Recommendations inconsistent for managing high-risk breast lesions detected by core needle biopsy

Management recommendations for high-risk lesions detected by a core needle biopsy of the breast are inconsistent, according to a new study published in Current Problems in Diagnostic Radiology. Could the development of consensus recommendations improve patient care?

“The lack of consensus on management recommendations for high-risk lesions is thought to be secondary to limitations in the available medical literature, including limitations in study designs and variations in the reported upgrade rates,” wrote lead author Eniola Falomo, MD, of the Russell H. Morgan Department of Radiology and Radiological Science at Johns Hopkins School of Medicine in Baltimore, Maryland, and colleagues. “Additionally, there is currently lack of pathological consensus regarding the diagnostic criteria for high-risk lesions, which also contributes to the lack of uniformity in management recommendations.”

The authors surveyed breast imagers from 41 academic institutions throughout the United States, asking about their own management recommendations when core needle biopsy of the breast detects a high-risk lesion. Overall, surgical excision was the most common recommendation for all high-risk lesions. Ninety-five percent of respondents recommended surgical excision for atypical ductal hyperplasia (ADH) and papilloma with associated atypia, making it the most consistent recommendation studied.

“This is not surprising since ADH and atypical papillomas are the high-risk lesions that tend to be associated with the highest reported upgrade rates in the medical literature,” the authors wrote.

In addition, 76 percent of respondents recommended surgical excision for flat epithelial atypia, 73 percent recommended it for radial scar/complex sclerosing lesion, 71 percent recommended it for lobular carcinoma in-situ, 61 percent recommended it for atypical lobular hyperplasia and 39 percent recommended it for intraductal papilloma without atypia.

Ninety percent of respondents said the management recommendations are consistent within their own department. However, seven of those institutions has multiple imagers fill out the survey; “conflicting responses” were present in the responses from six of them.

“This suggests that breast imagers may be unaware of the recommendations that fellow colleagues at their academic institutions give when they encounter the diagnosis of a high-risk lesion on a core needle biopsy,” the authors wrote.

Falomo and colleagues concluded that developing consensus recommendations could make a significant difference to patients.

“These variations in management recommendations that exist between institutions can have a negative impact on patient care, as patients sometimes transfer their care to another institution due to various factors, e.g., moving to a different city, new job, insurance changes or simply to obtain a second opinion,” the authors wrote. “Receiving different management recommendations for the same pathologic diagnosis at different institutions can be very confusing for patients and could decrease the level of confidence that they have in their physicians.”

Inconsistent recommendations can also be bad for trainees, the authors added, because it could make it more difficult for them to learn how to best take care of their patients.