Concordance with breast cancer pathology reporting practice guidelines

Breast Cancer, Version 3.2022, NCCN Clinical Practice Guidelines in Oncology

The therapeutic options for patients with noninvasive or invasive breast cancer are complex and varied. These NCCN Clinical Practice Guidelines for Breast Cancer include recommendations for clinical management of patients with carcinoma in situ, invasive breast cancer, Paget disease, phyllodes tumor, inflammatory breast cancer, and management of breast cancer during pregnancy. The content featured in this issue focuses on the recommendations for overall management of ductal carcinoma in situ and the workup and locoregional management of early stage invasive breast cancer. For the full version of the NCCN Guidelines for Breast Cancer, visit NCCN.org.

Adequacy of Pathologic Reports of Invasive Breast Cancer From Mastectomy Specimens at Tikur Anbessa Specialized Hospital Oncology Center in Ethiopia

Purpose Although information from pathology reports is essential to the care of individuals with cancer and to population-level cancer control, no systematic evidence exists regarding the adequacy of breast pathology reporting in Ethiopia. This study audited pathology reports of mastectomy specimens from patients evaluated at the Tikur Anbessa Specialized Hospital Oncology Center in Addis Ababa, Ethiopia. Methods Mastectomy pathology reports from February 2014 through January 2016 were assessed for gross and microscopic information considered by the Breast Cancer Initiative 2.5 (BCI 2.5; formerly the Breast Health Global Initiative) guideline to be necessary for care of patients with breast cancer stratified according to basic, limited, and enhanced resource settings. Results Fewer than two thirds (61.6%) of the 417 reports we reviewed included all four of the BCI 2.5 basic pathology data elements we could evaluate with available data (tumor category, lymph node category, histologic type, and histologic grade). Only 1.0% of reports included all three pathology data elements recommended for limited resource settings (estrogen receptor status, margin status, and lymphovascular invasion). Several elements were significantly more likely to be noted in reports from nonpublic hospitals than from public hospitals. Although only three of 417 reports included checklists or templates, all three of these reports included all of the basic pathology information, and they all included at least two of the three limited pathology elements not already on the basic list. Conclusion More than one third (38.4%) of mastectomy pathology reports did not meet BCI 2.5 standards for basic resource settings. Quality measurement and improvement programs and capacity-building interventions by national pathology and oncology organizations, collaboration with medical and public health organizations in neighboring countries, adoption of synoptic reporting templates, use of electronic pathology reporting, and histotechnology and histopathology training collaborations with laboratories in high-resource regions are recommended.

The pattern of prognostic and risk indicators among women with breast cancer undergoing modified radical mastectomy in Dar es Salaam, Tanzania

Background

Breast cancer is the commonest female malignancy globally and the second (after uterine cervix) in sub-Saharan Africa including Tanzania. Prognostic indicators reportedly influence post-mastectomy adjuvant therapy by predicting risks on survival and recurrence although in Tanzania this data is lacking. Here, we evaluate the pattern of prognostic and risk indicators among women with breast cancer undergoing modified-radical-mastectomy (MRM) at Muhimbili National Hospital (MNH) and Tumaini Hospital (TH), Dar es Salaam, Tanzania.

Methods

This hospital-based prospective cross-sectional study included female patients undergoing MRM from April 2011 to January 2012. Clinical stage I-III patients were enrolled after being scheduled for mastectomy. Patients with evidence of distant metastasis (stage IV) were excluded. Mastectomy and axillary lymph nodes biopsies were submitted to the Histopathology laboratory for grade, type, nodal and margins status. Data was collected using a structured questionnaire and analyzed using SPSS.

Results

A total of 348 patients were admitted with breast cancer including 86 patients (with 16 from TH having similar demography and presentation) meeting inclusion criteria. Age-range at diagnosis was 28–79 years, mean 52.1 years. Most (89 %) attained menarche after 11 years. About 56 % were postmenopausal. The majority (78 %) were multiparous with positive family history in 14.1 and 37.6 % used hormonal contraceptives.

