Obituary: “Alas poor FNA of breast—We knew thee well!”

In the May issue of Diagnostic Cytopathology, Liao et al. made a strong case for ultrasound-guided fine-needle aspiration (FNA) of nonpalpable, noncalcified breast lesions by showing excellent positive and negative predictive values and effective probabilistic reporting for indeterminate cases.1 Yet, to what end? Who will corroborate their study or put their findings to practice as we face the imminent demise of breast FNA? Core needle biopsy (CNB) is done instead on nonpalpable breast lesions (NPBLs) and increasingly on palpable breast masses, and, partly, pathologists are to blame, despite the magnitude of evidence affirming the usefulness of breast FNA even for nonpalpable breast masses.1–5 and the fact that it is fast, safe, and cheap. Ironically, the low cost of breast FNA may have contributed most significantly to its rapid decline in the United States and its virtual replacement by the more costly and risky (i.e., more pain, bleeding, and infection) CNB. Conversely, in many managed-care organizations, Health Maintenance Organizations (HMOs) and countries with socialized medicine, breast FNA continues to thrive, because in these settings cost-efficient health care is a priority and the lessexpensive but effective diagnostic methods are preferred. Also, in these settings, physicians are salaried employees; therefore, there is no monetary incentive to attempt procedures that are the domain of another specialty or to turf procedures to other specialists because of low compensation. This is not the routine in the private sector and in academia in the United States where “turf” battles are common and expensive procedures and tests often are promoted over less-expensive ones regardless of dubious benefits in some instances. Traditionally, radiologists have performed image-guided FNAs (IGFNAs) of deep-seated lesions. So, it follows that as FNA of palpable breast lesions soared during the 1980s and 1990s, many radiologists attempted to expand IGFNA to include NPBLs. As with other IGFNAs, the presence of a pathologist was needed to assess specimen adequacy. Perhaps expectedly, many pathologists balked. They believed the interpretation of such specimens was too difficult, because the lesions were small and yielded paucicellular samples compared with palpable breast masses. Yet, with every new procedure/test/technology there is a learning curve to overcome—recall the early tribulations with exfoliative and FNA cytology. Indeed, a minority of interested cytopathologists, such as Liao et al.,1 collaborated with radiologists to establish ultimately the feasibility and merit of IGFNAs for NPBLs.1–8 However, this procedure is not the standard in most centers, partly or largely, because of another important concern for the pathologist—compensation. Pathologists have long objected to the meager reimbursement for their assistance with IGFNAs, and expansion of this service generally is not welcomed. With a time commitment for the pathologist of up to 2 hrs, this activity remains far less profitable than other services, such as the microscopic review of surgical pathology cases. One article has specifically addressed and attempted to justify appropriate reimbursement for the pathologist’s participation in FNA procedures done by radiologists and other specialists.6 In this article, Layfield et al. showed that FNAs performed by clinicians and radiologists are much more likely to be diagnostic when a pathologist is present to assist with the procedure and that the added cost of fair compensation for the pathologist is offset by the reduction in repeat studies and more expensive diagnostic tests that often are subsequently needed when the pathologist is not present to assist with the procedure. Comparable studies would not only support a lobby for better pathology compensation, but also would foster other beneficial endeavors involving IGFNA. However, rather than partner with the radiologists, expand expertise, and strive for appropriate reimbursement, patholLos Angeles County University of Southern California Healthcare Network, Los Angeles, California *Correspondence to: Camilla J. Cobb, M.D., Los Angeles County and University of Southern California Healthcare Network, 1200 N. State St., Room 2900, Los Angeles, CA 90033. Email: cobb@usc.edu Received 22 August 2004; Accepted 22 October 2004 DOI 10.1002/dc.20189 Published online in Wiley InterScience (www.interscience.wiley.com).