Eric Whitacre, MD, FACSDepartment of Surgery, The Breast Center of Southern Arizona, Tucson, AZ‘‘Preoperative Needle Biopsy as a Potential QualityMeasure in Breast Cancer Surgery,’’ by Pocock et al., is avaluable contribution to our understanding of the role ofpreoperative needle biopsy as a quality indicator in breastsurgery. The report is valuable not only because of theinformation presented, but also because it demonstrates theprocess that should be applied to any proposed qualitymeasure before it is implemented in clinical practice: Firstto develop a hypothesis, then to collect and analyze data,and then return to the hypothesis with corrections or pro-posed improvements. In this instance, the authors proposethat preoperative needle biopsy of any suspicious lesionsbefore breast surgery is a useful quality measure, demon-strate how this can be applied in clinical practice, then usetheir results to formulate a tentative benchmark. Importantpractical information about real-world limitations of themeasure are documented, and useful proposals are put forthto improve the ability to collect data and measure com-pliance in the future.Application of the scientific method to the developmentand implementation of quality measures is important forseveral reasons. First, quality measures are not always whatthey seem. The Patient Safety and Quality Committee of theAmerican Society of Breast Surgeons recently completed areview of more than 40 proposed quality measures in breastsurgery, including a measure of time from initial diagnosisof breast cancer to the time of definitive surgical manage-ment. The survey included 20 surgeons who reported onmore than 60 data elements on up to 20 breast cancerpatients each. Because the surgeons included a group ofdedicated and highly motivated breast specialists, there wasevery expectation that the interval from diagnosis todefinitive surgery would be quite short. However, this wasnot the case. In fact, there was a wide range (mean ± SD,30 ± 15 days) (Lorraine Tafra, personal communication).Surprisingly, most of the ‘‘delays’’ resulted from patientchoice. On review, it was clear that measurement of asimple time interval was not reflective of quality; instead, itwould have been necessary to measure a combination ofappropriate surgical management and patient choice aboutthe timing of care.Collection of clinical performance data is also criticalfor development of quality measures, not only to establishbenchmarks but also to show that accurate data retrieval isfeasible in practice. Although preoperative percutaneousneedle biopsy has been recognized as a quality indicator formany years, remarkably little published information isavailable to document the frequency of needle biopsycompared with open surgical biopsy, or to establish abenchmark for measurement of clinical performance.