About 27.1 % were social alcohol drinkers. The majority (61 %) had T4b disease, 75.6 % had positive axillary nodes including 42.7 % with 4–9 involved nodes (N2). The commonest (91.9 %) histological type was invasive ductal carcinoma. Lobular, medullary and mucinous carcinomas were rare. Most (83.7 %) of our patients presented with stage III and the rest stage II. Intermediate- and high-grade tumors accounted for 73.5 %. Following MRM, 25 % of our patients had positive surgical margins and similarly for the base.

Conclusions

Most of our breast cancer patients present with frequent risks including younger age, multiparity, hormonal contraceptives use, alcohol use and family history. Unfavourable prognostic indicators including late stages, large primary tumor size, skin infiltration, positive surgical margins, positive axillary lymph nodes and a high histological grade were associated.

A sustainable screening program by self-examination to allow early diagnosis is needed to reduce morbidity and mortality from this cancer.

Validation of natural language processing to extract breast cancer pathology procedures and results

Background:

Pathology reports typically require manual review to abstract research data. We developed a natural language processing (NLP) system to automatically interpret free-text breast pathology reports with limited assistance from manual abstraction.

Methods:

We used an iterative approach of machine learning algorithms and constructed groups of related findings to identify breast-related procedures and results from free-text pathology reports. We evaluated the NLP system using an all-or-nothing approach to determine which reports could be processed entirely using NLP and which reports needed manual review beyond NLP. We divided 3234 reports for development (2910, 90%), and evaluation (324, 10%) purposes using manually reviewed pathology data as our gold standard.

Results:

NLP correctly coded 12.7% of the evaluation set, flagged 49.1% of reports for manual review, incorrectly coded 30.8%, and correctly omitted 7.4% from the evaluation set due to irrelevancy (i.e. not breast-related). Common procedures and results were identified correctly (e.g. invasive ductal with 95.5% precision and 94.0% sensitivity), but entire reports were flagged for manual review because of rare findings and substantial variation in pathology report text.

Conclusions:

The NLP system we developed did not perform sufficiently for abstracting entire breast pathology reports. The all-or-nothing approach resulted in too broad of a scope of work and limited our flexibility to identify breast pathology procedures and results. Our NLP system was also limited by the lack of the gold standard data on rare findings and wide variation in pathology text. Focusing on individual, common elements and improving pathology text report standardization may improve performance.

Quality of pathology reporting is crucial for cancer care and registration: a baseline assessment for breast cancers diagnosed in Belgium in 2008

OBJECTIVES

Given the crucial role of pathology reporting in the management of breast cancers, we aimed to investigate the quality and variability of breast cancer pathology reporting in Belgium.

MATERIALS AND METHODS

Detailed information on non-molecular and molecular parameters was retrieved from the pathology protocols available at the Belgian Cancer Registry for 10,007 breast cancers diagnosed in Belgium in 2008.

RESULTS

Substantial underreporting was shown for several clinically relevant non-molecular parameters, such as lymphovascular invasion. High-volume laboratories performed only slightly better than others, and analyses at the individual laboratory level showed clear inter-laboratory variability in reporting for all volume categories. Information on ER/PR and HER2 IHC was mentioned in respectively 91.7% and 90.8% of evaluative cases. HER2 ISH data were available for 78.5% of the cases judged to be 2+ for HER2 IHC. For cases with different specimens analysed, discordance between these specimens was highest for HER2, followed by PR. For HER2, results obtained from different laboratories were even less concordant. In addition, inter-laboratory differences were noted in the used ER/PR scoring systems, the proportion of ER-/PR+ cases, and the relation between histological grade and ER/PR positivity. Data on Ki67 were only available for 43.8% of the investigated cases, and showed inconsistent use of cut-off values.

CONCLUSION

Breast pathology reporting in Belgium in 2008 was suboptimal and showed considerable inter-laboratory variability. Synoptic reporting has been proposed as a facilitator towards increased reporting quality and harmonization, but the lack of aligned informatics remains a major hurdle in its concrete implementation.

Multi-level factors influence the implementation and use of complex innovations in cancer care: a multiple case study of synoptic reporting

BACKGROUND

The implementation of innovations (i.e., new tools and practices) in healthcare organizations remains a significant challenge. The objective of this study was to examine the key interpersonal, organizational, and system level factors that influenced the implementation and use of synoptic reporting tools in three specific areas of cancer care.

