An audit of breast cancer pathology reporting in Australia in 1995

[Adequacy of histopathology request forms and pathological reports of breast cancer surgical specimens in Benin]

Introduction

Breast cancer requires multidisciplinary management. Pathologists and physicians communicate using the histopathology request form and the pathology report. There are some minimal criteria that both should respect.

Objective

We assessed the adequacy of histopathology request forms and pathology reports in the management of female breast cancer specimens in Southern Benin.

Method

This was a cross-sectional, descriptive and analytical study, with retrospective data collection over 57 months (4 years and 9 months). The adequacy of the histopathology request forms and pathology reports was assessed on the basis of the recommendations of the Haute Autorité de Santé (HAS) of France. Data processing was done using SPSS software. We checked frequencies with the Chi2 test, with a significance level set at 5%.

Results

31.3% of histopathology request forms complied with HAS recommendations. Pathology reports were presented in a narrative way in 92.7% of cases and 68.8% met the minimal criteria. The presence of vascular embolus, of hormone receptors and the HER2 status were all reported in only 29.2% of the reports.

Discussion

The draft of histopathology request forms and pathology reports did not comply to the required minimal criteria. This situation could mainly be explained by the inexistence of consensus between physicians and pathologists and by the lack of immunohistochemistry. Editing national referentials and using synoptic reports would give better results.

Missing parameters in malignant polyp histology reports: can appropriate decisions be made?

The treatment of colorectal malignant polyps is dependent upon quality reporting of the histopathological features known to predict the risk of residual disease or lymph node metastasis. The Royal College of Pathologists of Australasia (RCPA) has produced protocols covering mandatory and recommended pathological parameters to be included in the pathology reporting of malignant polyps. This paper aimed to assess the quality of the pathological reporting in a population-wide analysis from 2011-2019 in Queensland, Australia. A retrospective population-wide cohort study was performed using the Queensland Oncology Repository as a data source. The number of missing pathological parameters (assessed against the RCPA protocol standards and guidelines) for each patient was then summed. Demographic and other patient details were collated. The number of patients whose recommended treatment could theoretically be altered by the full reporting of missing parameters was calculated. A total of 1,646 histopathological reports of malignant polyps were reviewed. From this, 30.8% of all reports had a sufficient number of missing parameters that may have seen an alternate management strategy chosen. The most commonly under-reported parameter from the standards was either a Haggitt or Kikuchi level with 48.6% missing. Synoptic reporting significantly reduced the mean number of missing pathological parameters (p<0.001) There was a significant improvement in the number of missing pathological details over time (p<0.001). Accurate and complete pathology reports are essential to formulate appropriate surgical recommendations after the resection of malignant polyps. In this population-based study, pathology reports remain incomplete for the established parameters despite the introduction of an RCPA structured reporting protocol. Fortunately, the quality of pathological reporting has improved since the introduction of the first RCPA protocol covering reporting of malignant polyps.

Quality of Histopathological Reporting in Breast Cancer: Results From Four South African Breast Units

PURPOSE

High-quality histopathology reporting forms the basis for treatment decisions. The quality indicator for pathology reports from the European Society of Breast Cancer Specialists was applied to a cohort from four South African breast units.

METHODS

The study included 1,850 patients with invasive breast cancer and evaluated 1,850 core biopsies and 1,158 surgical specimen reports with cross-center comparisons. A core biopsy report required histologic type; tumor grade; and estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 (HER2) status, with a confirmatory test for equivocal HER2 results. Ki-67 was regarded as optional. Pathologic stage, tumor size, lymphovascular invasion, and distance to nearest invasive margin were mandatory for surgical specimens. Specimen turnaround time (TAT) was added as a locally relevant indicator.

RESULTS

Seventy-five percent of core biopsy and 74.3% of surgical specimen reports were complete but showed large variability across study sites. The most common reason for an incomplete core biopsy report was missing tumor grade (17.9%). Half of the equivocal HER2 results lacked confirmatory testing (50.6%). Ki-67 was reported in 89.3%. For surgical specimens, the closest surgical margin was reported in 78.1% and lymphovascular invasion in 84.8% of patients. Mean TAT was 11.9 days (standard deviation [SD], 10.8 days) for core biopsies and 16.1 days (SD, 11.3) for surgical specimens.

