Utilization of minimally invasive breast biopsy for the evaluation of suspicious breast lesions
Percutaneous needle biopsy, also known as minimally invasive breast biopsy (MIBB), has become the gold standard for the initial assessment of suspicious breast lesions. The purpose of this study is to determine modern rates of MIBB and open breast biopsy. The Florida Agency for Health Care Administration outpatient surgery and procedure database was queried for patients undergoing open surgical biopsy and MIBB between 2003 and 2008. Although there was an increase in the use of MIBB, the overall rate of open surgical biopsy remained high (∼30%). A reduction in the open biopsy rate from 30% to 10% could be associated with a charge reduction of >$37.2 million per year. The current rate of open surgical breast biopsy remains high. Interventions and quality initiatives are warranted, which could lead to a reduction in unnecessary operations for women, improved patient care, and a reduction in breast health care costs.
Utilization of minimally invasive breast biopsy for the
evaluation of suspicious breast lesions
Luke G. Gutwein, M.D.
, Darwin N. Ang, M.D.
, Huazhi Liu,
Julia K. Marshall, M.D.
, Steven N. Hochwald, M.D.
, Edward M. Copeland, M.D.
Stephen R. Grobmyer, M.D.
Department of Surgery, Division of Acute Care Surgery, and
Department of Radiology, University of Florida,
Gainesville, FL, USA
BACKGROUND: Percutaneous needle biopsy, also known as minimally invasive breast biopsy
(MIBB), has become the gold standard for the initial assessment of suspicious breast lesions. The
purpose of this study is to determine modern rates of MIBB and open breast biopsy.
METHODS: The Florida Agency for Health Care Administration outpatient surgery and procedure
database was queried for patients undergoing open surgical biopsy and MIBB between 2003 and 2008.
RESULTS: Although there was an increase in the use of MIBB, the overall rate of open surgical
biopsy remained high (⬃30%). A reduction in the open biopsy rate from 30% to 10% could be
associated with a charge reduction of ⬎$37.2 million per year.
CONCLUSIONS: The current rate of open surgical breast biopsy remains high. Interventions and
quality initiatives are warranted, which could lead to a reduction in unnecessary operations for women,
improved patient care, and a reduction in breast health care costs.
© 2011 Elsevier Inc. All rights reserved.
Open surgical biopsy;
Agency for Health
Given the widespread use of mammographic screening
programs, many breast cancers in the modern era are de-
tected by imaging modalities, including mammography, ul-
trasound, and magnetic resonance imaging. Suspicious le-
sions detected on breast imaging require tissue diagnosis.
Tissue diagnosis of suspicious lesions may be obtained by
using image-guided minimally invasive techniques such as
stereotactic biopsy, ultrasound-guided core needle biopsy,
or surgical approaches (needle-localized excision or exci-
sional or incisional biopsy).
consensus statements on the
management of image-detected breast cancer strongly en-
dorse the application of needle biopsy for suspicious breast
lesions for optimal management. It has been suggested that
minimally invasive breast biopsy (MIBB) is associated with
numerous beneﬁts, including fewer operations, fewer reop-
erations, less scarring, less morbidity, and facilitation of
preoperative multidisciplinary treatment planning.
thermore, for most patients with benign lesions determined
by MIBB, the need for an operation is eliminated.
Several small series have suggested that the rate of use of
surgical procedures for the diagnosis of suspicious breast
lesions is high.
In the present study, we hypothesized that
despite the advantages of MIBB, open surgical biopsy con-
Portions of this manuscript have been presented at the 2010 Annual
Scientiﬁc Meeting of the Southeastern Surgical Congress, Savannah, Geor-
gia February 22nd, 2010.
* Corresponding author. Tel.: 352-265-0169; fax: 352-265-0262.
E-mail address: email@example.comﬂ.edu
Manuscript received June 4, 2010; revised manuscript September 14,
0002-9610/$ - see front matter © 2011 Elsevier Inc. All rights reserved.