METHODS

Using case study methodology, we studied three cases in Nova Scotia, Canada, wherein synoptic reporting tools were implemented within clinical departments/programs. Synoptic reporting tools capture and present information about a medical or surgical procedure in a structured, checklist-like format and typically report only items critical for understanding the disease and subsequent impacts on patient care. Data were collected through semi-structured interviews with key informants, document analysis, nonparticipant observation, and tool use/examination. Analysis involved production of case histories, in-depth analysis of each case, and a cross-case analysis. Numerous techniques were used during the research design, data collection, and data analysis stages to increase the rigour of this study.

RESULTS

The analysis revealed five common factors that were particularly influential to implementation and use of synoptic reporting tools across the three cases: stakeholder involvement, managing the change process (e.g., building demand, communication, training and support), champions and respected colleagues, administrative and managerial support, and innovation attributes (e.g., complexity, compatibility with interests and values). The direction of influence (facilitating or impeding) of each of these factors differed across and within cases.

CONCLUSIONS

The findings demonstrate the importance of a multi-level contextual analysis to gaining both breadth and depth to our understanding of innovation implementation and use in health care. They also provide new insights into several important issues under-reported in the literature on moving innovations into healthcare practice, including the role of middle managers in implementation efforts and the importance of attending to the interpersonal aspects of implementation.

Surgical pathology and the patient: a systematic review evaluating the primary audience of pathology reports

The pathology report is a critical document that helps guide the management of patients with cancer. More and more patients read their reports, intending to participate in decisions about their care. However, a substantial subset of patients may lack the ability to comprehend this often technical and complex document. We hypothesized that most literature on pathology reports discusses reports from the perspective of other physicians and not from the perspective of patients. An expert panel of physicians developed a list of search criteria, which we used to identify articles on PubMed, MEDLINE, Cochrane Reviews, and Google Scholar databases. Two reviewers independently evaluated all articles to identify for detailed review those that met search criteria. We identified the primary audience of the selected articles and the degree to which these articles addressed clarity of communication of pathology reports with patients. Of 801 articles identified in our search, 25 involved the formatting of pathology reports for clarity of communication. Recurrent themes in proposed improvements in reports included content standardization, variation in terminology, clarity of communication, and quality improvement. No articles discussed patients as their target audience. No study evaluated the health literacy level required of patients to comprehend pathology reports. In summary, there is a scarcity of patient-centered approaches to improve pathology reports. The literature on pathology reports does not include patients as a target audience. Limited resources are available to help patients comprehend their reports. Efforts to improve patient-centered communication are desirable to address this overlooked aspect of patient care.

Exploring the usefulness of two conceptual frameworks for understanding how organizational factors influence innovation implementation in cancer care

Moving knowledge into practice and the implementation of innovations in health care remain significant challenges. Few researchers adequately address the influence of organizations on the implementation of innovations in health care. The aims of this article are to (1) present 2 conceptual frameworks for understanding the organizational factors important to the successful implementation of innovations in health care settings; (2) discuss each in relation to the literature; and (3) briefly demonstrate how each may be applied to 3 initiatives involving the implementation of a specific innovation-synoptic reporting tools-in cancer care. Synoptic reporting tools capture information from diagnostic tests, surgeries, and pathology examinations in a standardized, structured manner and contain only the information necessary for patient care. The frameworks selected were the Promoting Action on Research Implementation in Health Services framework and an organizational framework of innovation implementation; these frameworks arise from different disciplines (nursing and management, respectively). The constructs from each framework are examined in relation to the literature, with each construct applied to synoptic reporting tool implementation to demonstrate how each may be used to inform both practice and research in this area. By improving our understanding of existing frameworks, we enhance our ability to more effectively study and target implementation processes.

Factors related to the implementation and use of an innovation in cancer surgery

OBJECTIVE

Nationally, efforts to implement an innovation in cancer surgery-a Web-based synoptic reporting tool-are ongoing in five provinces. The objective of the present study was to identify the key multilevel factors influencing implementation and early use of this innovation for breast and colorectal cancer surgery at two academic hospitals in Halifax, Nova Scotia.

