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Lincoln SE, Yang S, Cline MS, Kobayashi Y, Zhang C, Topper S, Haussler D, Paten B, Nussbaum RL. Consistency of BRCA1 and BRCA2 Variant Classifications Among Clinical Diagnostic Laboratories. JCO Precis Oncol 2017; 1:PO.16.00020. [PMID: 28782058 PMCID: PMC5542009 DOI: 10.1200/po.16.00020] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Genetic tests of the cancer predisposition genes BRCA1 and BRCA2 inform significant clinical decisions for both physicians and patients. Most uncovered variants are benign, and determining which few are pathogenic (disease-causing) is sometimes challenging and can potentially be inconsistent among laboratories. The ClinVar database makes de-identified clinical variant classifications from multiple laboratories publicly available for comparison and review, per recommendations of the American Medical Association (AMA), the American College of Medical Genetics (ACMG), the National Society for Genetic Counselors (NSGC), and other organizations. METHODS Classifications of more than 2000 BRCA1/2 variants in ClinVar representing approximately 22,000 patients were dichotomized as clinically actionable or not actionable and compared across up to seven laboratories. The properties of these variants and classification differences were investigated in detail. RESULTS Per-variant concordance was 98.5% (CI 97.9%-99.0%). All discordant variants were rare; thus, per patient concordance was estimated to be higher: 99.7%. ClinVar facilitated resolution of many of the discordant variants, and concordance increased to 99.0% per variant and 99.8% per patient when reclassified (but not yet resubmitted) variants and submission errors were addressed. Most of the remaining discordances appeared to involve either legitimate differences in expert judgment regarding particular scientific evidence, or were classifications that predated availability of important scientific evidence. CONCLUSIONS Significant classification disagreements among the professional clinical laboratories represented in ClinVar are infrequent yet important. The unrestricted sharing of clinical genetic data allows detailed interlaboratory quality control and peer review, as exemplified by this study.
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Affiliation(s)
- Stephen E. Lincoln
- Stephen E. Lincoln, Shan Yang, Yuya Kobayashi, and Scott Topper, Invitae; Robert L. Nussbaum, University of California, San Francisco, San Francisco; and Melissa S. Cline, Can Zhang, David Haussler, and Benedict Paten, University of California, Santa Cruz, Santa Cruz, CA
| | - Shan Yang
- Stephen E. Lincoln, Shan Yang, Yuya Kobayashi, and Scott Topper, Invitae; Robert L. Nussbaum, University of California, San Francisco, San Francisco; and Melissa S. Cline, Can Zhang, David Haussler, and Benedict Paten, University of California, Santa Cruz, Santa Cruz, CA
| | - Melissa S. Cline
- Stephen E. Lincoln, Shan Yang, Yuya Kobayashi, and Scott Topper, Invitae; Robert L. Nussbaum, University of California, San Francisco, San Francisco; and Melissa S. Cline, Can Zhang, David Haussler, and Benedict Paten, University of California, Santa Cruz, Santa Cruz, CA
| | - Yuya Kobayashi
- Stephen E. Lincoln, Shan Yang, Yuya Kobayashi, and Scott Topper, Invitae; Robert L. Nussbaum, University of California, San Francisco, San Francisco; and Melissa S. Cline, Can Zhang, David Haussler, and Benedict Paten, University of California, Santa Cruz, Santa Cruz, CA
| | - Can Zhang
- Stephen E. Lincoln, Shan Yang, Yuya Kobayashi, and Scott Topper, Invitae; Robert L. Nussbaum, University of California, San Francisco, San Francisco; and Melissa S. Cline, Can Zhang, David Haussler, and Benedict Paten, University of California, Santa Cruz, Santa Cruz, CA
| | - Scott Topper
- Stephen E. Lincoln, Shan Yang, Yuya Kobayashi, and Scott Topper, Invitae; Robert L. Nussbaum, University of California, San Francisco, San Francisco; and Melissa S. Cline, Can Zhang, David Haussler, and Benedict Paten, University of California, Santa Cruz, Santa Cruz, CA
| | - David Haussler
- Stephen E. Lincoln, Shan Yang, Yuya Kobayashi, and Scott Topper, Invitae; Robert L. Nussbaum, University of California, San Francisco, San Francisco; and Melissa S. Cline, Can Zhang, David Haussler, and Benedict Paten, University of California, Santa Cruz, Santa Cruz, CA
| | - Benedict Paten
- Stephen E. Lincoln, Shan Yang, Yuya Kobayashi, and Scott Topper, Invitae; Robert L. Nussbaum, University of California, San Francisco, San Francisco; and Melissa S. Cline, Can Zhang, David Haussler, and Benedict Paten, University of California, Santa Cruz, Santa Cruz, CA
| | - Robert L. Nussbaum
- Stephen E. Lincoln, Shan Yang, Yuya Kobayashi, and Scott Topper, Invitae; Robert L. Nussbaum, University of California, San Francisco, San Francisco; and Melissa S. Cline, Can Zhang, David Haussler, and Benedict Paten, University of California, Santa Cruz, Santa Cruz, CA
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302
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Elmore JG, Barnhill RL, Elder DE, Longton GM, Pepe MS, Reisch LM, Carney PA, Titus LJ, Nelson HD, Onega T, Tosteson ANA, Weinstock MA, Knezevich SR, Piepkorn MW. Pathologists' diagnosis of invasive melanoma and melanocytic proliferations: observer accuracy and reproducibility study. BMJ 2017; 357:j2813. [PMID: 28659278 PMCID: PMC5485913 DOI: 10.1136/bmj.j2813] [Citation(s) in RCA: 252] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/25/2017] [Indexed: 12/22/2022]
Abstract
Objective To quantify the accuracy and reproducibility of pathologists' diagnoses of melanocytic skin lesions.Design Observer accuracy and reproducibility study.Setting 10 US states.Participants Skin biopsy cases (n=240), grouped into sets of 36 or 48. Pathologists from 10 US states were randomized to independently interpret the same set on two occasions (phases 1 and 2), at least eight months apart.Main outcome measures Pathologists' interpretations were condensed into five classes: I (eg, nevus or mild atypia); II (eg, moderate atypia); III (eg, severe atypia or melanoma in situ); IV (eg, pathologic stage T1a (pT1a) early invasive melanoma); and V (eg, ≥pT1b invasive melanoma). Reproducibility was assessed by intraobserver and interobserver concordance rates, and accuracy by concordance with three reference diagnoses.Results In phase 1, 187 pathologists completed 8976 independent case interpretations resulting in an average of 10 (SD 4) different diagnostic terms applied to each case. Among pathologists interpreting the same cases in both phases, when pathologists diagnosed a case as class I or class V during phase 1, they gave the same diagnosis in phase 2 for the majority of cases (class I 76.7%; class V 82.6%). However, the intraobserver reproducibility was lower for cases interpreted as class II (35.2%), class III (59.5%), and class IV (63.2%). Average interobserver concordance rates were lower, but with similar trends. Accuracy using a consensus diagnosis of experienced pathologists as reference varied by class: I, 92% (95% confidence interval 90% to 94%); II, 25% (22% to 28%); III, 40% (37% to 44%); IV, 43% (39% to 46%); and V, 72% (69% to 75%). It is estimated that at a population level, 82.8% (81.0% to 84.5%) of melanocytic skin biopsy diagnoses would have their diagnosis verified if reviewed by a consensus reference panel of experienced pathologists, with 8.0% (6.2% to 9.9%) of cases overinterpreted by the initial pathologist and 9.2% (8.8% to 9.6%) underinterpreted.Conclusion Diagnoses spanning moderately dysplastic nevi to early stage invasive melanoma were neither reproducible nor accurate in this large study of pathologists in the USA. Efforts to improve clinical practice should include using a standardized classification system, acknowledging uncertainty in pathology reports, and developing tools such as molecular markers to support pathologists' visual assessments.
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Affiliation(s)
- Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, 98104, USA
| | - Raymond L Barnhill
- Department of Pathology, Institut Curie Institute Hospital, University of Paris Descartes Faculty of Medicine University, Paris, France
| | - David E Elder
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Gary M Longton
- Program in Biostatistics, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Margaret S Pepe
- Program in Biostatistics, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Lisa M Reisch
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, 98104, USA
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Linda J Titus
- Departments of Epidemiology and Pediatrics, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, NH, USA
| | - Heidi D Nelson
- Departments of Medical Informatics and Clinical Epidemiology and Medicine, School of Medicine, Oregon Health & Science University, Portland, OR, USA
- Providence Cancer Center, Providence Health and Services, Portland, OR, USA
| | - Tracy Onega
- Geisel School of Medicine at Dartmouth, Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
- Department of Biomedical Data Science, Department of Epidemiology, Norris Cotton Cancer Center, Lebanon, NH, USA
| | - Anna N A Tosteson
- Departments of Medicine and Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, NH, USA
| | - Martin A Weinstock
- Center for Dermatoepidemiology, Providence VA Medical Center, Providence, RI, USA
- Departments of Dermatology and Epidemiology, Brown University, Providence, RI, USA
| | | | - Michael W Piepkorn
- Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Dermatopathology Northwest, Bellevue, WA, USA
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303
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Valasek MA, Thung I, Gollapalle E, Hodkoff AA, Kelly KJ, Baumgartner JM, Vavinskaya V, Lin GY, Tipps AP, Hosseini MV, Lowy AM. Overinterpretation is common in pathological diagnosis of appendix cancer during patient referral for oncologic care. PLoS One 2017; 12:e0179216. [PMID: 28591173 PMCID: PMC5462425 DOI: 10.1371/journal.pone.0179216] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 05/25/2017] [Indexed: 11/18/2022] Open
Abstract
CONTEXT Low-grade appendiceal mucinous neoplasm (LAMN) and appendiceal adenocarcinoma are known to cause the majority of pseudomyxoma peritonei (PMP, i.e. mucinous ascites); however, recognition and proper classification of these neoplasms can be difficult despite established diagnostic criteria. OBJECTIVE To determine the pathological diagnostic concordance for appendix neoplasia and related lesions during patient referral to an academic medical center specialized in treating patients with PMP. DESIGN The anatomic pathology laboratory information system was searched to identify cases over a two-year period containing appendix specimens with mucinous neoplasia evaluated by an outside pathology group and by in-house slide review at a single large academic medical center during patient referral. RESULTS 161 cases containing appendix specimens were identified over this period. Forty-six of 161 cases (28.6%) contained appendiceal primary neoplasia or lesions. Of these, the originating pathologist diagnosed 23 cases (50%) as adenocarcinoma and 23 cases (50%) as LAMN; however, the reference pathologist diagnosed 29 cases (63.0%) as LAMN, 13 cases (28.3%) as adenocarcinoma, and 4 cases (8.7%) as ruptured simple mucocele. Importantly, for cases in which the originating pathologist rendered a diagnosis of adenocarcinoma, the reference pathologist rendered a diagnosis of adenocarcinoma (56.5%, 13 of 23), LAMN (39.1%, 9 of 23), or simple mucocele (4.3%, 1 of 23). The overall diagnostic concordance rate for these major classifications was 71.7% (33 of 46) with an unweighted observed kappa value of 0.48 (95% CI, 0.27-0.69), consistent with moderate interobserver agreement. All of the observed discordance (28.3%) for major classifications could be attributed to over-interpretation. In addition, the majority of LAMN cases (65.5%) had potential diagnostic deficiencies including over-interpretation as adenocarcinoma and lacking or discordant risk stratification (i.e. documentation of extra-appendiceal neoplastic epithelium). CONCLUSIONS Appendiceal mucinous lesions remain a difficult area for appropriate pathological classification with substantial discordance due to over-interpretation in this study. The findings highlight the critical need for recognition and application of diagnostic criteria regarding these tumors. Recently published consensus guidelines and a checklist provided herein may help facilitate improvement of diagnostic concordance and thereby reduce over-interpretation and potential overtreatment. Further studies are needed to determine the extent of this phenomenon and its potential clinical impact.