The American Journal of Surgery (2011) xx, xxx
tinues to be widely and excessively used for the initial
management of suspicious breast lesions in Florida. To test
the hypothesis, we evaluated trends in patterns of care over
a recent 5-year period in Florida and calculated the excess
charges associated with the overuse of surgical biopsies for
the evaluation of suspicious breast lesions. The ﬁndings
have signiﬁcant implications on the quality and cost of
breast care in both the state of Florida and the nation and
further suggest the need for efforts to educate and modify
current practice patterns.
This study was a population-based retrospective cohort
study based on administrative data from the Florida Agency
for Health Care Administration (AHCA) statewide outpa-
tient surgery and procedure database. The AHCA data set
was queried for all patients undergoing open surgical breast
biopsy and MIBB over the most recent 5-year period (2003–
2008) available for analysis. AHCA
oversees the licensure
of 36,000 health care facilities, health clinics, hospitals,
imaging facilities, and outpatient surgical centers in Florida.
AHCA collects data on ambulatory operations and outpa-
tient medical procedures
and shares health care data
through the Florida Center for Health Information and Pol-
icy Analysis. Data sets are available to the public for a fee.
Variations in the use of these procedures were analyzed
by hospital over time. Procedures were identiﬁed by Cur-
rent Procedural Terminology codes (Tables 1 and 2). Com-
parisons of multiple categories were tested with 1-way anal-
ysis of variance for parametric data. P values ⬍.05 were
Table 1 Current Procedural Terminology (CPT) code
deﬁnitions and associated charges
CPT Code Deﬁnition Charge*
19100 Biopsy of breast; percutaneous, needle
core, not using imaging guidance
19101 Biopsy of breast; open, incisional $10,271
19102 Biopsy of breast; percutaneous, needle
core, using imaging guidance
19103 Biopsy of breast; percutaneous,
automated vacuum assisted or
rotating biopsy device, using
19125 Excision of breast lesion identiﬁed by
preoperative placement of
radiological marker, open; single
*Charges calculated from fourth quarter 2007 to third quarter 2008
AHCA data (not including associated professional fees).
Table 2 Number and type of breast biopsies performed in Florida from fourth quarter 2003 to third quarter 2008
Current Procedural Terminology Code
19100 19101 19102 19103 19125
n%n%n%n %n %
2003 (4) 266 3.0 680 7.7 1,960 22.1 2,638 29.8 3,313 37.4
2004 (1) 239 2.5 583 6.1 2,248 23.4 2,927 30.4 3,628 37.7
2004 (2) 239 2.5 613 6.4 1,972 20.7 3,211 33.7 3,485 36.6
2004 (3) 178 2.2 555 6.8 1,648 20.3 2,826 34.8 2,913 35.9
2004 (4) 172 2.0 438 5.1 1,771 20.8 3,025 35.5 3,109 36.5
2004 828 2.3 2,189 6.1 7,639 21.3 11,989 33.5 13,135 36.7
2005 (1) 164 1.8 366 4.1 1,888 21.0 3,221 35.8 3,353 37.3
2005 (2) 170 1.9 427 4.8 2,012 22.8 3,029 34.4 3,175 36.0
2005 (3) 117 1.4 364 4.5 1,801 22.0 2,940 36.0 2,946 36.1
2005 (4) 84 1.1 399 5.0 1,624 20.4 3,001 37.7 2,858 35.9
2005 535 1.6 1,556 4.6 7,325 21.6 12,191 35.9 12,332 36.3
2006 (1) 80 .9 379 4.2 1,883 20.9 3,649 40.4 3,035 33.6
2006 (2) 76 .9 423 4.8 1,919 22.0 3,657 41.9 2,648 30.4
2006 (3) 50 .6 382 4.3 2,086 23.3 3,861 43.1 2,579 28.8
2006 (4) 75 .9 422 4.9 2,001 23.2 3,702 43.0 2,409 28.0
2006 281 .8 1,606 4.5 7,889 22.3 14,869 42.1 10,671 30.2
2007 (1) 109 1.3 372 4.3 1,951 22.7 3,711 43.1 2,469 28.7
2007 (2) 85 1.0 346 4.2 2,018 24.6 3,496 42.6 2,254 27.5
2007 (3) 73 .9 348 4.4 1,651 21.1 3,651 46.7 2,103 26.9
2007 (4) 71 .9 351 4.5 1,726 21.9 3,593 45.7 2,129 27.1
2007 338 1.0 1,417 4.4 7,346 22.6 14,451 44.5 8,955 27.5