METHODS

We used case-study methodology to examine the implementation of surgical synoptic reporting. Methods included semi-structured interviews with key informants (surgeons, implementation team members, and report end users; n = 9), nonparticipant observation, and document analysis. A thematic analysis was conducted separately for each method, followed by explanation-building to integrate the evidence and to identify the key multilevel factors influencing implementation. An audit was performed to determine use.

RESULTS

Key factors influencing implementation were these: Innovation-values fitFlexibility with the innovation and implementationThe innovation is not flawlessStrengthening the climate for implementationResource needs and availabilityPartner engagementSurgeon champions and involvementIn a 6-month period after implementation, 91.2% and 58.0% respectively of eligible breast and colorectal cancer surgeries were reported using the new tool.

CONCLUSIONS

An improved understanding of the multilevel factors influencing the implementation of innovations is critical to planning effective change interventions in health care. Further study is needed to explore differences in the use of the innovation between breast and colorectal cancer surgeons. Findings will inform the study of additional cases of synoptic reporting implementation, enabling cross-case analyses and identification of higher-level themes that may be applied in similar settings or contexts.

Postsurgical pathology reporting of thyroid cancer in New South Wales, Australia

BACKGROUND

Clear, accurate, and complete reporting of postsurgical pathology is crucial for the correct evaluation and management of thyroid cancer patients. This study aimed to describe the completeness, as defined by international guidelines, of pathology reporting in a cohort of newly diagnosed thyroid cancer patients in New South Wales (NSW) and to identify factors associated with the completeness of reports.

METHODS

Postsurgical pathology reports, held by the NSW Central Cancer Registry, for 448 thyroid cancer patients were reviewed. Presence or absence of recommended key features (tumor histology type, maximum dimension, focality, completeness of excision, extrathyroidal extension, lymphovascular invasion, and lymph node involvement) was recorded. Associations between the number of key items reported and several patient characteristics were investigated.

RESULTS

For 285 (63.6%) patients one or more key pathological features were missing, with 177 (39.5%) missing one only, 88 (19.6%) missing two, and 20 (4.5%) missing three or more. Extrathyroidal extension was the most poorly reported key feature, being present in only 228 (50.9%) reports [95% confidence interval 46.2, 55.6]. Pathology reports were less complete for patients with small tumor size (p<0.001) or localized spread (p<0.001). Synoptic reports were significantly more complete than narrative-style reports (98.3% vs. 27.1%, p<0.001).

CONCLUSIONS

Postsurgical pathology reporting of differentiated thyroid cancer in NSW was found to be far from complete, with 64% of reports missing information on at least one feature that is considered internationally to be a critical factor in the prognosis and treatment of thyroid cancer patients. Synoptic reporting reduces the number of key features missing from pathology reports.

Exploring the interpersonal-, organization-, and system-level factors that influence the implementation and use of an innovation-synoptic reporting-in cancer care

Background

The dominant method of reporting findings from diagnostic and surgical procedures is the narrative report. In cancer care, this report inconsistently provides the information required to understand the cancer and make informed patient care decisions. Another method of reporting, the synoptic report, captures specific data items in a structured manner and contains only items critical for patient care. Research demonstrates that synoptic reports vastly improve the quality of reporting. However, synoptic reporting represents a complex innovation in cancer care, with implementation and use requiring fundamental shifts in physician behaviour and practice, and support from the organization and larger system. The objective of this study is to examine the key interpersonal, organizational, and system-level factors that influence the implementation and use of synoptic reporting in cancer care.

Methods

This study involves three initiatives in Nova Scotia, Canada, that have implemented synoptic reporting within their departments/programs. Case study methodology will be used to study these initiatives (the cases) in-depth, explore which factors were barriers or facilitators of implementation and use, examine relationships amongst factors, and uncover which factors appear to be similar and distinct across cases. The cases were selected as they converge and differ with respect to factors that are likely to influence the implementation and use of an innovation in practice. Data will be collected through in-depth interviews, document analysis, observation of training sessions, and examination/use of the synoptic reporting tools. An audit will be performed to determine/quantify use. Analysis will involve production of a case record/history for each case, in-depth analysis of each case, and cross-case analysis, where findings will be compared and contrasted across cases to develop theoretically informed, generalisable knowledge that can be applied to other settings/contexts. Ethical approval was granted for this study.