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Affiliation(s)
- Mark A. Valasek
- Department of Pathology, Division of Anatomic Pathology, University of California San Diego Medical Center, San Diego, California, United States of America
- * E-mail:
| | - Irene Thung
- Department of Pathology, Division of Anatomic Pathology, University of California San Diego Medical Center, San Diego, California, United States of America
| | - Esha Gollapalle
- Department of Pathology, Division of Anatomic Pathology, University of California San Diego Medical Center, San Diego, California, United States of America
| | - Alexey A. Hodkoff
- Department of Pathology, Division of Anatomic Pathology, University of California San Diego Medical Center, San Diego, California, United States of America
| | - Kaitlyn J. Kelly
- Department of Surgery, Division of Surgical Oncology, University of California San Diego Moores Cancer Center, La Jolla, California, United States of America
| | - Joel M. Baumgartner
- Department of Surgery, Division of Surgical Oncology, University of California San Diego Moores Cancer Center, La Jolla, California, United States of America
| | - Vera Vavinskaya
- Department of Pathology, Division of Anatomic Pathology, University of California San Diego Medical Center, San Diego, California, United States of America
| | - Grace Y. Lin
- Department of Pathology, Division of Anatomic Pathology, University of California San Diego Medical Center, San Diego, California, United States of America
| | - Ann P. Tipps
- Department of Pathology, Division of Anatomic Pathology, University of California San Diego Medical Center, San Diego, California, United States of America
| | - Mojgan V. Hosseini
- Department of Pathology, Division of Anatomic Pathology, University of California San Diego Medical Center, San Diego, California, United States of America
| | - Andrew M. Lowy
- Department of Surgery, Division of Surgical Oncology, University of California San Diego Moores Cancer Center, La Jolla, California, United States of America
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Araújo T, Aresta G, Castro E, Rouco J, Aguiar P, Eloy C, Polónia A, Campilho A. Classification of breast cancer histology images using Convolutional Neural Networks. PLoS One 2017; 12:e0177544. [PMID: 28570557 PMCID: PMC5453426 DOI: 10.1371/journal.pone.0177544] [Citation(s) in RCA: 321] [Impact Index Per Article: 45.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 04/28/2017] [Indexed: 11/26/2022] Open
Abstract
Breast cancer is one of the main causes of cancer death worldwide. The diagnosis of biopsy tissue with hematoxylin and eosin stained images is non-trivial and specialists often disagree on the final diagnosis. Computer-aided Diagnosis systems contribute to reduce the cost and increase the efficiency of this process. Conventional classification approaches rely on feature extraction methods designed for a specific problem based on field-knowledge. To overcome the many difficulties of the feature-based approaches, deep learning methods are becoming important alternatives. A method for the classification of hematoxylin and eosin stained breast biopsy images using Convolutional Neural Networks (CNNs) is proposed. Images are classified in four classes, normal tissue, benign lesion, in situ carcinoma and invasive carcinoma, and in two classes, carcinoma and non-carcinoma. The architecture of the network is designed to retrieve information at different scales, including both nuclei and overall tissue organization. This design allows the extension of the proposed system to whole-slide histology images. The features extracted by the CNN are also used for training a Support Vector Machine classifier. Accuracies of 77.8% for four class and 83.3% for carcinoma/non-carcinoma are achieved. The sensitivity of our method for cancer cases is 95.6%.
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Affiliation(s)
- Teresa Araújo
- Faculdade de Engenharia da Universidade do Porto (FEUP), R. Dr. Roberto Frias s/n, 4200-465 Porto, Portugal
- Instituto de Engenharia de Sistemas e Computadores - Tecnologia e Ciência (INESC-TEC), R. Dr. Roberto Frias, 4200 Porto, Portugal
- * E-mail:
| | - Guilherme Aresta
- Faculdade de Engenharia da Universidade do Porto (FEUP), R. Dr. Roberto Frias s/n, 4200-465 Porto, Portugal
- Instituto de Engenharia de Sistemas e Computadores - Tecnologia e Ciência (INESC-TEC), R. Dr. Roberto Frias, 4200 Porto, Portugal
| | - Eduardo Castro
- Faculdade de Engenharia da Universidade do Porto (FEUP), R. Dr. Roberto Frias s/n, 4200-465 Porto, Portugal
| | - José Rouco
- Instituto de Engenharia de Sistemas e Computadores - Tecnologia e Ciência (INESC-TEC), R. Dr. Roberto Frias, 4200 Porto, Portugal
| | - Paulo Aguiar
- Instituto de Investigação e Inovação em Saúde (i3S), Universidade do Porto, Rua Alfredo Allen, 208, 4200-135 Porto, Portugal
- Instituto de Engenharia Biomédica (INEB), Universidade do Porto, Rua Alfredo Allen, 208, 4200-135 Porto, Portugal
| | - Catarina Eloy
- Laboratório de Anatomia Patológica, Ipatimup Diagnósticos, Rua Júlio Amaral de Carvalho, 45, 4200-135 Porto, Portugal
- Faculdade de Medicina, Universidade do Porto, Alameda Prof Hernâni Monteiro, 4200-319 Porto, Portugal
| | - António Polónia
- Laboratório de Anatomia Patológica, Ipatimup Diagnósticos, Rua Júlio Amaral de Carvalho, 45, 4200-135 Porto, Portugal
- Faculdade de Medicina, Universidade do Porto, Alameda Prof Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Aurélio Campilho
- Faculdade de Engenharia da Universidade do Porto (FEUP), R. Dr. Roberto Frias s/n, 4200-465 Porto, Portugal
- Instituto de Engenharia de Sistemas e Computadores - Tecnologia e Ciência (INESC-TEC), R. Dr. Roberto Frias, 4200 Porto, Portugal
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Onega T, Weaver DL, Frederick PD, Allison KH, Tosteson ANA, Carney PA, Geller BM, Longton GM, Nelson HD, Oster NV, Pepe MS, Elmore JG. The diagnostic challenge of low-grade ductal carcinoma in situ. Eur J Cancer 2017; 80:39-47. [PMID: 28535496 DOI: 10.1016/j.ejca.2017.04.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 03/30/2017] [Accepted: 04/05/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Diagnostic agreement among pathologists is 84% for ductal carcinoma in situ (DCIS). Studies of interpretive variation according to grade are limited. METHODS A national sample of 115 pathologists interpreted 240 breast pathology test set cases in the Breast Pathology Study and their interpretations were compared to expert consensus interpretations. We assessed agreement of pathologists' interpretations with a consensus reference diagnosis of DCIS dichotomised into low- and high-grade lesions. Generalised estimating equations were used in logistic regression models of rates of under- and over-interpretation of DCIS by grade. RESULTS We evaluated 2097 independent interpretations of DCIS (512 low-grade DCIS and 1585 high-grade DCIS). Agreement with reference diagnoses was 46% (95% confidence interval [CI] 42-51) for low-grade DCIS and 83% (95% CI 81-86) for high-grade DCIS. The proportion of reference low-grade DCIS interpretations over-interpreted by pathologists (i.e. categorised as either high-grade DCIS or invasive cancer) was 23% (95% CI 19-28); 30% (95% CI 26-34) were interpreted as a lower diagnostic category (atypia or benign proliferative). Reference high-grade DCIS was under-interpreted in 14% (95% CI 12-16) of observations and only over-interpreted 3% (95% CI 2-4). CONCLUSION Grade is a major factor when examining pathologists' variability in diagnosing DCIS, with much lower agreement for low-grade DCIS cases compared to high-grade. These findings support the hypothesis that low-grade DCIS poses a greater interpretive challenge than high-grade DCIS, which should be considered when developing DCIS management strategies.
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Affiliation(s)
- Tracy Onega
- Department of Biomedical Data Science, Department of Epidemiology, The Dartmouth Institute for Health Policy and Clinical Practice and Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.
| | - Donald L Weaver
- Department of Pathology, University of Vermont and UVM Cancer Center, Burlington, VT, USA
| | - Paul D Frederick
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Kimberly H Allison
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Anna N A Tosteson
- Department of Medicine, The Dartmouth Institute for Health Policy and Clinical Practice and Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Berta M Geller
- Department of Family Medicine, University of Vermont, Burlington, VT 05401, USA
| | - Gary M Longton
- Department of Biostatistics, University of Washington, Seattle, WA 98101, USA
| | - Heidi D Nelson
- Providence Cancer Center, Providence Health and Services Oregon, and Department of Medical Informatics and Clinical Epidemiology and Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Natalia V Oster
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Margaret S Pepe
- Department of Biostatistics, University of Washington, Seattle, WA 98101, USA
| | - Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
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306
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Samples LS, Rendi MH, Frederick PD, Allison KH, Nelson HD, Morgan TR, Weaver DL, Elmore JG. Surgical implications and variability in the use of the flat epithelial atypia diagnosis on breast biopsy specimens. Breast 2017; 34:34-43. [PMID: 28475933 DOI: 10.1016/j.breast.2017.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 03/31/2017] [Accepted: 04/06/2017] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Flat epithelial atypia (FEA) is a relatively new diagnostic term with uncertain clinical significance for surgical management. Any implied risk of invasive breast cancer associated with FEA is contingent upon diagnostic reproducibility, yet little is known regarding its use. MATERIALS AND METHODS Pathologists in the Breast Pathology Study interpreted one of four 60-case test sets, one slide per case, constructed from 240 breast biopsy specimens. An electronic data form with standardized diagnostic categories was used; participants were instructed to indicate all diagnoses present. We assessed participants' use of FEA as a diagnostic term within: 1) each test set; 2) 72 cases classified by reference as benign without FEA; and 3) six cases classified by reference as FEA. 115 pathologists participated, providing 6900 total independent assessments. RESULTS Notation of FEA ranged from 0% to 35% of the cases interpreted, with most pathologists noting FEA on 4 or more test cases. At least one participant noted FEA in 34 of the 72 benign non-FEA cases. For the 6 reference FEA cases, participant agreement with the case reference FEA diagnosis ranged from 17% to 52%; diagnoses noted by participating pathologists for these FEA cases included columnar cell hyperplasia, usual ductal hyperplasia, atypical lobular hyperplasia, and atypical ductal hyperplasia. CONCLUSIONS We observed wide variation in the diagnosis of FEA among U.S. pathologists. This suggests that perceptions of diagnostic criteria and any implied risk associated with FEA may also vary. Surgical excision following a core biopsy diagnosis of FEA should be reconsidered and studied further.
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Affiliation(s)
- Laura S Samples
- Department of Medicine, University of Washington School of Medicine, 325 Ninth Ave, Box 359780, Seattle, WA 98104, USA
| | - Mara H Rendi
- Department of Pathology, University of Washington School of Medicine, 1959 NE Pacific St., Box 356100, Seattle, WA, USA
| | - Paul D Frederick
- Department of Medicine, University of Washington School of Medicine, 325 Ninth Ave, Box 359780, Seattle, WA 98104, USA
| | - Kimberly H Allison
- Department of Pathology, Stanford University School of Medicine, 300 Pasteur Drive, Lane 235, Stanford, CA 94305, USA
| | - Heidi D Nelson
- Providence Cancer Center, Providence Health and Services Oregon, and Departments of Medical Informatics and Clinical Epidemiology and Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code FM, Portland, OR 97239, USA
| | - Thomas R Morgan
- Department of Medicine, University of Washington School of Medicine, 325 Ninth Ave, Box 359780, Seattle, WA 98104, USA
| | - Donald L Weaver
- Department of Pathology and University of Vermont Cancer Center, University of Vermont, Given Courtyard, 89 Beaumont Ave, Burlington, VT 05405, USA
| | - Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, 325 Ninth Ave, Box 359780, Seattle, WA 98104, USA.
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Wan T, Zhang W, Zhu M, Chen J, Achim A, Qin Z. Automated mitosis detection in histopathology based on non-gaussian modeling of complex wavelet coefficients. Neurocomputing 2017. [DOI: 10.1016/j.neucom.2017.01.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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308
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Jackson SL, Frederick PD, Pepe MS, Nelson HD, Weaver DL, Allison KH, Carney PA, Geller BM, Tosteson ANA, Onega T, Elmore JG. Diagnostic Reproducibility: What Happens When the Same Pathologist Interprets the Same Breast Biopsy Specimen at Two Points in Time? Ann Surg Oncol 2017; 24:1234-1241. [PMID: 27913946 PMCID: PMC5538724 DOI: 10.1245/s10434-016-5695-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Indexed: 01/02/2023]
Abstract
BACKGROUND Surgeons may receive a different diagnosis when a breast biopsy is interpreted by a second pathologist. The extent to which diagnostic agreement by the same pathologist varies at two time points is unknown. METHODS Pathologists from eight U.S. states independently interpreted 60 breast specimens, one glass slide per case, on two occasions separated by ≥9 months. Reproducibility was assessed by comparing interpretations between the two time points; associations between reproducibility (intraobserver agreement rates); and characteristics of pathologists and cases were determined and also compared with interobserver agreement of baseline interpretations. RESULTS Sixty-five percent of invited, responding pathologists were eligible and consented; 49 interpreted glass slides in both study phases, resulting in 2940 interpretations. Intraobserver agreement rates between the two phases were 92% [95% confidence interval (CI) 88-95] for invasive breast cancer, 84% (95% CI 81-87) for ductal carcinoma-in-situ, 53% (95% CI 47-59) for atypia, and 84% (95% CI 81-86) for benign without atypia. When comparing all study participants' case interpretations at baseline, interobserver agreement rates were 89% (95% CI 84-92) for invasive cancer, 79% (95% CI 76-81) for ductal carcinoma-in-situ, 43% (95% CI 41-45) for atypia, and 77% (95% CI 74-79) for benign without atypia. CONCLUSIONS Interpretive agreement between two time points by the same individual pathologist was low for atypia and was similar to observed rates of agreement for atypia between different pathologists. Physicians and patients should be aware of the diagnostic challenges associated with a breast biopsy diagnosis of atypia when considering treatment and surveillance decisions.