2008 (1) 50 .6 280 3.1 1,981 22.2 4,241 47.6 2,352 26.4
2008 (2) 43 .5 298 3.5 1,792 20.8 4,301 49.9 2,180 25.3
2008 (3) 58 .7 327 3.9 1,577 18.7 4,335 51.5 2,128 25.3
2 The American Journal of Surgery, Vol xx, No x, Month 2011
In this study, we hypothesized that MIBB was more
commonly performed at academic medical centers com-
pared with nonacademic institutions. Univariate and multi-
variate logistic regressions were used to compare the rela-
tionship between biopsy techniques among academic versus
nonacademic centers. Multivariate logistic regressions were
used to determine the association between academic center
designation and biopsy type. Covariates were added to the
logistic regression to adjust for confounding factors. For
multivariate regression, the groups were matched and ad-
justed for age, race, gender, and payer status. The Cochran-
Armitage test for trend was used to determine the signiﬁ-
cance of practice trends over time.
If the hospital
participates in graduate medical education and is colocated
with a medical school in Florida, it was included as an
“academic institution” for the purposes of this study. For the
purposes of this study, academic centers in Florida included
Shands Hospital–University of Florida, Mofﬁtt Cancer Cen-
ter, Jackson Memorial Hospital, and Tampa General Hos-
pital. Charge estimates associated using the various biopsy
procedures were analyzed using charges available from the
AHCA database. All data were analyzed using SAS version
9.1 (SAS Institute Inc, Cary, NC).
During the 5-year examination period, 172,342 breast
biopsy procedures were performed in Florida and were
available for analysis. Sociodemographic data for the pa-
tients are outlined in Table 3. The total number of biopsies
performed per year is shown in Figure 1. There was no
signiﬁcant change in the total number of biopsies performed
per year over the period of study.
Over the period of study, there was a signiﬁcant change
noted in the use of various biopsy procedures (P ⬍ .0001).
Although there was a signiﬁcant increase in the percentage
of patients having MIBB over the period of study, the rate
of open surgical biopsy remained very high (approximately
30%; Fig. 2). This ﬁnding suggests that open biopsy is being
overused in Florida. In 2008, $246.8 million was charged to
the performance of breast biopsy, $112.7 million for open
surgical biopsy, and $134 million for MIBB.
The use of MIBB was more common at academic centers
compared with nonacademic centers. The unadjusted odds
ratio was 1.82 (95% conﬁdence interval, 1.74 –1.91) for
academic centers, suggesting signiﬁcantly higher rates of
MIBB at academic centers. When patients were matched
and adjusted for age, race, gender, and payer status, this
odds ratio remained signiﬁcant at 1.49 (95% conﬁdence
It has been estimated that 1.6 million breast biopsies are
performed annually in the United States.
for patients undergoing these 1.6 million procedures is im-
portant for oncologic, cosmetic, and ﬁnancial concerns.
Advantages of MIBB have been clearly outlined and in-
clude less scarring, less postprocedural morbidity, and re-
The rate of hematoma requiring treatment has
been estimated to be 20 to 100 times more common in patients
undergoing open surgical biopsy.
rates have been estimated to be 38 to 63 times more com-
mon in patients undergoing open surgical biopsy.
dition, patients with diagnoses of cancer on MIBB are less
likely to require second operations for margin management
and/or sentinel node biopsy.
Finally, MIBB before
surgical management of cancerous lesions may also allow
for multidisciplinary planning and a discussion of eligibility
for clinical trial enrollment.
