Respuesta a cartas al editor sobre la curva de aprendizaje de punción-aspiración con aguja fina de tiroides / Reply to letters to the editor on the thyroid fine needle aspiration biopsy learning curve

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Comparative cost-effectiveness of fine needle aspiration biopsy versus image-guided biopsy, and open surgical biopsy in the evaluation of breast cancer in the era of Affordable Care Act: a changing landscape.

BACKGROUND: Proven as a time challenged and cost-effective sampling procedure, the use of FNAB has still remained controversial among the scientific community. Currently, other minimally invasive sampling procedures such as ultrasound guided fine needle aspiration biopsy (US-FNAB) and image guided core needle biopsy (IG-CNB) have become the preferred sampling procedures for evaluation of breast lesions. However, changes in the medical economy and the current growing emphasis on cost containment in the era of the Affordable Care Act make it necessary to stimulate a renewed interest in the use of FNAB as the initial diagnostic sampling procedure. This study was designed to define the changing trend in the practice of tissue sampling during the last several years, and to assess the comparative effectiveness and appropriateness of the procedure of choice for breast cancer diagnosis. METHODS: After Institutional Review Board (IRB) approval, the computer database of the Pathology Department, University of Florida, College of Medicine-Jacksonville at UF Health was retrospectively searched to identify all breast biopsy pathology reports issued during the period of January 2004 to December 2011. The inclusion criteria were all women that underwent any of the following biopsy types: FNAB, US-FNAB, IG-CNB, and surgical biopsy (SB). Diagnostic procedures were identified using current procedural terminology (CPT) codes recorded on claims from the UF Health Jacksonville patient accounting application files. The data obtained was used to determine which technique has the best cost-effectiveness in the diagnosis of breast cancer. The outcome variable for this project was a positive breast cancer diagnosis resulting from these methodologies. The predictor variable was the biopsy type used for sampling. The rate of cancer detection for each procedure was also determined. RESULTS: Among the four groups of procedures compared, the lower cost was attributed to FNAB, followed by US-FNAB, and SB. IG-CNB was the most costly procedure, even more expensive than SB. The more costs associated with IG-CNB compared to SB is related to the expense involved in the use of localizing devices and also attempts to sample a lesion more than once. More importantly, cancer yield by FNAB was the highest among all the procedures under study. CONCLUSION: This study confirms the comparative effectiveness of FNAB in the evaluation of patients with breast cancer and justifies serious endorsement of this procedure as the initial diagnostic sampling modality for its unique potential in rapid reporting and cost-saving.

Protocol biopsy: today's fine-needle aspiration biopsy?

This counter view of protocol biopsy suggests that the widespread clinical use of this technique may be questionable. It may remain primarily a valuable research tool. Cost and risk remain as major issues. Be it screening by routine computed tomography scan for apparently normal people or routine biopsy of normal functioning kidneys there is always the risk that more harm than good might be done. The proof of benefit should be strong (scientifically strong), which requires confirmation and reproducibility of controlled trials. Patients need to know how protocol biopsy is to be used (research, management or both) and the strength of the scientific evidence concerning benefit in long-term management.