CONCLUSION

Histopathology reporting is at a high level but can be improved, especially for tumor grade, HER2, and Ki-67, as is reporting of margins and lymphovascular invasion. A South African pathology consensus will reduce variability among laboratories. Routine use of standardized data sheets with synoptic reports and ongoing audits will improve completeness of reports over time.

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.

Breast Cancer Reporting in Lagos, Nigeria: Implications for Training and Education in Africa

PURPOSE

To assess the completeness and accuracy of breast cancer pathologic reporting in Nigeria.

MATERIALS AND METHODS

The histologic parameters provided in breast cancer pathology reports at a large teaching hospital in Nigeria were assessed. The corresponding slides were reviewed after the United Kingdom Royal College of Pathologists guidelines, and results were compared.

RESULTS

Out of 115 breast cancer cases, histologic type of breast carcinoma was concordant with the review type in 53.1% of cases and discordant in 46.9%. Grading was stated in 89.62% of cases, of which 50.5% were correctly graded, 35.8% were under-graded, and 8.5% were over-graded. Poor fixation and omission of the mitotic count were the main reasons for discordant grades. A comment on lymph node status was included in 40% of cases, and lymphovascular invasion was not commented on in 97.4% of cases. Only 26% of the tumors had hormone receptors and/or HER2 tested.

CONCLUSION

Some essential histologic parameters were absent from the histologic reports, and where present, a proportion were inaccurate. Attention to specimen fixation and method of grading and familiarity with uncommon breast cancer types are required; all can be facilitated by education and training. The use of a template/proforma is recommended to ensure cancer data set parameters are included in the pathology reports.

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.

Histopathology reporting of breast cancer in Queensland: the impact on the quality of reporting as a result of the introduction of recommendations

AIMS

Recommendations for the pathology reporting of breast cancer were released in Australia to ensure detailed communication of important prognostic features and good patient management. An audit of the reporting of invasive breast cancer in Queensland was conducted to determine how well these guidelines were utilised in 2004.

METHODS

A random sample of reports was audited for inclusion of recommended criteria. The proportion of reports meeting each of the criteria was determined and compared across whether the report was in a synoptic report template or in a free text format. Comparison was made with published data from prior to the release of the recommendations.

RESULTS

Of the 419 reports in the sample, at least 90% of reports included lesion size, histological type, histological grade, lymph node involvement, margins of excision, lymphovascular invasion, and changes in adjacent breast tissue individually, and 74% included all seven of these essential criteria. Synoptic reports accounted for 76% of the sample and were significantly more likely to have documented grade (p < 0.001), quadrant (p = 0.003), calcification (p < 0.001), lymphovascular invasion (p < 0.001), changes in non-neoplastic breast (p < 0.001) and ductal carcinoma in situ criteria (p < 0.001) compared with free text report format. The most notable improvements since the implementation of the recommendations were in documentation of adjacent breast tissue (92% versus 49%) and lymphovascular invasion (97% versus 54%).

CONCLUSION

Breast cancer reporting in Queensland has improved since the implementation of the recommendations, however further improvements would likely be seen if there is more widespread utilisation of a synoptic report format.

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.

Pathology reporting of breast cancer: trends in 1989-1999, following the introduction of mammographic screening in Western Australia

BACKGROUND

A survey of pathology reporting of breast cancer in Western Australia in 1989 highlighted the need for improvement. The current study documents (1) changes in pathology reporting from 1989 to 1999 and (2) changes in patterns of histopathological prognostic indicators for breast cancer following introduction of mammographic screening in 1989.

METHODS

Data concerning all breast cancer cases reported in Western Australia in 1989, 1994 and 1999 were retrieved using the State Cancer Registry, Hospital Morbidity data system, and pathology laboratory records.

RESULTS

Pathology reports improved in quality during the decade surveyed. For invasive carcinoma, tumour size was not recorded in 1.2% of pathology reports in 1999 compared with 16.1% in 1989 (p<0.001). Corresponding figures for other prognostic factors were: tumour grade 3.3% and 51.6% (p<0.001), tumour type 0.2% and 4.1% (p<0.001), vascular invasion 3.7% and 70.9% (p<0.001), and lymph node status 1.9% and 4.5% (p = 0.023). In 1999, 5.9% of reports were not in a synoptic/checklist format, whereas all reports were descriptive in 1989 (p<0.001). For the population as a whole, the proportion of invasive carcinomas <1 cm was 20.9% in 1999 compared with 14.5% in 1989 (p<0.001); for tumours <2 cm the corresponding figures were 65.4% and 59.7% (p = 0.013). In 1999, 30.5% of tumours were histologically well-differentiated compared with 10.6% in 1989 (p<0.001), and 61.7% were lymph node negative in 1999 compared with 57.1% in 1989 (p = 0.006). Pure ductal carcinoma in situ (DCIS) constituted 10.9% and 7.9% of total cases of breast carcinoma in 1999 and 1989, respectively (p = 0.01).

