Eberth Jan M, Xu Ying, Smith Grace L, Shen Yu, Jiang Jing, Buchholz Thomas A, Hunt Kelly K, Black Dalliah M, Giordano Sharon H, Whitman Gary J, Yang Wei, Shen Chan, Elting Linda, Smith Benjamin D
Jan M. Eberth, Arnold School of Public Health, University of South Carolina, Columbia, SC; and Ying Xu, Grace L. Smith, Yu Shen, Jing Jiang, Thomas A. Buchholz, Kelly K. Hunt, Dalliah M. Black, Sharon H. Giordano, Gary J. Whitman, Wei Yang, Chan Shen, Linda Elting, and Benjamin D. Smith, The University of Texas MD Anderson Cancer Center, Houston, TX.
J Clin Oncol. 2014 Jul 20;32(21):2206-16. doi: 10.1200/JCO.2013.52.8257. Epub 2014 Jun 9.
Use of needle biopsy is a proposed quality measure in the diagnosis and treatment of breast cancer, yet prior literature documents underuse. Nationally, little is known regarding the contribution of a patient's surgeon to needle biopsy use, and knowledge regarding downstream impact of needle biopsy on breast cancer care is incomplete.
Using 2003 to 2007 nationwide Medicare data from 89,712 patients with breast cancer and 12,405 surgeons, logistic regression evaluated the following three outcomes: surgeon consultation before versus after biopsy, use of needle biopsy (yes or no), and number of surgeries for cancer treatment. Multilevel analyses were adjusted for physician, patient, and structural covariates.
Needle biopsy was used in 68.4% (n = 61,353) of all patients and only 53.7% of patients seen by a surgeon before biopsy (n = 32,953/61,312). Patient factors associated with surgeon consultation before biopsy included Medicaid coverage, rural residence, residence more than 8.1 miles from a radiologic facility performing needle biopsy, and no mammogram within 60 days before consultation. Among patients with surgeon consultation before biopsy, surgeon factors such as absence of board certification, training outside the United States, low case volume, earlier decade of medical school graduation, and lack of specialization in surgical oncology were negatively correlated with receipt of needle biopsy. Risk of multiple cancer surgeries was 33.7% for patients undergoing needle biopsy compared with 69.6% for those who did not (adjusted relative risk, 2.08; P < .001).
Needle biopsy is underused in the United States, resulting in a negative impact on breast cancer diagnosis and treatment. Surgeon-level interventions may improve needle biopsy rates and, accordingly, quality of care.
在乳腺癌的诊断和治疗中，使用针吸活检是一项建议采用的质量指标，但既往文献表明其使用不足。在全国范围内，对于患者的外科医生在针吸活检使用方面的贡献知之甚少，并且关于针吸活检对乳腺癌治疗的下游影响的了解也不完整。
利用2003年至2007年全国医疗保险数据，涉及89,712例乳腺癌患者和12,405名外科医生，逻辑回归评估了以下三个结果：活检前与活检后接受外科医生会诊、针吸活检的使用情况（是或否）以及癌症治疗的手术次数。多水平分析针对医生、患者和结构协变量进行了调整。
所有患者中68.4%（n = 61,353）使用了针吸活检，而活检前接受外科医生诊治的患者中只有53.7%（n = 32,953/61,312）使用了针吸活检。与活检前接受外科医生会诊相关的患者因素包括医疗补助覆盖、农村居住、居住在距离进行针吸活检的放射科设施超过8.1英里处以及会诊前60天内未进行乳房X线检查。在活检前接受外科医生会诊的患者中，诸如未获得委员会认证、在美国境外接受培训、病例量少、医学院毕业时间较早以及缺乏外科肿瘤学专业等外科医生因素与接受针吸活检呈负相关。接受针吸活检的患者进行多次癌症手术的风险为33.7%，而未接受针吸活检的患者为69.6%（调整后的相对风险为2.08；P <.001）。
在美国，针吸活检未得到充分利用，这对乳腺癌的诊断和治疗产生了负面影响。针对外科医生层面的干预措施可能会提高针吸活检率，从而改善医疗质量。