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Affiliation(s)
- Sara L Jackson
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA.
| | - Paul D Frederick
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Margaret S Pepe
- Program in Biostatistics and Biomathematics, Fred Hutchinson Cancer Research Center, Seattle, USA
| | - Heidi D Nelson
- Providence Cancer Center, Providence Health and Services Oregon, Portland, USA
- Departments of Medical Informatics and Clinical Epidemiology and Medicine, Oregon Health & Science University, Portland, USA
| | - Donald L Weaver
- Department of Pathology and University of Vermont Cancer Center, University of Vermont, Burlington, VT, USA
| | - Kimberly H Allison
- Department of Pathology, Stanford University School of Medicine, Stanford, USA
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health & Science University, Portland, USA
| | - Berta M Geller
- Department of Family Medicine, University of Vermont, Burlington, USA
| | - Anna N A Tosteson
- Department of Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, USA
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, USA
| | - Tracy Onega
- Department of Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, USA
| | - Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
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East EG, Zhao L, Pang JC, Jorns JM. Characteristics of a Breast Pathology Consultation Practice. Arch Pathol Lab Med 2017; 141:578-584. [PMID: 28353380 DOI: 10.5858/arpa.2016-0371-oa] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT - Intradepartmental consultation is a routine practice commonly used for new diagnoses. Expert interinstitutional case review provides insight into particularly challenging cases. OBJECTIVE - To investigate the practice of breast pathology consultation at a large tertiary care center. DESIGN - We reviewed breast pathology cases sent for private consultation and internal cases reviewed by multiple pathologists at a tertiary center. Requisitions and reports were evaluated for diagnostic reason for consultation, rate of multiple pathologist review at the tertiary center, use of immunohistochemistry, and, for private consultation cases, type of sender and concordance with the outside diagnosis. RESULTS - In the 985 private consultation cases, the most frequent reasons for review were borderline atypia (292 of 878; 33.3%), papillary lesion classification (151 of 878; 17.2%), evaluating invasion (123 of 878; 14%), subtyping carcinoma (75 of 878; 8.5%), and spindle cell (67 of 878; 7.6%) and fibroepithelial (65 of 878; 7.4%) lesion classification. Of 4981 consecutive internal cases, 358 (7.2%) were reviewed, most frequently for borderline atypia (90 of 358; 25.1%), subtyping carcinoma (63 of 358; 17.6%), staging/prognostic features (59 of 358; 16.5%), fibroepithelial lesion classification (45 of 358; 12.6%), evaluating invasion (37 of 358; 10.3%), and papillary (20 of 358; 5.6%) and spindle cell (18 of 358; 5.0%) lesion classification. Of all internal cases, those with a final diagnosis of atypia had a significantly higher rate of review (58 of 241; 24.1%) than those with benign (119 of 2933; 4.1%) or carcinoma (182 of 1807; 10.1%) diagnoses. Immunohistochemistry aided in diagnosis of 39.7% (391 of 985) and 21.2% (76 of 359) of consultation and internally reviewed cases, respectively. CONCLUSIONS - This study confirms areas of breast pathology that represent diagnostic challenge and supports that pathologists are appropriately using expert consultation.
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Affiliation(s)
| | | | | | - Julie M Jorns
- From the Departments of Pathology (Drs East, Pang, and Jorns) and Biostatistics (Dr Zhao), University of Michigan, Ann Arbor
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310
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Chang Sen LQ, Berg WA, Carter GJ. Upgrade Rate and Imaging Features of Atypical Apocrine Lesions. Breast J 2017; 23:569-578. [DOI: 10.1111/tbj.12789] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Lauren Q. Chang Sen
- Department of Radiology; Magee-Womens Hospital of University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - Wendie A. Berg
- Department of Radiology; Magee-Womens Hospital of University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
- University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania
| | - Gloria J. Carter
- Department of Pathology; Magee-Womens Hospital of University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
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311
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Elmore JG, Longton GM, Pepe MS, Carney PA, Nelson HD, Allison KH, Geller BM, Onega T, Tosteson ANA, Mercan E, Shapiro LG, Brunyé TT, Morgan TR, Weaver DL. A Randomized Study Comparing Digital Imaging to Traditional Glass Slide Microscopy for Breast Biopsy and Cancer Diagnosis. J Pathol Inform 2017; 8:12. [PMID: 28382226 PMCID: PMC5364740 DOI: 10.4103/2153-3539.201920] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 01/18/2017] [Indexed: 01/19/2023] Open
Abstract
Background: Digital whole slide imaging may be useful for obtaining second opinions and is used in many countries. However, the U.S. Food and Drug Administration requires verification studies. Methods: Pathologists were randomized to interpret one of four sets of breast biopsy cases during two phases, separated by ≥9 months, using glass slides or digital format (sixty cases per set, one slide per case, n = 240 cases). Accuracy was assessed by comparing interpretations to a consensus reference standard. Intraobserver reproducibility was assessed by comparing the agreement of interpretations on the same cases between two phases. Estimated probabilities of confirmation by a reference panel (i.e., predictive values) were obtained by incorporating data on the population prevalence of diagnoses. Results: Sixty-five percent of responding pathologists were eligible, and 252 consented to randomization; 208 completed Phase I (115 glass, 93 digital); and 172 completed Phase II (86 glass, 86 digital). Accuracy was slightly higher using glass compared to digital format and varied by category: invasive carcinoma, 96% versus 93% (P = 0.04); ductal carcinoma in situ (DCIS), 84% versus 79% (P < 0.01); atypia, 48% versus 43% (P = 0.08); and benign without atypia, 87% versus 82% (P < 0.01). There was a small decrease in intraobserver agreement when the format changed compared to when glass slides were used in both phases (P = 0.08). Predictive values for confirmation by a reference panel using glass versus digital were: invasive carcinoma, 98% and 97% (not significant [NS]); DCIS, 70% and 57% (P = 0.007); atypia, 38% and 28% (P = 0.002); and benign without atypia, 97% and 96% (NS). Conclusions: In this large randomized study, digital format interpretations were similar to glass slide interpretations of benign and invasive cancer cases. However, cases in the middle of the spectrum, where more inherent variability exists, may be more problematic in digital format. Future studies evaluating the effect these findings exert on clinical practice and patient outcomes are required.
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Affiliation(s)
- Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle, WA 98104, USA
| | - Gary M Longton
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Margaret S Pepe
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA; Department of Biostatistics, University of Washington School of Public Health, Seattle, WA 98104, USA
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health and Science University, Portland, OR 97239, USA
| | - Heidi D Nelson
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, OR 97239, USA; Providence Cancer Center, Providence Health and Services Oregon, Portland, OR 97213, USA
| | - Kimberly H Allison
- Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Berta M Geller
- Department of Family Medicine, University of Vermont, Burlington, VT 05405, USA
| | - Tracy Onega
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756, USA
| | - Anna N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756, USA
| | - Ezgi Mercan
- Department of Computer Science and Engineering, University of Washington, Seattle, WA 98195, USA
| | - Linda G Shapiro
- Department of Computer Science and Engineering, University of Washington, Seattle, WA 98195, USA
| | - Tad T Brunyé
- Department of Psychology, Tufts University, Medford, MA 02155, USA
| | - Thomas R Morgan
- Department of Medicine, University of Washington School of Medicine, Seattle, WA 98104, USA
| | - Donald L Weaver
- Department of Pathology, UVM Cancer Center, University of Vermont, Burlington, VT 05405, USA
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El Khoury M, Sanchez LM, Lalonde L, Trop I, David J, Mesurolle B. Is the outcome at surgery different when flat epithelial atypia and lobular neoplasia are found in association at biopsy? Br J Radiol 2017; 90:20160750. [PMID: 28118035 DOI: 10.1259/bjr.20160750] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To assess the impact on the final outcome at surgery of flat epithelial atypia (FEA) when found concomitantly with lobular neoplasia (LN) in biopsy specimens compared with pure biopsy-proven FEA. METHODS The approval from the institutional review board of the CHUM (Centre Hospitalier Universitaire de Montréal) was obtained. A retrospective review of our database between 2009 and 2013 identified 81 females (mean age 54 years, range 38-90 years) with 81 FEA biopsy-proven lesions. These were pure or associated with LN only in 59/81 (73%) and 22/81 (27%) cases, respectively. Overall, 57/81 (70%) patients underwent surgery and 24/81 (30%) patients underwent mammographic surveillance with a mean follow-up of 36 months. RESULTS FEA presented more often as microcalcifications in 68/81 (84%) patients and were mostly amorphous in 49/68 (72%). After excluding radio pathologically discordant cases, pure FEA proved to be malignant at surgery in 1/41 (2%; 95% confidence interval 0.06-12.9). There was no statistically significant difference in the upgrade to malignancy whether FEA lesions were pure or associated to LN at biopsy (p = 0.4245); however, when paired in biopsy specimens, these lesions were more frequently associated with atypical ductal hyperplasia (ADH) at surgery than with pure FEA (p = 0.012). CONCLUSION Our results show a 2% upgrade rate to malignancy of pure FEA lesions. When FEA is found in association with LN at biopsy, surgical excision yields more frequently ADH than pure FEA thus warranting close surveillance or even surgical excision. Advances in knowledge: The association of LN with FEA at biopsy was more frequently associated with ADH at surgery than with pure FEA. If a biopsy-proven FEA lesion is deemed concordant with the imaging finding, when paired with LN at biopsy, careful surveillance or even surgical excision is suggested.
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Affiliation(s)
- Mona El Khoury
- 1 Department of Radiology, Breast Centre, Centre Hospitalier Universitaire de Montréal, Montreal, QC, Canada
| | - Lilia Maria Sanchez
- 2 Department of Pathology, Centre Hospitalier Universitaire de Montréal, Montreal, QC, Canada
| | - Lucie Lalonde
- 1 Department of Radiology, Breast Centre, Centre Hospitalier Universitaire de Montréal, Montreal, QC, Canada
| | - Isabelle Trop
- 1 Department of Radiology, Breast Centre, Centre Hospitalier Universitaire de Montréal, Montreal, QC, Canada
| | - Julie David
- 1 Department of Radiology, Breast Centre, Centre Hospitalier Universitaire de Montréal, Montreal, QC, Canada
| | - Benoît Mesurolle
- 3 Department of Radiology, Cedar Breast Centre, McGill University Health Center, Montreal, QC, Canada
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313
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Kurian AW, Friese CR, Bondarenko I, Jagsi R, Li Y, Hamilton AS, Ward KC, Katz SJ. Second Opinions From Medical Oncologists for Early-Stage Breast Cancer: Prevalence, Correlates, and Consequences. JAMA Oncol 2017; 3:391-397. [PMID: 28033448 PMCID: PMC5520652 DOI: 10.1001/jamaoncol.2016.5652] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
IMPORTANCE Advances in the evaluation and treatment of breast cancer have made the clinical decision-making context much more complex. A second opinion from a medical oncologist may facilitate decision making for women with breast cancer, yet little is known about second opinion use. OBJECTIVE To investigate the patterns and correlates of second opinion use and the effect on chemotherapy decisions. DESIGN, SETTING, AND PARTICIPANTS A total of 1901 women newly diagnosed with stages 0 to II breast cancer between July 2013 and September 2014 (response rate, 71.0%) were accrued through 2 population-based Surveillance, Epidemiology, and End Results registries (Georgia and Los Angeles County, California) and surveyed about their experiences with medical oncologists, decision making, and chemotherapy use. MAIN OUTCOMES AND MEASURES Factors associated with second opinion use were evaluated using logistic regression. Also assessed was the association between second opinion and chemotherapy use, adjusting for chemotherapy indication and propensity for receiving a second opinion. Multiple imputation and weighting were used to account for missing data. RESULTS A total of 1901 patients with stage I to II breast cancer (mean [SD] age, 61.6 [11.0] years; 1071 [56.3%] non-Hispanic white) saw any medical oncologist. Analysis of multiply imputed, weighted data (mean n = 1866) showed that 168 (9.8%) (SE, 0.74%) received a second opinion and 54 (3.2%) (SE, 0.47%) received chemotherapy from the second oncologist. Satisfaction with chemotherapy decisions was high and did not differ between those who did (mean [SD], 4.3 [0.08] on a 1- to 5-point scale) or did not (4.4 [0.03]) obtain a second opinion (P = .29). Predictors of second opinion use included college education vs less education (odds ratio [OR], 1.85; 95% CI, 1.24-2.75), frequent use of internet-based support groups (OR, 2.15; 95% CI, 1.12-4.11), an intermediate result on the 21-gene recurrence score assay (OR, 1.85; 95% CI, 1.11-3.09), and a variant of uncertain significance on hereditary cancer genetic testing (OR, 3.24; 95% CI, 1.09-9.59). After controlling for patient and tumor characteristics, second opinion use was not associated with chemotherapy receipt (OR, 1.04; 95% CI, 0.71-1.52). CONCLUSIONS AND RELEVANCE Second opinion use was low (<10%) among patients with early-stage breast cancer, and high decision satisfaction regardless of second opinion use suggests little unmet demand. Along with educational level and use of internet support groups, uncertain results on genomic testing predicted second opinion use. Patient demand for second opinions may increase as more complex genomic tests are disseminated.