Discussion

This study will contribute to our knowledge base on the multi-level factors, and the relationships amongst factors in specific contexts, that influence implementation and use of innovations such as synoptic reporting in healthcare. Such knowledge is critical to improving our understanding of implementation processes in clinical settings, and to helping researchers, clinicians, and managers/administrators develop and implement ways to more effectively integrate innovations into routine clinical care.

Completeness of dictated operative reports in breast cancer--the case for synoptic reporting

BACKGROUND

Currently, the dictated operative report forms the cornerstone of documenting breast cancer surgery. Synoptic electronic reporting using a standardized template has been proposed for breast cancer operative notes to improve documentation. The goal of this study was to determine the current completeness of dictated operative reports for breast cancer surgery.

METHODS

An iterative, consensus-based approach to determining elements of a proposed synoptic surgical operative report identified critical elements. We then evaluated the dictated operative reports of 100 consecutive breast cancer patients for completeness of these elements.

RESULTS

Details regarding presentation and diagnosis were frequently incomplete (84%). Among patients undergoing mastectomy, the potential for breast conservation was partially described in only 60%. Only 41% had data regarding intra-operative margin assessment during breast conservation surgery. In axillary lymph node dissections, 92% of patients had complete data about preservation of nerves, yet only 14% of reports contained complete information regarding sentinel lymph node biopsy. Closure was partially described in 91%.

CONCLUSIONS

The dictated operative report for breast cancer surgery does not adequately capture important data. A synoptic reporting system, which requires documentation of important elements, is a potentially beneficial tool in breast cancer surgery.

Variability in the quality of pathology reporting of margin status following breast cancer surgery

BACKGROUND

Accurately determining margin status is important for breast cancer treatment. The College of American Pathologists (CAP) developed guidelines to standardize reporting of margin status. The aim of this study is to determine statewide concordance with CAP breast cancer reporting guidelines for margin status.

METHODS

The Vermont Breast Cancer Surveillance System (VBCSS) tracks mammography-related services provided to all women treated for breast cancer at hospitals in Vermont. These data include accompanying pathology reports, which were analyzed for descriptions of margin status. The CAP protocols have both requirements and recommendations for margin status reporting. Reports were "minimally compliant" if they adhered to the requirements stated in the CAP protocols or "maximally compliant" if they included the recommended protocols in addition to those required.

RESULTS

There were 2,016 reports that met the inclusion criteria. A total of 71.1% were minimally compliant and 37.3% were maximally compliant with the CAP guideline standards. There was a statistically significant rise in compliant reports, with minimally compliant reports increasing from 55.7% in 1998 to 79.3% in 2006, and maximally compliant reports rising from 4.7% in 1998 to 53.7% in 2006 (χ(2) trend test, P < 0.001) for both cohorts.

CONCLUSIONS

Reporting of margin status in breast-conserving surgery varies widely. There is a significant rise in guideline compliance with margin status reporting from 1998 to 2006; however, overall compliance remains suboptimal. This study provides evidence to support the need for quality improvement measures in the implementation of CAP guidelines for reporting margin status following breast-conserving surgery.

The Impact of Lymphovascular Invasion on Lymph Node Status in Patients with Breast Cancer

Lymphovascular invasion (LVI) is not uniformly found or reported in breast cancer tumor reports. We sought to determine the impact of the finding of LVI on various parameters of lymph node status in patients with breast cancer. A chart review was performed of 400 node-positive patients from a cohort of patients in a prospective multicenter national sentinel node registry. The finding of LVI was then correlated to number of positive sentinel nodes, the number of positive non-sentinel nodes, the lymph node ratio, and the size of the largest metastatic deposit. Of the 400 patients, data regarding LVI were missing in 98 (24.5%) cases. Although all of these patients were node-positive, LVI was noted to be present in 155 patients (38.8%) and absent in 147 (36.8%). LVI was found to correlate with more positive sentinel nodes (mean, 1.72 vs 1.35; P < 0.001), more positive nonsentinel nodes (mean, 2.16 vs 0.54; P < 0.001), and a higher lymph node ratio (0.29 vs 0.16; P < 0.001). LVI also correlated with size of largest metastatic deposit ( P = 0.002). Although LVI is known to be associated with lymph node status, it is not frequently noted on pathology reports. Given its prognostic value, LVI should be carefully evaluated and reported.