Several consensus conferences have ﬁrmly recom-
mended the use of MIBB for evaluating breast lesions when
Despite this, our data suggest that open surgical
biopsy still accounts for nearly one-third of the biopsy
procedures performed in Florida in 2008. Although the use
of open surgical biopsy decreased over the study period, the
30% rate seen in 2008 is signiﬁcantly above what many
have suggested to be an appropriate rate of open biopsy
Most lesions determined to be suspicious are amenable
to MIBB. There are reasons why MIBB may not be safely
performed, including an unfavorable position of the lesion
in the breast (eg, near the chest wall, near an implant),
small breast size, active use anticoagulants for other medical
conditions, patient refusal, or the lesion not being seen on
any imaging studies.
These situations occur uncommonly
but do account for up to 5% to 10% of surgical biopsies.
MIBB is highly accurate,
and in most circumstances,
a benign needle biopsy result can prevent the need for an
open surgical procedure.
Uncommonly, situations of dis-
cordance between needle biopsy results and imaging char-
acteristics prompt performance of open surgical biopsy for
diagnosis of suspicious breast lesions.
A prior MIBB is
not associated with higher rates of surgical site infection in
patients subsequently requiring open biopsy or lumpec-
Friese et al
recently reported a high historical rate of
open surgical biopsy. In analyzing only cancer patients in
the Surveillance Epidemiology and End Results database
from 1991 to 1999, they reported a MIBB rate of only
24.3%. This low observed rate of MIBB likely corresponds
to the limited availability of MIBB technology in the early
and mid-1990s. A small study of a historical cohort of 6,282
women (1997–2002) who presented with early-stage breast
cancer to a member institution of the National Comprehen-
sive Cancer Network demonstrated a 57% rate of MIBB for
This suggested that the practice of open surgical
biopsy was prevalent even among breast cancer focused
surgeons who practiced at specialized cancer centers in the
1990s through 2002. It is unclear if the practice has changed
in more recent years at these specialized institutions or
3L.G. Gutwein et al. MIBB for suspicious breast lesions
nonspecialized institutions because of consensus recom-
mendations supporting the use of MIBB. Clarke-Pearson et
have recently reported that 36% of 465 biopsies per-
formed at a single institution were done using the open
technique. These authors also suggested that open surgical
biopsy rates were higher among nonspecialist breast sur-
geons compared with breast focused surgeons.
The present study is the largest to date and the ﬁrst to
estimate the extent of open surgical breast biopsy use for
breast lesion evaluation on a large population of unselected
patients with and without cancer. The present modern study
differs from other large series that have focused on breast
cancer patients treated in the 1990s. The present study
included all patients undergoing breast biopsy (benign and
malignant) captured in the AHCA outpatient database dur-
ing the most recent period available for analysis. This is
important because most breast biopsies are done for lesions
ultimately determined to be benign and to not require an
operation. The rate of open surgical biopsy in Florida in
2003 was 45%, similar to that in the National Comprehen-
Table 3 Sociodemographic data from breast biopsy patients in Florida (2003–2008)
Current Procedural Terminology Code
19100 19101 19102 19103 19125
(n ⫽ 2,399) (n ⫽ 8,353) (n ⫽ 37,509) (n ⫽ 69,015) (n ⫽ 55,066)
ⱕ20 30 152 454 294 170
21–30 96 345 1,682 1,229 834
31–40 321 872 4,925 6,612 4,655
41–50 636 1,974 10,737 18,155 13,424
51–60 562 1,809 8,414 16,757 13,410
61–70 414 1,580 5,958 13,618 11,645
71–80 257 1,186 3,824 9,188 8,284
⬎80 83 435 1,515 3,162 2,644
Male 40 286 373 270 164
Female 2,359 8,067 37,136 68,745 54,901
Not known 0 0001
American Indian/Eskimo/Aleut 2 9 77 83 53
Asian or Paciﬁc islander 21 65 477 613 510
Black 376 988 5,414 8,721 5,438
White 1,086 5,582 25,882 47,758 42,187