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Affiliation(s)
- Allison W. Kurian
- Stanford University, Departments of Medicine and Health Research and Policy, Stanford, CA
| | - Christopher R. Friese
- Department of Systems, Populations, and Leadership, and Institute for Healthcare Policy and Innovation, University of Michigan School of Nursing, Ann Arbor, MI
| | - Irina Bondarenko
- University of Michigan, Department of Biostatistics, School of Public Health, Ann Arbor, MI
| | - Reshma Jagsi
- University of Michigan, Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, Ann Arbor, MI
| | - Yun Li
- University of Michigan, Department of Biostatistics, School of Public Health, Ann Arbor, MI
| | - Ann S. Hamilton
- Keck School of Medicine, University of Southern California, Department of Preventive Medicine in the Keck School of Medicine, Los Angeles, CA
| | - Kevin C. Ward
- Emory University, Rollins School of Public Health, Department of Epidemiology, Atlanta, GA
| | - Steven J. Katz
- University of Michigan, Department of Health Management and Policy, School of Public Health, Department of Internal Medicine, Division of General Medicine, Ann Arbor, MI
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314
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Wan T, Cao J, Chen J, Qin Z. Automated grading of breast cancer histopathology using cascaded ensemble with combination of multi-level image features. Neurocomputing 2017. [DOI: 10.1016/j.neucom.2016.05.084] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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315
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Thomas JS, Hanby AM, Russell N, van Tienhoven G, Riddle K, Anderson N, Cameron DA, Bartlett JMS, Piper T, Cunningham C, Canney P, Kunkler IH. The BIG 2.04 MRC/EORTC SUPREMO Trial: pathology quality assurance of a large phase 3 randomised international clinical trial of postmastectomy radiotherapy in intermediate-risk breast cancer. Breast Cancer Res Treat 2017; 163:63-69. [PMID: 28190252 PMCID: PMC5387007 DOI: 10.1007/s10549-017-4145-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 02/06/2017] [Indexed: 12/17/2022]
Abstract
Introduction SUPREMO is a phase 3 randomised trial evaluating radiotherapy post-mastectomy for intermediate-risk breast cancer. 1688 patients were enrolled from 16 countries between 2006 and 2013. We report the results of central pathology review carried out for quality assurance. Patients and methods A single recut haematoxylin and eosin (H&E) tumour section was assessed by one of two reviewing pathologists, blinded to the originally reported pathology and patient data. Tumour type, grade and lymphovascular invasion were reviewed to assess if they met the inclusion criteria. Slides from potentially ineligible patients on central review were scanned and reviewed online together by the two pathologists and a consensus reached. A subset of 25 of these cases was double-reported independently by the pathologists prior to the online assessment. Results The major contributors to the trial were the UK (75%) and the Netherlands (10%). There is a striking difference in lymphovascular invasion (LVi) rates (41.6 vs. 15.1% (UK); p = <0.0001) and proportions of grade 3 carcinomas (54.0 vs. 42.0% (UK); p = <0.0001) on comparing local reporting with central review. There was no difference in the locally reported frequency of LVi rates in node-positive (N+) and node-negative (N−) subgroups (40.3 vs. 38.0%; p = 0.40) but a significant difference in the reviewed frequency (16.9 vs. 9.9%; p = 0.004). Of the N− cases, 104 (25.1%) would have been ineligible by initial central review by virtue of grade and/or lymphovascular invasion status. Following online consensus review, this fell to 70 cases (16.3% of N− cases, 4.1% of all cases). Conclusions These data have important implications for the design, powering and interpretation of outcomes from this and future clinical trials. If critical pathology criteria are determinants for trial entry, serious consideration should be given to up-front central pathology review. Electronic supplementary material The online version of this article (doi:10.1007/s10549-017-4145-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- J S Thomas
- Department of Pathology, Western General Hospital, Edinburgh, EH4 2XU, UK.
| | - A M Hanby
- Leeds Institute of Cancer and Pathology, St James's University Hospital, Leeds, LS9 7TF, UK
| | - N Russell
- Department of Radiation Oncology, Netherlands Cancer Institute, Postbus 90203, 1006 BE, Amsterdam, Netherlands
| | - G van Tienhoven
- Academic Medical Center, University of Amsterdam, 1105 AZ, Amsterdam, Netherlands
| | - K Riddle
- Scottish Clinical Trials Research Unit, NHS National Services Scotland, Edinburgh, EH12 9EB, UK
| | - N Anderson
- Centre of Population Health Sciences, Edinburgh University Medical School, Edinburgh, EH8 9AG, UK
| | - D A Cameron
- Edinburgh Cancer Centre, Western General Hospital, Edinburgh, EH4 2XU, UK
| | - J M S Bartlett
- Ontario Institute for Cancer Research, Toronto, ON, M5G0A3, Canada
| | - T Piper
- Edinburgh Cancer Centre, Western General Hospital, Edinburgh, EH4 2XU, UK
| | - C Cunningham
- Edinburgh Cancer Centre, Western General Hospital, Edinburgh, EH4 2XU, UK
| | - P Canney
- Beatson Oncology Centre, Gartnavel Campus, Glasgow, G12 0YN, UK
| | - I H Kunkler
- Edinburgh Cancer Centre, Western General Hospital, Edinburgh, EH4 2XU, UK
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316
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Blank MAB, Antaki JF. Breast Lesion Elastography Region of Interest Selection and Quantitative Heterogeneity: A Systematic Review and Meta-Analysis. ULTRASOUND IN MEDICINE & BIOLOGY 2017; 43:387-397. [PMID: 27746010 DOI: 10.1016/j.ultrasmedbio.2016.09.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 07/22/2016] [Accepted: 09/06/2016] [Indexed: 05/20/2023]
Abstract
In this systematic review and meta-analysis, we report measured elasticities of benign and malignant breast pathologies from shear wave elastography (SWE), quantitatively confirm the effect of the selected region of interest (ROI) on these measures and test the hypothesis that a metric of heterogeneity based on the mean and maximum elasticity can improve specificity of diagnosis. The elasticities of benign, malignant and specific pathologic states are reported from 22 publications encompassing 2989 patients, identified from a structured search of the literature from May to September 2015. Twelve articles were included in a meta-analysis that grouped results by the method of ROI selection to discriminate between different pathologies. We observe a significant correlation between the method of selection of ROI for malignant mean (p < 0.001) and maximum (p = 0.027) elasticities, but no correlation with benign measures. We define a quantitative heterogeneity parameter, the "stiffness gradient," computed from the mean and maximum measured elasticities. The stiffness gradient out-performed the current standard maximum elasticity metric in stratifying malignancy risk by a margin of 15% for the partial ROI, and 42% for the maximized ROI. An anecdotal example of improved differentiation using the stiffness gradient on pathology-specific lesions is also provided. These results quantitatively indicate that the method of ROI selection in SWE not only has a significant impact on the resulting mean reported elasticity of a lesion, but may provide some insight into lesion heterogeneity. Our results suggest that further exploration of quantitative heterogeneity is warranted to improve the specificity of diagnosis.
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Affiliation(s)
- Molly A B Blank
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, USA.
| | - James F Antaki
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, USA
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317
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Groen EJ, Elshof LE, Visser LL, Rutgers EJT, Winter-Warnars HA, Lips EH, Wesseling J. Finding the balance between over- and under-treatment of ductal carcinoma in situ (DCIS). Breast 2017; 31:274-283. [DOI: 10.1016/j.breast.2016.09.001] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 08/19/2016] [Accepted: 09/01/2016] [Indexed: 12/21/2022] Open
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318
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Vierkant RA, Degnim AC, Radisky DC, Visscher DW, Heinzen EP, Frank RD, Winham SJ, Frost MH, Scott CG, Jensen MR, Ghosh K, Manduca A, Brandt KR, Whaley DH, Hartmann LC, Vachon CM. Mammographic breast density and risk of breast cancer in women with atypical hyperplasia: an observational cohort study from the Mayo Clinic Benign Breast Disease (BBD) cohort. BMC Cancer 2017; 17:84. [PMID: 28143431 PMCID: PMC5282712 DOI: 10.1186/s12885-017-3082-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 01/23/2017] [Indexed: 02/07/2023] Open
Abstract
Background Atypical hyperplasia (AH) and mammographic breast density (MBD) are established risk factors for breast cancer (BC), but their joint contributions are not well understood. We examine associations of MBD and BC by histologic impression, including AH, in a subcohort of women from the Mayo Clinic Benign Breast Disease Cohort. Methods Women with a diagnosis of BBD and mammogram between 1985 and 2001 were eligible. Histologic impression was assessed via pathology review and coded as non-proliferative disease (NP), proliferative disease without atypia (PDWA) and AH. MBD was assessed clinically using parenchymal pattern (PP) or BI-RADS criteria and categorized as low, moderate or high. Percent density (PD) was also available for a subset of women. BC and clinical information were obtained by questionnaires, medical records and the Mayo Clinic Tumor Registry. Women were followed from date of benign biopsy to BC, death or last contact. Standardized incidence ratios (SIRs) compared the observed number of BCs to expected counts. Cox regression estimated multivariate-adjusted MBD hazard ratios. Results Of the 6271 women included in the study, 1132 (18.0%) had low MBD, 2921 (46.6%) had moderate MBD, and 2218 (35.4%) had high MBD. A total of 3532 women (56.3%) had NP, 2269 (36.2%) had PDWA and 470 (7.5%) had AH. Over a median follow-up of 14.3 years, 528 BCs were observed. The association of MBD and BC risk differed by histologic impression (p-interaction = 0.03), such that there was a strong MBD and BC association among NP (p < 0.001) but non-significant associations for PDWA (p = 0.27) and AH (p = 0.96). MBD and BC associations for AH women were not significant within subsets defined by type of MBD measure (PP vs. BI-RADS), age at biopsy, number of foci of AH, type of AH (lobular vs. ductal) and body mass index, and after adjustment for potential confounding variables. Women with atypia who also had high PD (>50%) demonstrated marginal evidence of increased BC risk (SIR 4.98), but results were not statistically significant. Conclusion We found no evidence of an association between MBD and subsequent BC risk in women with AH. Electronic supplementary material The online version of this article (doi:10.1186/s12885-017-3082-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Robert A Vierkant
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Amy C Degnim
- Department of Subspecialty General Surgery, Mayo Clinic, Rochester, MN, USA
| | - Derek C Radisky
- Department of Cancer Biology, Mayo Clinic, Jacksonville, FL, USA
| | | | - Ethan P Heinzen
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Ryan D Frank
- Department of Health Sciences Research, Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL, USA
| | - Stacey J Winham
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Marlene H Frost
- Department of Medical Oncology, Division of the Women's Cancer Program, Mayo Clinic, Rochester, MN, USA
| | - Christopher G Scott
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Matthew R Jensen
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Karthik Ghosh
- Department of General Internal Medicine, Division of the Breast Diagnostic Clinic, Mayo Clinic, Rochester, MN, USA
| | - Armando Manduca
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA
| | | | - Dana H Whaley
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Lynn C Hartmann
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Celine M Vachon
- Department of Health Sciences Research, Division of Epidemiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Segnan N, Minozzi S, Ponti A, Bellisario C, Balduzzi S, González-Lorenzo M, Gianola S, Armaroli P. Estimate of false-positive breast cancer diagnoses from accuracy studies: a systematic review. J Clin Pathol 2017; 70:282-294. [DOI: 10.1136/jclinpath-2016-204184] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 12/12/2016] [Accepted: 12/13/2016] [Indexed: 11/04/2022]
Abstract
BackgroundFalse-positive histological diagnoses have the same consequences of overdiagnosis in terms of unnecessary treatment. The aim of this systematic review is to assess their frequency at needle core biopsy (CB) and/or surgical excision of the breast.MethodsPubMed, Embase, Cochrane Library were systematically searched up to 30 October 2015. Eligibility criteria: cross-sectional studies assessing diagnostic accuracy of CB compared with surgical excision; studies assessing reproducibility of pathologists reading the same slides. Outcomes: false-positive rates; Misclassification of Benign as Malignant (MBM) histological diagnosis; K statistic. Independent reviewers extracted data and assessed quality using an adapted QUADAS-2 tool.ResultsSixteen studies assessed CB false-positive rates. In 10 studies (41 989 screen-detected lesions), the range of false-positive rates was 0%–7.1%. Twenty-seven studies assessed pathologists' reproducibility. Studies with consecutive, random or stratified samples of all the specimens: at CB the MBM range was 0.25%–2.4% (K values 0.83–0.98); at surgical excision, it was 0.67%–1.2% (K values 0.86–0.94). Studies with enriched samples: the MBM range was 1.4%–6.2% (K values 0.57–0.86). Studies of cases selected for second opinion: the MBM range was 0.29%–12.2% (K values 0.48 and 0.50).ConclusionsHigh heterogeneity of the included studies precluded formal pooling estimates. When considering studies of higher sample size or methodological quality, false-positive rates and MBM are around 1%. The impact of false-positive histological diagnoses of breast cancer on unnecessary treatment, as well as that of overdiagnosis, is not negligible and is of importance in clinical practice.