Standardized synoptic cancer pathology reporting: a population-based approach

Cancer pathology reports contain information which is critical for patient management and for cancer surveillance, resource planning, and quality purposes. The College of American Pathologists (CAP) has defined scientifically validated content of checklists that form the basis for synoptic cancer pathology reporting. We outline how the CAP standards were implemented in a large Canadian province over a 3-year period resulting in improvements in rates of synoptic reporting and completeness of cancer pathology reporting.

Improving the Quality of Surgical Pathology Reports for Breast Cancer: A Centralized Audit With Feedback

Context.—Good communication of pathologic characteristics of a malignancy is crucial to therapy choices and accurate prognostication. The information must be easily retrieved from a surgical pathology report.

Objectives.—To evaluate, first in 1999, the quality of surgical pathology reports for segmental breast resections for cancer in Quebec hospitals. Subsequently, to reevaluate, in 2003, the same indicators to determine if the first surveillance, with feedback, was associated with an improvement in the quality of the reports.

Design.—All Quebec hospitals performing the preset number of 20 or more segmental breast resections for cancer in 1999 and 2003 participated. A committee of pathologists, after review of the literature, chose 7 diagnostic elements deemed vital to a surgical pathology report for conservative breast cancer surgery. Medical archivists in each institution were instructed on how to retrieve the data. The main outcome measure was the presence or absence of the diagnostic information clearly presented on the surgical pathology report.

Results.—Fifty-one hospitals participated in 1999 and 50 in 2003. Overall, conformity improved from 85.0% in 1999 for the first evaluation to 92.5% in 2003 for the second evaluation (P &lt; .001). Six of the 7 indicators showed an improvement in the level of conformity between the first and second evaluations. Conformity was weakest for recording the distance between the tumor and the resection margin (68.2%) and vascular/lymphatic invasion (61.4%) in 1999.

Conclusions.—Surveillance of quality of surgical pathology reports, with feedback, is significantly associated with an improvement in the quality of reports.

Comparison of estrogen receptor results from pathology reports with results from central laboratory testing

We compared estrogen receptor (ER) assay results abstracted from pathology reports with ER results determined on the same specimens by a central laboratory with an immunohistochemical assay. Paraffin sections were cut from tissue microarrays containing 3093 breast cancer specimens from women enrolled in the Nurses' Health Study, 1851 of which had both pathology reports and tissue available for central laboratory testing. All sections were immunostained for ER at the same time. The original assays were biochemical for 1512 (81.7%) of the 1851 specimens, immunohistochemical for 336 (18.2%), and immunofluorescent for three (0.2%). ER results from pathology reports and repeat central laboratory testing were in agreement for 87.3% of specimens (1615 of the 1851 specimens; kappa statistic = 0.64, P < .001). When the comparison was restricted to the specimens for which the ER assays were originally performed by immunohistochemistry, the agreement rate increased to 92.3% of specimens (310 of the 336 specimens; kappa statistic = 0.78, P < .001). Thus, ER assay results from pathology reports appear to be a reasonable alternative to central laboratory ER testing for large, population-based studies of patients with breast cancer.

Baseline radiological staging in primary breast cancer: impact of educational interventions on adherence to published guidelines

RATIONALE

The purpose of baseline radiological staging in newly diagnosed breast cancer patients is to rule out overt metastatic disease. We have previously compared the use of radiological staging at our institution with the recommendations of the Cancer Care Ontario Practice Guidelines Initiative (CCOPGI). Our results demonstrated that between January 2000 to December 2002, a high proportion of our cohort (n = 135) of patients underwent unnecessary investigations.

OBJECTIVES

To implement and assess an educational intervention to encourage staging guideline utilization in a cohort of early breast cancer patients.

METHODS

In January 2003, multidisciplinary educational rounds were held, highlighting the CCOPGI guidelines, and reporting results of the audit of staging investigations. The staging guidelines were then included in the Clinical Practice Guidelines of the Breast Disease Site Group, Toronto-Sunnybrook Regional Cancer Centre. A retrospective chart review was completed that assessed staging investigations from a random sample of a similar group of patients (n = 134) from January 2003 to April 2005, to explore the effects of these educational interventions on clinical practice.

