Lannin D R, Silverman J F, Walker C, Pories W J
Ann Surg. 1986 May;203(5):474-80. doi: 10.1097/00000658-198605000-00005.
Although fine needle aspiration (FNA) biopsy of the breast has been shown to be a safe and accurate technique, many surgeons question whether it is reliable enough to replace excisional biopsy. If FNA biopsy is followed by excisional biopsy for confirmation, it would seem that the cost of diagnostic work-up would be increased. In this study, however, the authors show that the major economic benefit of FNA biopsy is not that it replaces excisional biopsy, but that it allows the surgeon to triage which patients should have a 1-stage inpatient procedure with frozen section and which patients should have an excisional biopsy as an outpatient under local anesthesia. Over the past 2 years, the average cost at the East Carolina University School of Medicine of excisional outpatient biopsy (negative) was +702 +/- 348; inpatient biopsy (negative) was +1410 +/- 262; inpatient 1-stage procedure (positive) was +4135 +/- 361; and outpatient biopsy (positive) followed by inpatient procedure was +4822 +/- 586. The authors' last 100 FNA biopsies were read as 23 positive, three suspicious, 65 negative, and nine insufficient. There were no false-positives and four false-negatives, for a sensitivity of 87%, specificity of 100%, and accuracy of 96%. Using the above figures, it is possible to calculate the cost per case if all 100 cases had been biopsied by the 1-stage inpatient technique (+2227), by the 2-stage outpatient method (+1938), or guided by the FNA biopsy where positive and suspicious readings are followed by an inpatient 1-stage procedure and negative and insufficient readings followed by an outpatient 2-stage procedure (+1759). Since the FNA biopsy costs +75, it resulted in a savings per case of +393 over routine inpatient biopsy and +104 per case over routine outpatient biopsy. Computer analysis revealed that the FNA biopsy would still be economically favorable if the sensitivity of the test fell as low as 37%, the specificity as low as 80%, or if the percentage of cases of cancer in the population biopsied fell as low as 13%. Since FNA biopsy is cost effective even when followed by an excisional or frozen section biopsy for confirmation, it would be safe and reasonable to expand its use to smaller hospitals where the personnel may be initially less experienced with the technique.
尽管乳房细针穿刺抽吸活检（FNA）已被证明是一种安全且准确的技术，但许多外科医生质疑其可靠性是否足以取代切除活检。如果在FNA活检后再进行切除活检以作确认，那么诊断检查的费用似乎会增加。然而，在本研究中，作者表明FNA活检的主要经济效益并非在于它能取代切除活检，而是在于它能让外科医生对患者进行分类，确定哪些患者应接受一期住院手术并进行冰冻切片检查，哪些患者应在局部麻醉下作为门诊病人接受切除活检。在过去两年中，东卡罗来纳大学医学院门诊切除活检（阴性）的平均费用为702±348美元；住院活检（阴性）为1410±262美元；住院一期手术（阳性）为4135±361美元；门诊活检（阳性）后再进行住院手术为4822±586美元。作者对最近100例FNA活检的结果解读为23例阳性、3例可疑、65例阴性和9例结果不足。无假阳性，4例假阴性，敏感性为87%，特异性为100%，准确性为96%。利用上述数据，如果所有100例病例都采用一期住院技术进行活检（2227美元）、采用两期门诊方法进行活检（1938美元），或者在FNA活检的指导下，阳性和可疑结果后进行住院一期手术，阴性和结果不足后进行门诊两期手术（1759美元），就可以计算出每个病例的费用。由于FNA活检的费用为75美元，与常规住院活检相比，每个病例节省了393美元，与常规门诊活检相比，每个病例节省了104美元。计算机分析表明，如果该检查的敏感性低至37%，特异性低至80%，或者接受活检人群中的癌症病例百分比低至13%时，FNA活检在经济上仍然是有利的。由于即使在FNA活检后再进行切除活检或冰冻切片活检以作确认时它仍具有成本效益，因此将其应用扩展到人员对该技术最初经验较少的较小医院是安全且合理的。