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320
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Brunyé TT, Mercan E, Weaver DL, Elmore JG. Accuracy is in the eyes of the pathologist: The visual interpretive process and diagnostic accuracy with digital whole slide images. J Biomed Inform 2017; 66:171-179. [PMID: 28087402 DOI: 10.1016/j.jbi.2017.01.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 01/06/2017] [Accepted: 01/09/2017] [Indexed: 12/30/2022]
Abstract
Digital whole slide imaging is an increasingly common medium in pathology, with application to education, telemedicine, and rendering second opinions. It has also made it possible to use eye tracking devices to explore the dynamic visual inspection and interpretation of histopathological features of tissue while pathologists review cases. Using whole slide images, the present study examined how a pathologist's diagnosis is influenced by fixed case-level factors, their prior clinical experience, and their patterns of visual inspection. Participating pathologists interpreted one of two test sets, each containing 12 digital whole slide images of breast biopsy specimens. Cases represented four diagnostic categories as determined via expert consensus: benign without atypia, atypia, ductal carcinoma in situ (DCIS), and invasive cancer. Each case included one or more regions of interest (ROIs) previously determined as of critical diagnostic importance. During pathologist interpretation we tracked eye movements, viewer tool behavior (zooming, panning), and interpretation time. Models were built using logistic and linear regression with generalized estimating equations, testing whether variables at the level of the pathologists, cases, and visual interpretive behavior would independently and/or interactively predict diagnostic accuracy and efficiency. Diagnostic accuracy varied as a function of case consensus diagnosis, replicating earlier research. As would be expected, benign cases tended to elicit false positives, and atypia, DCIS, and invasive cases tended to elicit false negatives. Pathologist experience levels, case consensus diagnosis, case difficulty, eye fixation durations, and the extent to which pathologists' eyes fixated within versus outside of diagnostic ROIs, all independently or interactively predicted diagnostic accuracy. Higher zooming behavior predicted a tendency to over-interpret benign and atypia cases, but not DCIS cases. Efficiency was not predicted by pathologist- or visual search-level variables. Results provide new insights into the medical interpretive process and demonstrate the complex interactions between pathologists and cases that guide diagnostic decision-making. Implications for training, clinical practice, and computer-aided decision aids are considered.
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Affiliation(s)
- Tad T Brunyé
- Center for Applied Brain & Cognitive Sciences, Tufts University, Medford, MA, United States.
| | - Ezgi Mercan
- Department of Computer Science and Engineering, University of Washington, Seattle, WA, United States
| | - Donald L Weaver
- Department of Pathology and UVM Cancer Center, University of Vermont, Burlington, VT, United States
| | - Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, United States
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Abstract
Overdiagnosis in breast cancer has been a focus of increasing concern with wide ranges of calculations made indirectly through the study of prospective randomized trials and analyses of large registries. While most admit that some degree of overdiagnosis is inherent with ductal carcinoma in situ (DCIS), the rate of overdiagnosis with invasive disease is highly controversial. Although it is generally accepted that overdiagnosis is calculated through indirect means and deductive reasoning, this is not entirely the case. Patients who refuse treatment, yet curiously return for follow-up, allow a direct glimpse at the natural history of screen-detected cancers. And historic autopsy studies offer information as to undiagnosed disease prevalence from the pre-screening era. While these autopsy studies support a modest degree of overdiagnosis in DCIS, they do not support widespread overdiagnosis for invasive cancer. The 1.3% mean incidence of invasive disease from seven autopsy studies correlates closely with disease prevalence, a direct observation that cancers do not remain quiescent in the breast until death. If invasive breast cancer does not regress in untreated patients and does not remain quiescent, then the high estimates being calculated for overdiagnosis are more likely to be length bias from long natural histories rather than true overdiagnosis.
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323
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Yang S, Cline M, Zhang C, Paten B, Lincoln SE. DATA SHARING AND REPRODUCIBLE CLINICAL GENETIC TESTING: SUCCESSES AND CHALLENGES. PACIFIC SYMPOSIUM ON BIOCOMPUTING. PACIFIC SYMPOSIUM ON BIOCOMPUTING 2017; 22:166-176. [PMID: 27896972 PMCID: PMC5340191 DOI: 10.1142/9789813207813_0017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Open sharing of clinical genetic data promises to both monitor and eventually improve the reproducibility of variant interpretation among clinical testing laboratories. A significant public data resource has been developed by the NIH ClinVar initiative, which includes submissions from hundreds of laboratories and clinics worldwide. We analyzed a subset of ClinVar data focused on specific clinical areas and we find high reproducibility (>90% concordance) among labs, although challenges for the community are clearly identified in this dataset. We further review results for the commonly tested BRCA1 and BRCA2 genes, which show even higher concordance, although the significant fragmentation of data into different silos presents an ongoing challenge now being addressed by the BRCA Exchange. We encourage all laboratories and clinics to contribute to these important resources.
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Affiliation(s)
- Shan Yang
- Invitae, San Francisco, California, USA,
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324
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Rakha EA, Ahmed MA, Aleskandarany MA, Hodi Z, Lee AHS, Pinder SE, Ellis IO. Diagnostic concordance of breast pathologists: lessons from the National Health Service Breast Screening Programme Pathology External Quality Assurance Scheme. Histopathology 2016; 70:632-642. [DOI: 10.1111/his.13117] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 11/02/2016] [Indexed: 12/13/2022]
Affiliation(s)
- Emad A Rakha
- Department of Histopathology; Nottingham City Hospital; Nottingham B UK
| | - Mohamed A Ahmed
- Department of Histopathology; Nottingham City Hospital; Nottingham B UK
| | | | - Zsolt Hodi
- Department of Histopathology; Nottingham City Hospital; Nottingham B UK
| | - Andrew H S Lee
- Department of Histopathology; Nottingham City Hospital; Nottingham B UK
| | - Sarah E Pinder
- Cancer Studies; King's College London; Guy's Hospital; London UK
| | - Ian O Ellis
- Department of Histopathology; Nottingham City Hospital; Nottingham B UK
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325
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Shimkhada R, Solon O, Tamondong-Lachica D, Peabody JW. Misdiagnosis of obstetrical cases and the clinical and cost consequences to patients: a cross-sectional study of urban providers in the Philippines. Glob Health Action 2016; 9:32672. [PMID: 27987297 PMCID: PMC5161800 DOI: 10.3402/gha.v9.32672] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 11/15/2016] [Accepted: 11/16/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Misdiagnosis may be a significant and under-recognized quality of care problem. In birthing facilities located in anurban Philippine setting, we investigated the diagnostic accuracy for three obstetric conditions: cephalopelvic disproportion (CPD), post-partum hemorrhage (PPH), and pre-eclampsia. DESIGN Identical simulated cases were used to measure diagnostic accuracy for every provider (n=103). We linked misdiagnosis - identified by the simulated cases - to obstetrical complications of the patients at the participating facilities. Patient-level data on health outcomes and costs were obtained from medical records and follow-home in-person interviews. RESULTS The prevalence of misdiagnosis among obstetric providers was 29.8% overall, 25% for CPD, 33% for PPH, and 31% for pre-eclampsia. Linking provider decision-making to patients, we found those who misdiagnosed the simulated cases were more likely to have patients with a complication (OR 2.96; 95% CI 1.39-3.77) compared with those who did not misdiagnose. Complicated patients were significantly less likely to be referred to a hospital immediately, were more likely to be readmitted to a hospital after delivery, had significantly higher medical costs, and lost more income than non-complicated patients. CONCLUSION Diagnosis is arguably the most important task a clinician performs because it determines the subsequent course of evaluation and treatment, with the direct and indirect costs of diagnostic error, placing large financial burdens on the patient.
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Affiliation(s)
| | - Orville Solon
- School of Economics, University of Philippines, Quezon City, Philippines
| | | | - John W Peabody
- QURE Healthcare, San Francisco, CA, USA.,Global Health Sciences, University of California, San Francisco, CA, USA;
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326
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Affiliation(s)
- Joann G Elmore
- From the Department of Medicine, University of Washington School of Medicine, Seattle
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327
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Abstract
PURPOSE OF REVIEW Ductal carcinoma in situ (DCIS) accounts for approximately 20% of mammographically diagnosed breast cancers. Currently, there is a trend to consider DCIS as a lesion for which treatment deescalation is advocated to avoid overtreatment, that is, radiotherapy in addition to breast-conserving surgery or even surgery at all. RECENT FINDINGS The long-term follow-up updates of the four first-generation randomized trials comparing lumpectomy with and without radiation therapy have confirmed that radiation halves the local failure rates. However, radiotherapy is not associated with a survival benefit just as affirmed by the recently published evaluation of the Surveillance, Epidemiology, and End Results registries database, including 108,196 women with DCIS. Nevertheless, the risk of dying of breast cancer increases about factor 18 after experience of an invasive local recurrence. That means at least some DCIS have the potential to progress to a life threatening disease. At the same time, none of the recently updated prospective trials that tested the outcome after excision alone in low-risk DCIS achieved a 10-year local failure rate below 10%. SUMMARY DCIS is not a uniform disease. Its clinical behaviour is heterogeneous, but up to date no citeria are available that allow a precise identification of patients with low or very low progression risk who do not need irradiation. Therefore, excision followed by radiotherapy is still the standard of care in patients undergoing breast conservation. Promising new approaches for risk estimation have to be validated prospectively before their use in daily practice can be recommended.
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328
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Allison KH, Rendi MH, Peacock S, Morgan T, Elmore JG, Weaver DL. Histological features associated with diagnostic agreement in atypical ductal hyperplasia of the breast: illustrative cases from the B-Path study. Histopathology 2016; 69:1028-1046. [PMID: 27398812 DOI: 10.1111/his.13035] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 07/08/2016] [Indexed: 01/26/2023]
Abstract
AIMS This study examined the case-specific characteristics associated with interobserver diagnostic agreement in atypical ductal hyperplasia (ADH) of the breast. METHODS AND RESULTS Seventy-two test set cases with a consensus diagnosis of ADH from the B-Path study were evaluated. Cases were scored for 17 histological features, which were then correlated with the participant agreement with the consensus ADH diagnosis. Participating pathologists' perceptions of case difficulty, borderline features or whether they would obtain a second opinion were also examined for associations with agreement. Of the 2070 participant interpretations of the 72 consensus ADH cases, 48% were scored by participants as difficult and 45% as borderline between two diagnoses; the presence of both of these features was significantly associated with increased agreement (P < 0.001). A second opinion would have been obtained in 80% of interpretations, and this was associated with increased agreement (P < 0.001). Diagnostic agreement ranged from 10% to 89% on a case-by-case basis. Cases with papillary lesions, cribriform architecture and obvious cytological monotony were associated with higher agreement. Lower agreement rates were associated with solid or micropapillary architecture, borderline cytological monotony, or cases without a diagnostic area that was obvious on low power. CONCLUSIONS The results of this study suggest that pathologists frequently recognize the challenge of ADH cases, with some cases being more prone to diagnostic variability. In addition, there are specific histological features associated with diagnostic agreement on ADH cases. Multiple example images from cases in this test set are provided to serve as educational illustrations of these challenges.
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Affiliation(s)
- Kimberly H Allison
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Mara H Rendi
- Department of Pathology, University of Washington School of Medicine, Seattle, WA, USA
| | - Sue Peacock
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Tom Morgan
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Donald L Weaver
- Department of Pathology and University of Vermont Cancer Center, University of Vermont, Burlington, VT, USA
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329
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Nagarkar DB, Mercan E, Weaver DL, Brunyé TT, Carney PA, Rendi MH, Beck AH, Frederick P, Shapiro LG, Elmore JG. Region of interest identification and diagnostic agreement in breast pathology. Mod Pathol 2016; 29:1004-11. [PMID: 27198567 PMCID: PMC6436917 DOI: 10.1038/modpathol.2016.85] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 02/01/2016] [Accepted: 03/30/2016] [Indexed: 11/11/2022]
Abstract
A pathologist's accurate interpretation relies on identifying relevant histopathological features. Little is known about the precise relationship between feature identification and diagnostic decision making. We hypothesized that greater overlap between a pathologist's selected diagnostic region of interest (ROI) and a consensus derived ROI is associated with higher diagnostic accuracy. We developed breast biopsy test cases that included atypical ductal hyperplasia (n=80); ductal carcinoma in situ (n=78); and invasive breast cancer (n=22). Benign cases were excluded due to the absence of specific abnormalities. Three experienced breast pathologists conducted an independent review of the 180 digital whole slide images, established a reference consensus diagnosis and marked one or more diagnostic ROIs for each case. Forty-four participating pathologists independently diagnosed and marked ROIs on the images. Participant diagnoses and ROI were compared with consensus reference diagnoses and ROI. Regression models tested whether percent overlap between participant ROI and consensus reference ROI predicted diagnostic accuracy. Each of the 44 participants interpreted 39-50 cases for a total of 1972 individual diagnoses. Percent ROI overlap with the expert reference ROI was higher in pathologists who self-reported academic affiliation (69 vs 65%, P=0.002). Percent overlap between participants' ROI and consensus reference ROI was then classified into ordinal categories: 0, 1-33, 34-65, 66-99 and 100% overlap. For each incremental change in the ordinal percent ROI overlap, diagnostic agreement increased by 60% (OR 1.6, 95% CI (1.5-1.7), P<0.001) and the association remained significant even after adjustment for other covariates. The magnitude of the association between ROI overlap and diagnostic agreement increased with increasing diagnostic severity. The findings indicate that pathologists are more likely to converge with an expert reference diagnosis when they identify an overlapping diagnostic image region, suggesting that future computer-aided detection systems that highlight potential diagnostic regions could be a helpful tool to improve accuracy and education.