White Hispanic 766 1,354 3,656 7,504 4,985
Black Hispanic 15 23 106 184 76
Other (if none of the above) 68 218 1,038 2,600 1,179
No response (data not available) 65 114 859 1,552 638
Medicare 404 2,035 6,933 15,086 14,424
Medicare HMO 149 567 1,799 4,726 3,646
Medicaid 122 303 894 1,120 988
Medicaid HMO 59 129 492 817 586
Commercial insurance (includes self-insured and
Blue Cross Blue Shield) 166 743 1,765 3,866 4,529
Commercial HMO (includes point-of-service HMOs) 548 1,857 11,638 21,086 14,019
Commercial PPO (review provider ID card to
identify PPO network) 411 1,946 9,907 16,713 13,781
Workers’ compensation 0 2 15 15 15
Champus 30 150 736 1,086 859
VA 11 10 60 73 45
Other state/local government 62 123 500 925 605
Self pay/underinsured (no third-party coverage or
⬍30% estimated coverage) 65 295 1,178 1,599 916
Other 7 31 228 306 149
Charity 364 159 1,348 1,570 493
Kidcare (Healthy Kids, Medikids, and Children’s
Medical Services) 1 3 16 27 11
Total charges, fourth quarter 2007 to third quarter
2008 (millions) ($246.8 million) $1.2 $12.9 $33.4 $99.5 $99.8
HMO ⫽ health maintenance organization; PPO ⫽ preferred provider organization; VA ⫽ US Department of Veterans Affairs.
4 The American Journal of Surgery, Vol xx, No x, Month 2011
sive Cancer Network study of patients in the late 1990s.
The present study suggests that some improvement in the
reduction of the rate of open surgical biopsy has been
achieved over the past 5 years (Fig. 2). However, the rate of
open surgical biopsy remains unacceptably high. Further-
more, the use of open surgical biopsy is signiﬁcantly higher
at nonacademic centers compared with academic centers.
Reasons for persistently high rates of utilization of open
biopsy may be related to the lack of access to resources for
performing MIBB, a lack of education among practitioners
about the value of MIBB, or ﬁnancial factors associated
with the performance of open biopsy. This is an area clearly
worthy of further investigation.
This is the ﬁrst study to elucidate the signiﬁcant elevation in
charges associated with the persistent overuse of open surgical
breast biopsy. Open surgical biopsy is associated with higher
charges compared with MIBB (Table 1). Consequently, more
widespread use of MIBB would be associated with signiﬁcantly
less resource use.
In 2008, reducing the open surgical biopsy rate
by 20% would result in a charge reduction of $37.2 million in
Florida (on the basis of average charge data obtained from the
AHCA database). On a national level (assuming similar practice
patterns in other states), we estimate that reducing the use of open
surgical biopsy could be associated with a charge reduction into
the hundreds of millions of dollars per year. These charge esti-
mates are conservative, as they only reﬂect facility fees and do not
include the expenses related to professional fees, postsurgical
complications, and time lost from work often associated with
recovery from unnecessary surgical procedures.
A strength of this study is the fact that the AHCA database is
comprehensive, and reporting is required by Florida law for all
hospitals and outpatient facilities.
This requirement allows an
accurate estimation of the rate of unnecessary surgical breast
biopsy procedures being performed on women in Florida over the
time period of the review. It is not clear if the present results
observed in Florida are able to be generalized to other states, but
there is no speciﬁc reason to believe that the practice patterns in
Florida differ from those in other states. The present ﬁndings
suggest the importance of performing similar analyses in other
states. We analyzed only charges that are accurately recorded in
the AHCA database. Exact costs associated with the overuse of
open breast biopsy cannot accurately be determined but likely are
substantial given the charge estimates.
The present study has identiﬁed the persistent overuse of
open surgical breast biopsy procedures on a statewide level
Figure 1 Total number of biopsies performed in Florida by quarter (fourth quarter 2003 to third quarter 2008).