CONCLUSIONS

Quality of pathology reporting improved markedly over the period, in parallel with adoption of standardised synoptic pathology reports. By 1999, recording of important prognostic information was almost complete. Frequency of favourable prognostic factors generally increased over time, reflecting expected effects of mammographic screening.

Surgery and outcomes of ductal carcinoma in situ of the breast: a population-based study in Australia

We examined surgery and outcome in a population-based series of 2109 women newly diagnosed with ductal carcinoma in situ (DCIS) in 1995-2000 in New South Wales (NSW), Australia. The sole data source for the study was pathology records in the NSW Cancer Registry. Most DCIS was treated with breast-conserving surgery (BCS); use of breast conservation increased throughout the 6 years of the study. Women who were younger, had higher grade DCIS or had larger lesions were significantly and independently less likely to have BCS than other women. Eighteen percent of women had lymph nodes removed, most often with mastectomy. The NSW Cancer Registry does not collect information about radiotherapy. Based on cancer registrations alone, 97.7% of women were free of ipsilateral invasive cancer after three years; more women who had mastectomy were cancer-free (100%) than women who had breast-conserving surgery (97.2%; P=0.05).

Ductal carcinoma in situ of the breast, a population-based study of epidemiology and pathology

In a population-based series of 2109 women with ductal carcinoma in situ (DCIS) diagnosed in 1995–2000 in New South Wales, Australia, incidence increased by an average of 5.5% a year, mostly between 1995 and 1996 and in women 50–69 years of age. This increase paralleled the increases in mammographic screening. BreastScreen NSW, an organised mammographic screening programme, detected 65% of all DCIS. High-grade lesions were 54% of all lesions and were more likely to be 2+ cm in diameter (OR=2.12, 95%CI 1.46–3.14) than low-grade lesions. In all, 40% of DCIS in women younger than 40 years was 2+ cm in diameter compared with 21% in women 40 years and older. Young age, high grade, mixed architecture and multifocality were significant and independent predictors of 2+ cm DCIS.

Supporting the implementation of breast pathology recommendations: feasibility of a feedback mechanism to pathologists

AIMS

The aims of the study were to explore the feasibility, acceptability, impact and cost of a feedback program to pathologists reporting on breast specimens through a BreastScreen Service.

METHODS

The study was conducted at a single BreastScreen NSW Screening and Assessment Service. Pathology reports were audited against the ACN recommendations about pathology reporting [Australian Cancer Network Pathology Working Party. The Pathology Reporting of Breast Cancer: a guide for pathologists, surgeons and radiologists. Sydney: Australian Cancer Network, 1997] during two consecutive periods. Feedback was provided to pathologists at the completion of each audit. A comparison of completeness of pathology reports between audits was undertaken. The Screening and Assessment Service staff and participating pathologists were interviewed to assess acceptability and information about resource allocation.

RESULTS

The study demonstrated that the feedback mechanism was acceptable to pathologists and staff at the BreastScreen Screening and Assessment Service, and that participation in the study resulted in some improvements in pathology reporting.

CONCLUSIONS

The study demonstrated the feasibility of providing feedback to pathologists about their reporting of breast specimens. However, there were costs to the Service of participating. A way of managing these costs would need to be explored if the feedback mechanism was made a routine BreastScreen procedure.

Concordance with breast cancer pathology reporting practice guidelines

BACKGROUND

Accurate pathology reporting is important for treatment of breast cancer. The College of American Pathologists (CAP) distributed guidelines for reporting cancer specimens in 1998. The aim of this study was to determine community-wide concordance with CAP breast cancer reporting guidelines.

STUDY DESIGN

Pathology reporting of stage I and II breast cancers was examined for adherence to CAP guidelines. Pathology reports were reviewed from 100 consecutive cases of invasive breast cancers referred to Roswell Park Cancer Institute in 1998 to 1999 from community hospitals after excisional breast biopsy and 20 consecutive cases with excisional biopsy at RPCI. Adherence to CAP guidelines for clinically relevant items was determined from the original pathology report in each case.