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Affiliation(s)
| | - Ezgi Mercan
- Department of Computer Science and Engineering, University of Washington
| | - Donald L. Weaver
- Department of Pathology and UVM Cancer Center, University of VT, Burlington, VT
| | | | | | - Mara H. Rendi
- Department of Pathology, University of Washington School of Medicine
| | - Andrew H Beck
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Paul Frederick
- Department of Medicine, University of Washington School of Medicine
| | - Linda G. Shapiro
- Department of Computer Science and Engineering, University of Washington
| | - Joann G. Elmore
- Department of Medicine, University of Washington School of Medicine
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330
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Turkki R, Linder N, Kovanen PE, Pellinen T, Lundin J. Antibody-supervised deep learning for quantification of tumor-infiltrating immune cells in hematoxylin and eosin stained breast cancer samples. J Pathol Inform 2016; 7:38. [PMID: 27688929 PMCID: PMC5027738 DOI: 10.4103/2153-3539.189703] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 07/01/2016] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Immune cell infiltration in tumor is an emerging prognostic biomarker in breast cancer. The gold standard for quantification of immune cells in tissue sections is visual assessment through a microscope, which is subjective and semi-quantitative. In this study, we propose and evaluate an approach based on antibody-guided annotation and deep learning to quantify immune cell-rich areas in hematoxylin and eosin (H&E) stained samples. METHODS Consecutive sections of formalin-fixed parafin-embedded samples obtained from the primary tumor of twenty breast cancer patients were cut and stained with H&E and the pan-leukocyte CD45 antibody. The stained slides were digitally scanned, and a training set of immune cell-rich and cell-poor tissue regions was annotated in H&E whole-slide images using the CD45-expression as a guide. In analysis, the images were divided into small homogenous regions, superpixels, from which features were extracted using a pretrained convolutional neural network (CNN) and classified with a support of vector machine. The CNN approach was compared to texture-based classification and to visual assessments performed by two pathologists. RESULTS In a set of 123,442 labeled superpixels, the CNN approach achieved an F-score of 0.94 (range: 0.92-0.94) in discrimination of immune cell-rich and cell-poor regions, as compared to an F-score of 0.88 (range: 0.87-0.89) obtained with the texture-based classification. When compared to visual assessment of 200 images, an agreement of 90% (κ = 0.79) to quantify immune infiltration with the CNN approach was achieved while the inter-observer agreement between pathologists was 90% (κ = 0.78). CONCLUSIONS Our findings indicate that deep learning can be applied to quantify immune cell infiltration in breast cancer samples using a basic morphology staining only. A good discrimination of immune cell-rich areas was achieved, well in concordance with both leukocyte antigen expression and pathologists' visual assessment.
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Affiliation(s)
- Riku Turkki
- Institute for Molecular Medicine Finland, University of Helsinki, Helsinki, Finland
| | - Nina Linder
- Institute for Molecular Medicine Finland, University of Helsinki, Helsinki, Finland
| | - Panu E. Kovanen
- Department of Pathology, HUSLAB and Haartman Institute, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland
| | - Teijo Pellinen
- Institute for Molecular Medicine Finland, University of Helsinki, Helsinki, Finland
| | - Johan Lundin
- Institute for Molecular Medicine Finland, University of Helsinki, Helsinki, Finland
- Department of Public Health Sciences/Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden
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331
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Pattern classification of endocervical adenocarcinoma: reproducibility and review of criteria. Mod Pathol 2016; 29:1083-94. [PMID: 27255163 PMCID: PMC5506840 DOI: 10.1038/modpathol.2016.94] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 04/07/2016] [Accepted: 04/14/2016] [Indexed: 11/09/2022]
Abstract
Previously, our international team proposed a three-tiered pattern classification (Pattern Classification) system for endocervical adenocarcinoma of the usual type that correlates with nodal disease and recurrence. Pattern Classification-A tumors have well-demarcated glands lacking destructive stromal invasion or lymphovascular invasion, Pattern Classification-B tumors show localized, limited destructive invasion arising from A-type glands, and Pattern Classification-C tumors have diffuse destructive stromal invasion, significant (filling a 4 × field) confluence, or solid architecture. Twenty-four cases of Pattern Classification-A, 22 Pattern Classification-B, and 38 Pattern Classification-C from the tumor set used in the original description were chosen using the reference diagnosis originally established. One H&E slide per case was reviewed by seven gynecologic pathologists, four from the original study. Kappa statistics were prepared, and cases with discrepancies reviewed. We found a majority agreement with reference diagnosis in 81% of cases, with complete or near-complete (six of seven) agreement in 50%. Overall concordance was 74%. Overall kappa (agreement among pathologists) was 0.488 (moderate agreement). Pattern Classification-B has lowest kappa, and agreement was not improved by combining B+C. Six of seven reviewers had substantial agreement by weighted kappas (>0.6), with one reviewer accounting for the majority of cases under or overcalled by two tiers. Confluence filling a 4 × field, labyrinthine glands, or solid architecture accounted for undercalling other reference diagnosis-C cases. Missing a few individually infiltrative cells was the most common cause of undercalling reference diagnosis-B. Small foci of inflamed, loose or desmoplastic stroma lacking infiltrative tumor cells in reference diagnosis-A appeared to account for those cases up-graded to Pattern Classification-B. In summary, an overall concordance of 74% indicates that the criteria can be reproducibly applied by gynecologic pathologists. Further refinement of criteria should allow use of this powerful classification system to delineate which cervical adenocarcinomas can be safely treated conservatively.
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332
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Menen RS, Ganesan N, Bevers T, Ying J, Coyne R, Lane D, Albarracin C, Bedrosian I. Long-Term Safety of Observation in Selected Women Following Core Biopsy Diagnosis of Atypical Ductal Hyperplasia. Ann Surg Oncol 2016; 24:70-76. [PMID: 27573525 DOI: 10.1245/s10434-016-5512-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Indexed: 11/18/2022]
Abstract
PURPOSE Atypical ductal hyperplasia (ADH) found on core biopsy is associated with an upgrade to carcinoma in 10-30 % of women, thus surgical excision remains the standard of care. This study compares the incidence of breast cancer in women with ADH who were observed with those who underwent surgical excision of the ADH site. METHODS Our departmental, prospectively maintained registry was reviewed to identify patients with ADH diagnosed by core biopsy. Surgically treated patients were excluded if upstaged to carcinoma following excision for ADH diagnosis. Breast cancer events were classified as index site (site of ADH biopsy), ipsilateral breast unrelated to index site, or contralateral breast. RESULTS Overall, 175 women met the study criteria; 125 were observed and 50 underwent excision. With a median follow-up of 3 years, 14 breast cancer events were noted in 13 patients. In the surgery group, six women developed breast cancer (12 %), including one bilateral, compared with seven cancers (5.6 %) in the observed group (p = 0.14). Index site events and ipsilateral cancers were the same in both groups [2 vs. 0.8 % (p = 0.49) and 4 versus 4.8 % (p = 1.00), respectively]. All contralateral cancers occurred in the surgical group (8 vs. 0 %; p < 0.01). A prior history of breast cancer was the only variable associated with subsequent breast cancer events (hazard ratio 12.53, 95 % confidence interval 3.30-47.57). CONCLUSION Observation is appropriate in selected women with ADH on core biopsy. Index site failures are rare and are superseded by cancer risk elsewhere in the breast.
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Affiliation(s)
- Rhiana S Menen
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nivetha Ganesan
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Therese Bevers
- Department of Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jun Ying
- Department of Biostatics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Robin Coyne
- Department of Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Deanna Lane
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Constance Albarracin
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Isabelle Bedrosian
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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333
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Mastropasqua MG, Viale G. Clinical and pathological assessment of high-risk ductal and lobular breast lesions: What surgeons must know. Eur J Surg Oncol 2016; 43:278-284. [PMID: 27544280 DOI: 10.1016/j.ejso.2016.07.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 06/16/2016] [Accepted: 07/06/2016] [Indexed: 12/13/2022] Open
Abstract
Terminology in pathology is sometimes over-complicated and may be misinterpreted by clinicians facing patients and having difficulty answering questions posed by them. This may especially be true for some breast lesions with an increased risk of malignant transformation, the complex terminology of which reflects attempts to stratify them according to potential risk. On the basis of morphological and molecular features, both ductal and lobular proliferations have been classified and named in different ways by pathologists, and this often makes it difficult for the treating physicians and the patients to fully understand the nature of the lesions and their associated risks. In order to clarify pathology reports, unambiguous and simple terms are needed.
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Affiliation(s)
- M G Mastropasqua
- Division of Pathology and Laboratory Medicine, European Institute of Oncology, Milan, Italy.
| | - G Viale
- Division of Pathology and Laboratory Medicine, European Institute of Oncology, Milan, Italy; Division of Pathology and Laboratory Medicine, European Institute of Oncology and University of Milan, School of Medicine, Milan, Italy
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334
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Tozbikian G, Brogi E, Vallejo CE, Giri D, Murray M, Catalano J, Olcese C, Van Zee KJ, Wen HY. Atypical Ductal Hyperplasia Bordering on Ductal Carcinoma In Situ. Int J Surg Pathol 2016; 25:100-107. [PMID: 27481892 DOI: 10.1177/1066896916662154] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The clinical implications of the diagnosis of atypical ductal hyperplasia (ADH) and ductal carcinoma in situ (DCIS) are very different. Yet there are "borderline" breast lesions that have characteristics of both ADH and DCIS. We examined interobserver diagnostic variability for such lesions and correlated pathologic features of the lesions with clinical outcomes. METHODS We identified all cases of borderline ADH/DCIS lesions treated at our center from 1997 to 2010. Five specialized breast pathologists blinded to clinical outcomes independently reviewed all available slides from each case and were instructed to classify each as benign, ADH, or DCIS. A majority diagnosis (MajDx) was defined as a diagnosis agreed upon by ≥3 pathologists. RESULTS A total of 105 women with borderline ADH/DCIS and slides available for review were identified. The MajDx was ADH in 84 (80%), and DCIS in 18 (17%). There were split diagnoses in 3 (3%). MajDx of DCIS correlated significantly with lesion size and nuclear grade. There was diagnostic agreement by all 5 pathologists in 30% of cases, 4 pathologists in 42%, and 3 pathologists in 25%. At a median follow-up of 37 months, 4 (3.8%) patients developed subsequent ipsilateral breast carcinoma (2 invasive, 2 DCIS); all 4 cases had MajDx of ADH. CONCLUSIONS Borderline ADH/DCIS represents an entity for which reproducible categorization as ADH or DCIS cannot be achieved. Furthermore, histologic features of borderline lesions resulting in MajDx of ADH vs. DCIS are not prognostic for risk of subsequent breast carcinoma.
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Affiliation(s)
- Gary Tozbikian
- 1 Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Edi Brogi
- 1 Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Dilip Giri
- 1 Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Melissa Murray
- 1 Memorial Sloan Kettering Cancer Center, New York, NY, USA
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335
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Rakha EA, Bennett RL, Coleman D, Pinder SE, Ellis IO. Review of the national external quality assessment (EQA) scheme for breast pathology in the UK. J Clin Pathol 2016; 70:51-57. [DOI: 10.1136/jclinpath-2016-203800] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 05/23/2016] [Accepted: 06/09/2016] [Indexed: 01/05/2023]
Abstract
BackgroundThe National Health Service Breast Screening Programme (NHSBSP; pathology) external quality assurance (EQA) scheme aims to provide a mechanism for examination and monitoring of concordance of pathology reporting within the UK. This study aims to review the breast EQA scheme performance data collected over a 24-year period following its introduction.MethodsData on circulations, number of cases and diagnosis were collected. Detailed analyses with and without combinations of certain diagnostic entities, and over different time periods were performed.ResultsOverall, of 576 cases (172 benign, 11 atypical hyperplasia, 98 ductal carcinoma in situ/microinvasive and 295 invasive disease), consistency of assessment of diagnostic parameters was very high (overall k=0.80; k for benign diagnosis=0.79; k for invasive disease=0.91). For distinguishing benign versus malignant lesions, no further improvement is considered possible in view of the limitations of the scheme methodology. Although diagnostic consistency of atypical hyperplasia remains at a low level, combining it with the benign category results in a high level of agreement (k=0.93). The level of consistency of reporting prognostic information is variable and some items such as lymphovascular invasion and tumour size measurement may need further intervention to improve their reporting consistency. Although the level of consistency of reporting of histological grade remained at a moderate level overall (k=0.48), it was variable among cases and appears to have levelled off; no further significant improvement is expected and no significant impact of the previous publication of guidelines is observed.ConclusionsThese results provide further evidence to indicate the value of the breast EQA scheme in monitoring performance and the identification of specific areas where improvement or new approaches are required. For most parameters, the concordance of reporting reached a plateaux a few years after the introduction of the EQA scheme. It is important to maintain this high level and also to tackle specific low-performance areas innovatively.