RESULTS

For patients with Stage I breast cancer, there was a significant decrease (P < 0.004) in each type of investigation: a twofold decrease in chest X-rays; 2.5-fold decrease bone scans and fourfold decrease in the number of abdominal ultrasounds. For patients in Stage II, there was no significant change in the proportion of patients undergoing radiological investigations. There was a non-significant trend towards appropriately receiving all three investigations for patients with Stage III disease.

CONCLUSIONS

Our results demonstrate that prior to the educational intervention, many patients with early breast cancer were undergoing inappropriate radiological staging. Since 2003 however, for Stage I patients there has been a significant improvement in adherence with the guidelines. We hypothesize that our educational intervention had a positive impact on improving the utilization of baseline radiological staging in patients with primary breast cancer.

Variability in gross and microscopic pathology reporting in excisional biopsies of breast cancer tissue

Accurate and complete information in pathology reporting is essential since most breast cancer treatment decisions are based on pathologic findings. The College of American Pathologists (CAP) has guidelines for breast cancer reporting; however, pathology reports remain variable. Data were collected on 91 consecutive breast cancer excisional biopsies from "outside slide review" (OSR) cases for a 2-year period to determine the variability in pathology reports in gross and microscopic examinations from 50 different outside community and university hospitals located primarily in the southwestern United States. From the gross pathology report, the following items were analyzed: measurement and weight of specimens, orientation provided by surgeons, number of blocks submitted, designation of margins, and whether margins were indicated as "shaved" or "perpendicular" in relation to the breast tissue at the time of grossing. From the final diagnoses, the following items were analyzed: type and size of tumor, and surgical margins. The results show that 100% of the reports documented the measurement of specimen size, and 30% documented the specimen weight. Surgeons provided orientation of the breast specimens in 65% of cases. Surgical margins were inked in 58%, while only 18% described how margins were submitted (either shaved or perpendicular to the mass). Only 30% of specimens were submitted in toto, 1% were submitted with an unknown amount of tissue, and 69% were submitted in representative sections with an average of 13 blocks for lumpectomies. In the final diagnoses, all reports had documentation of the tumor type and size of the invasive cancer; 26% of the final diagnoses had ductal carcinoma in situ (DCIS) and just 5% of those reports documented the size of the DCIS. The surgical margin status was reported in only 76% of the final diagnoses. This study shows that the pathology reports were heterogeneous with respect to reporting gross and microscopic final diagnoses from the variable hospitals.

Pathologic evaluation of radical cystectomy specimens

BACKGROUND

The authors evaluated the pathology of radical cystectomy and pelvic lymph node specimens from patients with bladder carcinoma who were enrolled in a cooperative group trial. Their objective was to determine whether current practices conform to suggested pathology practice guidelines for reporting on radical cystectomy and pelvic lymph node specimens.

METHODS

Overall, 268 patients underwent radical cystectomy with pelvic lymph node dissection over 11 years in a total of 109 diverse geographic locations and types of institutions. Institutions included 50 community hospitals, 36 academic hospitals, and 23 Veterans Administration (VA)/military hospitals, which evaluated 84, 137, and 47 patients, respectively. The quality of pathology examination was assessed based on the original pathology reports of specimens that were submitted according to published practice guidelines.

RESULTS

Among all types of institutions, pathologic evaluation of radical cystectomy specimens generally was complete for tumor histology, grade, size, location, pathologic stage, lymph node status, prostate involvement, and associated mucosal abnormalities, including ureters and urethra. Perivesical fat (soft tissue) margins were not recorded in 10% of specimens, and 18% of patients did not mention either the presence or the number of lymph nodes. These deficiencies were observed primarily at community and VA hospitals.

CONCLUSIONS

The overall quality of pathologic examination of radical cystectomy specimens is high. Better reporting of soft tissue margin status and pelvic lymph node counts is needed to achieve compliance with the standards published by evolving practice protocols. Standardized pathologic evaluation and reporting of radical cystectomy specimens will optimize important prognostic information and foster better communication between the pathologist, surgeon, and interested oncologists to benefit patients.