5L.G. Gutwein et al. MIBB for suspicious breast lesions
and the associated charges with this practice. The present
study is important because it provides a clear demonstration
of the potential to improve quality and reduce charges in
modern health care through modiﬁcation of practice pat-
terns. These ﬁndings suggest the need for further efforts to
educate practitioners and patients about the numerous ad-
vantages of MIBB for the evaluation of suspicious image
detected breast lesions. Achieving a reduction in the rate of
open surgical biopsy should remain a priority in health care
delivery, which could eliminate many unnecessary opera-
tions in women.
1. Silverstein MJ, Recht A, Lagios MD, et al. Special report: consensus
conference III. Image-detected breast cancer: state-of-the-art diagnosis
and treatment. J Am Coll Surg 2009;209:504 –20.
2. Silverstein MJ, Lagios MD, Recht A, et al. Image-detected breast
cancer: state of the art diagnosis and treatment. J Am Coll Surg
3. American Society of Breast Surgeons. Ofﬁcial consensus statement of
percutaneous needle biopsy for image detected breast abnormalities.
Available at: http://www.breastsurgeons.org. Accessed December 5,
4. Lind DS, Minter R, Steinbach B, et al. Stereotactic core biopsy reduces
the reexcision rate and the cost of mammographically detected cancer.
J Surg Res 1998;78:23– 6.
5. Clarke-Pearson EM, Jacobson AF, Boolbol SK, et al. Quality assur-
ance initiative at one institution for minimally invasive breast biopsy
as the initial diagnostic technique. J Am Coll Surg 2009;208:75– 8.
6. Silverstein M. Where’s the outrage? J Am Coll Surg 2009;208:78 –9.
7. Edge SB, Ottesen RA, Lepisto EM, et al. Surgical biopsy to diagnose
breast cancer adversely affects outcomes of breast cancer care: ﬁnding
from the National Comprehensive Cancer Network. Presented at: San
Antonio Breast Cancer Symposium; San Antonio, TX; 2005.
8. Florida Agency for Health Care Administration. Home page. Available
at: http://ahca.myﬂorida.com/#. Accessed February 23, 2010.
9. Florida Agency for Health Care Administration. Available at: http://
www.ﬂoridahealthﬁnder.gov/researchers/researchers.aspx. Accessed Feb-
ruary 23, 2010.
10. Witmer MT, Margo CE. Analysis of ophthalmology workforce and
delivery of emergency department eye care in Florida. Arch Ophthal-
11. Armitage P. Tests for linear trends in proportions and frequencies.
Biometrics 1955;11:375– 86.
12. Bruening W, Schoelles K, Treadwell J, et al. Comparative effective-
ness of core-needle biopsies and open surgical biopsy for the diagnosis
of breast lesions. Rockville, MD: Agency for Healthcare Research and
13. Friese CR, Neville BA, Edge SB, et al. Breast biopsy patterns and
outcomes in Surveillance, Epidemiology, and End Results-Medicare
data. Cancer 2009;115:716 –24.
14. Silverstein M, Levine GM. Reply to: “Minimally invasive breast
biopsy.” J Am Coll Surg 2009;209:289.
15. Paajanen H, Hermunen H. Does preoperative core needle biopsy increase
surgical site infections in breast cancer surgery? Randomized study of
antibiotic prophylaxis. Surg Infect (Larchmt) 2009;10:317–21.
Figure 2 The percentage use of breast biopsy procedures in Florida by quarter (fourth quarter 2003 to third quarter 2008). Current
Procedural Terminology code 19100 ⫽ needle biopsy (MIBB); code 19101 ⫽ incisional biopsy (open surgical biopsy); code 19102 ⫽
needle biopsy with image guidance (MIBB); code 19103 ⫽ vacuum-assisted biopsy with image guidance (MIBB); code 19125 ⫽
needle-localized biopsy (open surgical biopsy).
6 The American Journal of Surgery, Vol xx, No x, Month 2011