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Brunyé TT, Eddy MD, Mercan E, Allison KH, Weaver DL, Elmore JG. Pupil diameter changes reflect difficulty and diagnostic accuracy during medical image interpretation. BMC Med Inform Decis Mak 2016; 16:77. [PMID: 27378371 PMCID: PMC4932753 DOI: 10.1186/s12911-016-0322-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 06/08/2016] [Indexed: 11/10/2022] Open
Abstract
Background No automated methods exist to objectively monitor and evaluate the diagnostic process while physicians review computerized medical images. The present study tested whether using eye tracking to monitor tonic and phasic pupil dynamics may prove valuable in tracking interpretive difficulty and predicting diagnostic accuracy. Methods Pathologists interpreted digitized breast biopsies varying in diagnosis and rated difficulty, while pupil diameter was monitored. Tonic diameter was recorded during the entire duration of interpretation, and phasic diameter was examined when the eyes fixated on a pre-determined diagnostic region during inspection. Results Tonic pupil diameter was higher with increasing rated difficulty levels of cases. Phasic diameter was interactively influenced by case difficulty and the eventual agreement with consensus diagnosis. More difficult cases produced increases in pupil diameter, but only when the pathologists’ diagnoses were ultimately correct. All results were robust after adjusting for the potential impact of screen brightness on pupil diameter. Conclusions Results contribute new understandings of the diagnostic process, theoretical positions regarding locus coeruleus-norepinephrine system function, and suggest novel approaches to monitoring, evaluating, and guiding medical image interpretation.
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Affiliation(s)
- Tad T Brunyé
- Center for Applied Brain and Cognitive Sciences, 200 Boston Ave, Suite 3000, Medford, 02155, MA, USA. .,Department of Psychology, Tufts University, 490 Boston Ave, Medford, 02155, MA, USA.
| | - Marianna D Eddy
- Center for Applied Brain and Cognitive Sciences, 200 Boston Ave, Suite 3000, Medford, 02155, MA, USA.,Department of Psychology, Tufts University, 490 Boston Ave, Medford, 02155, MA, USA
| | - Ezgi Mercan
- Department of Computer Science and Engineering, University of Washington, Seattle, 98104, WA, USA
| | - Kimberly H Allison
- Department of Pathology, Stanford University School of Medicine, Palo Alto, 94305, CA, USA
| | - Donald L Weaver
- Department of Pathology and UVM Cancer Center, University of Vermont, Burlington, 05401, VT, USA
| | - Joann G Elmore
- Department of Medicine, University of Washington, Seattle, 98104, WA, USA
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337
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Identifying and processing the gap between perceived and actual agreement in breast pathology interpretation. Mod Pathol 2016; 29:717-26. [PMID: 27056072 PMCID: PMC4925256 DOI: 10.1038/modpathol.2016.62] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 02/17/2016] [Accepted: 02/23/2016] [Indexed: 11/29/2022]
Abstract
We examined how pathologists' process their perceptions of how their interpretations on diagnoses for breast pathology cases agree with a reference standard. To accomplish this, we created an individualized self-directed continuing medical education program that showed pathologists interpreting breast specimens how their interpretations on a test set compared with a reference diagnosis developed by a consensus panel of experienced breast pathologists. After interpreting a test set of 60 cases, 92 participating pathologists were asked to estimate how their interpretations compared with the standard for benign without atypia, atypia, ductal carcinoma in situ and invasive cancer. We then asked pathologists their thoughts about learning about differences in their perceptions compared with actual agreement. Overall, participants tended to overestimate their agreement with the reference standard, with a mean difference of 5.5% (75.9% actual agreement; 81.4% estimated agreement), especially for atypia and were least likely to overestimate it for invasive breast cancer. Non-academic affiliated pathologists were more likely to more closely estimate their performance relative to academic affiliated pathologists (77.6 vs 48%; P=0.001), whereas participants affiliated with an academic medical center were more likely to underestimate agreement with their diagnoses compared with non-academic affiliated pathologists (40 vs 6%). Before the continuing medical education program, nearly 55% (54.9%) of participants could not estimate whether they would overinterpret the cases or underinterpret them relative to the reference diagnosis. Nearly 80% (79.8%) reported learning new information from this individualized web-based continuing medical education program, and 23.9% of pathologists identified strategies they would change their practice to improve. In conclusion, when evaluating breast pathology specimens, pathologists do a good job of estimating their diagnostic agreement with a reference standard, but for atypia cases, pathologists tend to overestimate diagnostic agreement. Many participants were able to identify ways to improve.
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338
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Collins LC, Schnitt SJ, Tamimi RM. Reply to breast cancer risk by the extent and type of atypical hyperplasia. Cancer 2016; 122:3088-9. [PMID: 27352006 DOI: 10.1002/cncr.30149] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Laura C Collins
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Stuart J Schnitt
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Rulla M Tamimi
- Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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Elmore JG, Tosteson AN, Pepe MS, Longton GM, Nelson HD, Geller B, Carney PA, Onega T, Allison KH, Jackson SL, Weaver DL. Evaluation of 12 strategies for obtaining second opinions to improve interpretation of breast histopathology: simulation study. BMJ 2016; 353:i3069. [PMID: 27334105 PMCID: PMC4916777 DOI: 10.1136/bmj.i3069] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To evaluate the potential effect of second opinions on improving the accuracy of diagnostic interpretation of breast histopathology. DESIGN Simulation study. SETTING 12 different strategies for acquiring independent second opinions. PARTICIPANTS Interpretations of 240 breast biopsy specimens by 115 pathologists, one slide for each case, compared with reference diagnoses derived by expert consensus. MAIN OUTCOME MEASURES Misclassification rates for individual pathologists and for 12 simulated strategies for second opinions. Simulations compared accuracy of diagnoses from single pathologists with that of diagnoses based on pairing interpretations from first and second independent pathologists, where resolution of disagreements was by an independent third pathologist. 12 strategies were evaluated in which acquisition of second opinions depended on initial diagnoses, assessment of case difficulty or borderline characteristics, pathologists' clinical volumes, or whether a second opinion was required by policy or desired by the pathologists. The 240 cases included benign without atypia (10% non-proliferative, 20% proliferative without atypia), atypia (30%), ductal carcinoma in situ (DCIS, 30%), and invasive cancer (10%). Overall misclassification rates and agreement statistics depended on the composition of the test set, which included a higher prevalence of difficult cases than in typical practice. RESULTS Misclassification rates significantly decreased (P<0.001) with all second opinion strategies except for the strategy limiting second opinions only to cases of invasive cancer. The overall misclassification rate decreased from 24.7% to 18.1% when all cases received second opinions (P<0.001). Obtaining both first and second opinions from pathologists with a high volume (≥10 breast biopsy specimens weekly) resulted in the lowest misclassification rate in this test set (14.3%, 95% confidence interval 10.9% to 18.0%). Obtaining second opinions only for cases with initial interpretations of atypia, DCIS, or invasive cancer decreased the over-interpretation of benign cases without atypia from 12.9% to 6.0%. Atypia cases had the highest misclassification rate after single interpretation (52.2%), remaining at more than 34% in all second opinion scenarios. CONCLUSION Second opinions can statistically significantly improve diagnostic agreement for pathologists' interpretations of breast biopsy specimens; however, variability in diagnosis will not be completely eliminated, especially for breast specimens with atypia.
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Affiliation(s)
- Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Anna Na Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, NH, USA Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | | | - Gary M Longton
- Program in Biostatistics and Biomathematics, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Heidi D Nelson
- Providence Cancer Center, Providence Health and Services Oregon; and Departments of Medical Informatics and Clinical Epidemiology and Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Berta Geller
- Department of Family Medicine, University of Vermont, Burlington, VT, USA
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Tracy Onega
- Community and Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Kimberly H Allison
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Sara L Jackson
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Donald L Weaver
- Department of Pathology; and UVM Cancer Center, University of Vermont, Burlington, VT, USA
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340
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Rahbar H, McDonald ES, Lee JM, Partridge SC, Lee CI. How Can Advanced Imaging Be Used to Mitigate Potential Breast Cancer Overdiagnosis? Acad Radiol 2016; 23:768-73. [PMID: 27017136 DOI: 10.1016/j.acra.2016.02.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 02/22/2016] [Accepted: 02/24/2016] [Indexed: 02/08/2023]
Abstract
Radiologists, as administrators and interpreters of screening mammography, are considered by some to be major contributors to the potential harms of screening, including overdiagnosis and overtreatment. In this article, we outline current efforts within the breast imaging community toward mitigating screening harms, including the widespread adoption of tomosynthesis and potentially adjusting screening frequency and thresholds for image-guided breast biopsy. However, the emerging field of breast radiomics may offer the greatest promise for reducing overdiagnosis by identifying imaging-based biomarkers strongly associated with tumor biology, and therefore helping prevent the harms of unnecessary treatment for indolent cancers.
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341
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Elmore JG, Nelson HD, Pepe MS, Longton GM, Tosteson ANA, Geller B, Onega T, Carney PA, Jackson SL, Allison KH, Weaver DL. Variability in Pathologists' Interpretations of Individual Breast Biopsy Slides: A Population Perspective. Ann Intern Med 2016; 164:649-55. [PMID: 26999810 PMCID: PMC5064832 DOI: 10.7326/m15-0964] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The effect of physician diagnostic variability on accuracy at a population level depends on the prevalence of diagnoses. OBJECTIVE To estimate how diagnostic variability affects accuracy from the perspective of a U.S. woman aged 50 to 59 years having a breast biopsy. DESIGN Applied probability using Bayes' theorem. SETTING B-Path (Breast Pathology) Study comparing pathologists' interpretations of a single biopsy slide versus a reference consensus interpretation from 3 experts. PARTICIPANTS 115 practicing pathologists (6900 total interpretations from 240 distinct cases). MEASUREMENTS A single representative slide from each of the 240 cases was used to estimate the proportion of biopsies with a diagnosis that would be verified if the same slide were interpreted by a reference group of 3 expert pathologists. Probabilities of confirmation (predictive values) were estimated using B-Path Study results and prevalence of biopsy diagnoses for women aged 50 to 59 years in the Breast Cancer Surveillance Consortium. RESULTS Overall, if 1 representative slide were used per case, 92.3% (95% CI, 91.4% to 93.1%) of breast biopsy diagnoses would be verified by reference consensus diagnoses, with 4.6% (CI, 3.9% to 5.3%) overinterpreted and 3.2% (CI, 2.7% to 3.6%) underinterpreted. Verification of invasive breast cancer and benign without atypia diagnoses is highly probable; estimated predictive values were 97.7% (CI, 96.5% to 98.7%) and 97.1% (CI, 96.7% to 97.4%), respectively. Verification is less probable for atypia (53.6% overinterpreted and 8.6% underinterpreted) and ductal carcinoma in situ (DCIS) (18.5% overinterpreted and 11.8% underinterpreted). LIMITATIONS Estimates are based on a testing situation with 1 slide used per case and without access to second opinions. Population-adjusted estimates may differ for women from other age groups, unscreened women, or women in different practice settings. CONCLUSION This analysis, based on interpretation of a single breast biopsy slide per case, predicts a low likelihood that a diagnosis of atypia or DCIS would be verified by a reference consensus diagnosis. This diagnostic grey zone should be considered in clinical management decisions in patients with these diagnoses. PRIMARY FUNDING SOURCE National Cancer Institute.
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342
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van Lee CB, Ip Vai Ching EEF, Nasserinejad K, Neumann HAM, Bol MGW, Dikrama PK, Kelleners-Smeets NWJ, Koljenović S, Munte K, Noordhoek Hegt V, de Vijlder HC, Nijsten T, van den Bos RR. Reliability of diagnosis from Mohs slides: interpersonal and intrapersonal agreement on basal cell carcinoma presence and histological subtype. Br J Dermatol 2016; 175:549-54. [PMID: 27038202 DOI: 10.1111/bjd.14623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND The success of Mohs micrographic surgery (MMS) depends partly on the correct diagnosis of slides. OBJECTIVES To determine reliability of diagnosis from Mohs slides. METHODS This was a prospective study evaluating the reliability of diagnosis from Mohs slides of basal cell carcinoma (BCC) presence, BCC location on the slide and BCC subtype among six raters who independently assessed 50 Mohs slides twice with a 2-month interval. Slides were randomly selected whereby difficult-to-diagnose slides were oversampled. For each slide, a reference diagnosis was established by an expert panel. Cohen's kappa (κ) was calculated to determine levels of agreement interpersonally (rater vs. reference diagnosis) and intrapersonally (rater at T1 vs. T2). Multivariable logistic regression was used to determine independent risk factors for slides with interpersonal discordant diagnosis. The variables studied were BCC presence, whether a slide was scored as easy or difficult to diagnose, review duration of the 50 slides, profession and years of experience in diagnosis from Mohs slides. RESULTS Interpersonal and intrapersonal agreement were substantial on BCC presence (κ = 0·66 and 0·68) and moderate on BCC subtype (κ = 0·45 and 0·55). Slides that were scored as difficult to diagnose were an independent risk factor for interpersonal discordant diagnosis on BCC presence (odds ratio 3·54, 95% confidence interval 1·81-6·84). CONCLUSIONS Reliability of diagnosis from Mohs slides was substantial on BCC presence and moderate on BCC subtype. For slides that are scored difficult to diagnose, a second opinion is recommended to prevent misinterpretation and thereby recurrence of skin cancer.
