不必要的手术。提供关于指南依从性的特定医师反馈，可能减少不必要手术的差异。
Ann Surg Oncol. 2021 Jan 29. Online ahead of print.
Underutilization of Needle Biopsy Before Breast Surgery: A Measure of Low-Value Care.
Gilmore RC, Wang P, Kaczmarski K, Hutfless S, Euhus DM, Jacobs LK, Habibi M, Lange J, Camp M, Makary MA.
Johns Hopkins University School of Medicine, Baltimore, MD, USA; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
BACKGROUND: Breast core needle biopsy (CNB) can obviate the need for breast surgery in patients with an unknown breast lesion; however, variation in compliance with this guideline may represent a disparity in health care and a surrogate measure of unnecessary surgery. We evaluated variation in breast CNB rates prior to initial breast cancer surgery.
METHODS: We performed a retrospective analysis using Medicare claims from 2015 to 2017 to evaluate the proportion of patients who received a CNB within 6 months prior to initial breast cancer surgery. Outlier practice pattern was defined as a preoperative CNB rate ≤ 70%. Logistic regression was used to evaluate surgeon characteristics associated with outlier practice pattern.
RESULTS: We identified 108,935 female patients who underwent initial breast cancer surgery performed by 3229 surgeons from July 2015 to June 2017. The mean CNB rate was 86.7%. A total of 7.7% of surgeons had a CNB performed prior to initial breast surgery ≤ 70% of the time, and 2.0% had a CNB performed ≤ 50% of the time. Outlier breast surgeons were associated with practicing in a micropolitan area (odds ratio [OR] 1.88, 95% confidence interval [CI] 1.29-2.73), in the South (OR 1.84, 95% CI 1.20-2.84) or West region (OR 1.78, 95% CI 1.11-2.86), > 20 years in practice (OR 1.52, 95% CI 1.09-2.11), and low breast cancer surgery volume (< 30 cases in the study period; OR 4.03, 95% CI 2.75-5.90).
CONCLUSIONS: Marked variation exists in whether a breast core biopsy is performed prior to initial breast surgery, which may represent unnecessary surgery on individual patients. Providing surgeon-specific feedback on guideline compliance may reduce unwarranted variation.
PMID: 33512674
DOI: 10.1245/s10434-020-09340-6