RESULTS

One hundred one cases met the inclusion criteria. Most reports did not include at least one of the guideline required elements. Surgical margins were inked in only 77%, and the margins oriented in only 25% of patients. Many specimens were not oriented by the surgeon. Grade was reported in most cases, but the Bloom Scarf Richardson grade was reported in only 6%. The presence or absence of lymphovascular invasion, and of coexisting in situ disease, was reported in 57% and 71%, respectively. The extent and type of in situ disease was reported in 47% and 49%, respectively.

CONCLUSIONS

Breast cancer pathology reporting varies widely. Key elements that affect treatment are often omitted. These include gross description and size, orientation and involvement of surgical margins, and description of histologic features, including Bloom Scarf Richardson reporting of grade and the extent of an in situ component. Passive distribution of CAP practice guidelines might be insufficient to accomplish community-wide quality improvement in breast pathology reporting.

Breast cancer pathology practices among Medicare patients undergoing unilateral extended simple mastectomy

OBJECTIVE

Information in pathology reports of breast cancer specimens is of critical importance to treating physicians for selection of local regional treatment and adjuvant therapy, evaluation of therapy, estimation of prognosis, and analysis of outcomes. This information is also of great importance to patients and their families. The Cancer Committee of the College of American Pathologists (CAP) and the Association of Directors of Anatomic and Surgical Pathology (ADASP) have published protocols for reporting the findings on breast cancer specimens to encourage adequate specimen examination and promote the reporting of findings in standardized formats and to provide treating physicians and their patients with vital information.

METHODS

To assess the quality of breast cancer pathology practices and the degree to which they agree with published guidelines, we undertook a retrospective analysis among Medicare patients in New York State. Our random sample consisted of 748 (43.5%) of the 1718 cases of unilateral extended simple mastectomy, also referred to as total mastectomy with lymph node dissection (ICD-9-CM procedure code 85.43), for calendar year 1999. Of these, 555 (74.2%) were available for study, whereas the rest did not satisfy inclusion criteria. Among the 555 cases, 545 (98.2%) were women, and 10 (1.8%) were men. The gender distribution was proportionately the same at 98.2% and 1.8% for all 1718 cases.

RESULTS

We examined the 555 hospital records for 16 elements (quality indicators). Aggregate performance on 7 of these was > or =83.7%, and performance was < or = 69.4% on 9 others. There were significant interhospital disparities in performance levels for a number of quality indicators. Although some hospitals always recorded certain indicators, others never did.

CONCLUSIONS

The issues with breast cancer pathology reports identified in this study are amenable to improvement to better serve patients, especially women, and their treating physicians in making adjuvant decisions, estimating prognosis, and evaluating outcomes.

Variations in treatment and survival in breast cancer

To achieve optimum quality of care for women with breast cancer in the UK, uniformity of care in accordance with consensus guidelines is needed. This review highlights variations in provision of care for women with breast cancer, with particular emphasis on care received in the UK, examines differences in survival, and discusses the factors that may underlie these differences. Strong variation in treatment was identified, which appeared to affect survival significantly. These findings reinforce the need for women with breast cancer to be treated by dedicated specialists working within a multidisciplinary team to provide a high standard of care.

Variations in diagnostic and therapeutic procedures in a multicentre, randomized clinical trial (EORTC 10853) investigating breast-conserving treatment for DCIS

AIMS

To evaluate the diagnostic and therapeutic procedures which were followed in a European Organization for Research and Treatment of Cancer (EORTC) randomized clinical trial investigating the role of radiotherapy in breast-conserving treatment (BCT) for ductal carcinoma in situ (DCIS) of the breast.

METHODS

The medical files of 824 of the 1010 randomized patients (82%) were reviewed during site visits to 30 participating institutes.

RESULTS

Large variations occurred, particularly in the surgical procedures and histopathological work-up which were performed. Important risk factors like tumour size and margin status were poorly quantified in the medical files.

CONCLUSIONS

These findings emphasize the need for establishing uniform guidelines for diagnostic and therapeutic procedures for DCIS, and for clearly defined risk factors for recurrence after BCT for DCIS. Because of its randomized nature, the main question of the trial, i.e. the effect of radiotherapy on the risk of local recurrence, will not be influenced by variation. The risk of local recurrence in itself, and hence the success of BCT for DCIS, may however be influenced by the quality of the initial procedures that were conducted.