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Affiliation(s)
- C B van Lee
- Department of Dermatology, Erasmus University Medical Centre, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - E E F Ip Vai Ching
- Department of Dermatology, Erasmus University Medical Centre, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - K Nasserinejad
- Department of Biostatistics, Erasmus University Medical Centre, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - H A M Neumann
- Department of Dermatology, Erasmus University Medical Centre, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - M G W Bol
- Department of Pathology, Isala Hospital, Zwolle, the Netherlands
| | - P K Dikrama
- Department of Dermatology, Erasmus University Medical Centre, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - N W J Kelleners-Smeets
- Department of Dermatology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - S Koljenović
- Department of Pathology, Erasmus University Medical Centre, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - K Munte
- Department of Dermatology, Maasstad Hospital, Rotterdam, the Netherlands
| | - V Noordhoek Hegt
- Department of Pathology, Erasmus University Medical Centre, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - H C de Vijlder
- Department of Dermatology, Isala Hospital, Zwolle, the Netherlands
| | - T Nijsten
- Department of Dermatology, Erasmus University Medical Centre, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - R R van den Bos
- Department of Dermatology, Erasmus University Medical Centre, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands.
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343
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Frederick PD, Nelson HD, Carney PA, Brunyé TT, Allison KH, Weaver DL, Elmore JG. The Influence of Disease Severity of Preceding Clinical Cases on Pathologists' Medical Decision Making. Med Decis Making 2016; 37:91-100. [PMID: 27037007 DOI: 10.1177/0272989x16638326] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 01/30/2016] [Indexed: 01/29/2023]
Abstract
BACKGROUND Medical decision making may be influenced by contextual factors. We evaluated whether pathologists are influenced by disease severity of recently observed cases. METHODS Pathologists independently interpreted 60 breast biopsy specimens (one slide per case; 240 total cases in the study) in a prospective randomized observational study. Pathologists interpreted the same cases in 2 phases, separated by a washout period of >6 months. Participants were not informed that the cases were identical in each phase, and the sequence was reordered randomly for each pathologist and between phases. A consensus reference diagnosis was established for each case by 3 experienced breast pathologists. Ordered logit models examined the effect the pathologists' diagnoses on the preceding case or the 5 preceding cases had on their diagnosis for the subsequent index case. RESULTS Among 152 pathologists, 49 provided interpretive data in both phases I and II, 66 from only phase I, and 37 from phase II only. In phase I, pathologists were more likely to indicate a more severe diagnosis than the reference diagnosis when the preceding case was diagnosed as ductal carcinoma in situ (DCIS) or invasive cancer (proportional odds ratio [POR], 1.28; 95% confidence interval [CI], 1.15-1.42). Results were similar when considering the preceding 5 cases and for the pathologists in phase II who interpreted the same cases in a different order compared with phase I (POR, 1.17; 95% CI, 1.05-1.31). CONCLUSION Physicians appear to be influenced by the severity of previously interpreted test cases. Understanding types and sources of diagnostic bias may lead to improved assessment of accuracy and better patient care.
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Affiliation(s)
- Paul D Frederick
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA (PDF, JGE)
| | - Heidi D Nelson
- Providence Cancer Center, Providence Health and Services Oregon, and Departments of Medical Informatics and Clinical Epidemiology and Medicine, Oregon Health & Science University, Portland, OR, USA (HDN)
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA (PAC)
| | - Tad T Brunyé
- Center for Applied Brain & Cognitive Sciences, Tufts University, Medford, MA, USA (TTB)
| | - Kimberly H Allison
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA (KHA)
| | - Donald L Weaver
- Department of Pathology, University of Vermont and UVM Cancer Center, Burlington, VT, USA (DLW)
| | - Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA (PDF, JGE)
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Chapa J, An G, Kulkarni SA. Examining the Relationship between Pre-Malignant Breast Lesions, Carcinogenesis and Tumor Evolution in the Mammary Epithelium Using an Agent-Based Model. PLoS One 2016; 11:e0152298. [PMID: 27023391 PMCID: PMC4811527 DOI: 10.1371/journal.pone.0152298] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 03/12/2016] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Breast cancer, the product of numerous rare mutational events that occur over an extended time period, presents numerous challenges to investigators interested in studying the transformation from normal breast epithelium to malignancy using traditional laboratory methods, particularly with respect to characterizing transitional and pre-malignant states. Dynamic computational modeling can provide insight into these pathophysiological dynamics, and as such we use a previously validated agent-based computational model of the mammary epithelium (the DEABM) to investigate the probabilistic mechanisms by which normal populations of ductal cells could transform into states replicating features of both pre-malignant breast lesions and a diverse set of breast cancer subtypes. METHODS The DEABM consists of simulated cellular populations governed by algorithms based on accepted and previously published cellular mechanisms. Cells respond to hormones, undergo mitosis, apoptosis and cellular differentiation. Heritable mutations to 12 genes prominently implicated in breast cancer are acquired via a probabilistic mechanism. 3000 simulations of the 40-year period of menstrual cycling were run in wild-type (WT) and BRCA1-mutated groups. Simulations were analyzed by development of hyperplastic states, incidence of malignancy, hormone receptor and HER-2 status, frequency of mutation to particular genes, and whether mutations were early events in carcinogenesis. RESULTS Cancer incidence in WT (2.6%) and BRCA1-mutated (45.9%) populations closely matched published epidemiologic rates. Hormone receptor expression profiles in both WT and BRCA groups also closely matched epidemiologic data. Hyperplastic populations carried more mutations than normal populations and mutations were similar to early mutations found in ER+ tumors (telomerase, E-cadherin, TGFB, RUNX3, p < .01). ER- tumors carried significantly more mutations and carried more early mutations in BRCA1, c-MYC and genes associated with epithelial-mesenchymal transition. CONCLUSIONS The DEABM generates diverse tumors that express tumor markers consistent with epidemiologic data. The DEABM also generates non-invasive, hyperplastic populations, analogous to atypia or ductal carcinoma in situ (DCIS), via mutations to genes known to be present in hyperplastic lesions and as early mutations in breast cancers. The results demonstrate that agent-based models are well-suited to studying tumor evolution through stages of carcinogenesis and have the potential to be used to develop prevention and treatment strategies.
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Affiliation(s)
- Joaquin Chapa
- Pritzker School of Medicine, University of Chicago, 924 East 57th Street #104, Chicago, Illinois, 60637, United States of America
| | - Gary An
- Department of Surgery, University of Chicago, 5841 S. Maryland Ave, Chicago, Illinois, 60637, United States of America
| | - Swati A. Kulkarni
- Department of Surgery, Northwestern University, Robert H. Lurie Comprehensive Cancer Center, 303 E Superior Street, Lurie, 4–105, Chicago, Illinois, 60611, United States of America
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345
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Pilling M, Gardner P. Fundamental developments in infrared spectroscopic imaging for biomedical applications. Chem Soc Rev 2016; 45:1935-57. [PMID: 26996636 DOI: 10.1039/c5cs00846h] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Infrared chemical imaging is a rapidly emerging field with new advances in instrumentation, data acquisition and data analysis. These developments have had significant impact in biomedical applications and numerous studies have now shown that this technology offers great promise for the improved diagnosis of the diseased state. Relying on purely biochemical signatures rather than contrast from exogenous dyes and stains, infrared chemical imaging has the potential to revolutionise histopathology for improved disease diagnosis. In this review we discuss the recent advances in infrared spectroscopic imaging specifically related to spectral histopathology (SHP) and consider the current state of the field. Finally we consider the practical application of SHP for disease diagnosis and consider potential barriers to clinical translation highlighting current directions and the future outlook.
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Affiliation(s)
- Michael Pilling
- Manchester Institute of Biotechnology, University of Manchester, 131 Princess Street, Manchester, M1 7DN, UK.
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346
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Yuan Y, Li M, Yang J, Elliot T, Dabbs K, Dickinson JA, Fisher S, Winget M. Factors related to breast cancer detection mode and time to diagnosis in Alberta, Canada: a population-based retrospective cohort study. BMC Health Serv Res 2016; 16:65. [PMID: 26892589 PMCID: PMC4759735 DOI: 10.1186/s12913-016-1303-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 02/10/2016] [Indexed: 01/07/2023] Open
Abstract
Background Understanding the factors affecting the mode and timeliness of breast cancer diagnosis is important to optimizing patient experiences and outcomes. The purposes of the study were to identify factors related to the length of the diagnostic interval and assess how they vary by mode of diagnosis: screen or symptom detection. Methods All female residents of Alberta diagnosed with first primary breast cancer in years 2004–2010 were identified from the Alberta Cancer Registry. Data were linked to Physician Claims and screening program databases. Screen-detected patients were identified as having a screening mammogram within 6-months prior to diagnosis; remaining patients were considered symptom-detected. Separate quantile regression was conducted for each detection mode to assess the relationship between demographic/clinical and healthcare factors. Results Overall, 38 % of the 12,373 breast cancer cases were screen-detected compared to 47 % of the screen-eligible population. Health region of residence was strongly associated with cancer detection mode. The median diagnostic interval for screen and symptom-detected cancers was 19 and 21 days, respectively. The variation by health region, however, was large ranging from an estimated median of 4 to 37 days for screen-detected patients and from 17 to 33 days for symptom-detected patients. Cancer stage was inversely associated with the diagnostic interval for symptom-detected cancers, but not for screen-detected cancers. Conclusion Significant variation by health region in both the percentage of women with screen-detected cancer and the length of the diagnostic interval for screen and symptom-detected breast cancers suggests there could be important differences in local breast cancer diagnostic care coordination.
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Affiliation(s)
- Yan Yuan
- School of Public Health, University of Alberta, Edmonton, Alberta, T6G 1C9, Canada
| | - Maoji Li
- School of Public Health, University of Alberta, Edmonton, Alberta, T6G 1C9, Canada
| | - Jing Yang
- Cancer Control Alberta, Alberta Health Services, Edmonton, Alberta, T5J 3H1, Canada
| | - Tracy Elliot
- Department of Diagnostic Imaging, Foothills Medical Centre, Calgary, Alberta, T2N 2T9, Canada
| | - Kelly Dabbs
- Department of Surgery, University of Alberta, Edmonton, Alberta, T6G 1C9, Canada
| | - James A Dickinson
- Family Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, T2N 4N1, Canada
| | - Stacey Fisher
- School of Public Health, University of Alberta, Edmonton, Alberta, T6G 1C9, Canada
| | - Marcy Winget
- Divison of General Medical Disciplines, Stanford University School of Medicine, Stanford, CA, 94305, USA.
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347
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Clauser P, Marino MA, Baltzer PAT, Bazzocchi M, Zuiani C. Management of atypical lobular hyperplasia, atypical ductal hyperplasia, and lobular carcinoma in situ. Expert Rev Anticancer Ther 2016; 16:335-46. [PMID: 26780850 DOI: 10.1586/14737140.2016.1143362] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Atypical hyperplasia and lobular carcinoma in situ are rare proliferative breast lesions, growing inside ducts and terminal ducto-lobular units. They represent a marker of increased risk for breast cancer and a non-obligate precursor of malignancy. Evidence available on diagnosis and management is scarce. They are frequently found incidentally associated with other lesions, but can be visible through mammography, ultrasound or magnetic resonance. Due to the risk of underestimation, surgical excision is often performed. The analysis of imaging and histopathological characteristics could help identifying low-risk cases, for which surgery is not necessary. Chemopreventive agents can be used for risk reduction. Careful imaging follow up is mandatory; the role of breast MRI as screening modality is under discussion.
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Affiliation(s)
- Paola Clauser
- a Department of Biomedical Imaging and Image-guided Therapy, Division of Molecular and Gender Imaging , Medical University of Vienna , Vienna , Austria
| | - Maria A Marino
- a Department of Biomedical Imaging and Image-guided Therapy, Division of Molecular and Gender Imaging , Medical University of Vienna , Vienna , Austria
| | - Pascal A T Baltzer
- a Department of Biomedical Imaging and Image-guided Therapy, Division of Molecular and Gender Imaging , Medical University of Vienna , Vienna , Austria
| | - Massimo Bazzocchi
- b Institute of Diagnostic Radiology , Department of Medical and Biological Sciences, University of Udine , Udine , Italy
| | - Chiara Zuiani
- b Institute of Diagnostic Radiology , Department of Medical and Biological Sciences, University of Udine , Udine , Italy
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348
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Dickson DJ, Pfeifer JD. Real-world data in the molecular era-finding the reality in the real world. Clin Pharmacol Ther 2016; 99:186-97. [PMID: 26565654 DOI: 10.1002/cpt.300] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 11/10/2015] [Indexed: 01/06/2023]
Abstract
Real-world data (RWD) promises to provide a pivotal element to the understanding of personalized medicine. However, without true representation (or the reality) of the patient-disease biosystem and its molecular contributors, RWD may hamper rather than help this advancement. In this review article, we discuss RWD vs. clinical reality and the disconnects that exist currently (emphasizing molecular medicine), and methods of closing the gaps between RWD and reality.
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Affiliation(s)
- D J Dickson
- Molecular Evidence Development Consortium, Rexburg, Idaho, USA
| | - J D Pfeifer
- Department of Pathology, Washington University School of Medicine, St. Louis, Missouri, USA
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Calhoun BC, Collins LC. Recommendations for excision following core needle biopsy of the breast: a contemporary evaluation of the literature. Histopathology 2015; 68:138-51. [DOI: 10.1111/his.12852] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
| | - Laura C Collins
- Department of Pathology; Beth Israel Deaconess Medical Center and Harvard Medical School; Boston MA USA
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Abstract
In the year-end editorial, the PLOS Medicine editors ask 11 researchers and clinicians about the most relevant challenges, promising research, and important initiatives in their fields as we head into 2016.
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