A review of pathology reporting for breast cancer

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.

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.

Does the caseload of the pathologist influence the minimum and extended data set of pathology variables reported for rectal adenocarcinoma?

BACKGROUND

The role of adjuvant therapy for rectal carcinoma, both radiotherapy and chemotherapy, remains controversial. Nevertheless, some stages of rectal cancer may benefit from adjuvant therapies. Post-operative decision making is determined by accurate pathology staging of the tumour which may depend on the experience, expertise and activity of the pathologist and by surgeon variables.

METHODS

Pathology reports for consecutive rectal cancer resection specimens at five University of Sydney teaching hospitals were assessed for the presence of important pathology variables. The desired minimum data set included the assessment of six major variables: extent of tumour penetration, distal and circumferential margins, degree of differentiation, number of nodes and identification of an apical node. A multivariate analysis was performed to see if the activity of the pathologist (number of specimens reported in time period) correlated with the number of minimum data set pathology variables reported. Multivariate analysis was also used to determine if the activity (number of resections) or training (colorectal society vs non-society) of the surgeon were correlated with variables potentially related to adequate surgical clearance of the tumour and to abdominoperineal (APE) resection rates.

RESULTS

Four hundred and forty-five consecutive rectal cancer pathology reports were reviewed. Of the minimum data set (six variables) only 17% of the reports documented all of these major variables (range 2-6). Apical node identification was reported in only 47% of reports and circumferential margin in only 39%. Circumferential margin was reported significantly more frequently in the higher activity group of pathologists (51% vs 29%, P=0.00001). APE rates were significantly different between some of the hospitals (range 19-31%). Surgeons performing more than 20 resections had lower APE rates (16% vs 37%, P=0.000 001) than those with less than 20 resections. There was no difference in APE rates between society and non-society surgeons. Distal margins of <2 cm for anterior resections were significantly higher in non-society surgeons (52% vs 36%, P=0.004).

DISCUSSION

Standardized reporting, template proformas and perhaps dedicated gastrointestinal pathologists may improve reporting of surgical rectal cancer specimens.

An audit of breast cancer pathology reporting in Australia in 1995

To measure the quality of pathology reporting of breast cancer and establish a baseline against which future changes can be measured, we audited item completeness in breast cancer reports in Australia in 1995 before the release of specific recommendations from the Australian Cancer Network. Tumour type and size were given in reports of invasive breast cancer for 93% of women, 70% had, in addition, grade and clearance of the margins while only 28% had all recommended information. The most complete items in reports were histological type of breast cancer (99.6% of cases), tumour size (94%, 95% confidence interval (CI) 92-95) and margins of excision (87%, 95% CI 85-89). Histological grade (84%, 95% CI 82-86 of cases) and presence or absence of ductal carcinoma in situ (DCIS) (79%, 95% CI 77-81) were less complete and vessel invasion (61%, 95% CI 58-63) and changes in non-neoplastic breast tissue adjacent to the breast cancer (68%, 95% CI 66-71) the least complete. Less than half the reports of DCIS reported on tumour size (49%, 95% CI 42-57), presence or absence of necrosis (41%, 95% CI 34-49) or nuclear grade (39%, 95% CI 31-46). Around 1500 reports were identified as issued by 147 laboratories and 392 pathologists; 69% of pathologists issued fewer than two reports a month in the audit. We concluded that infrequency of reporting may have contributed to incompleteness of reporting. In addition, we found significant variation across Australian states with some indication that reporting was consistently poor in one state. The audit highlighted areas for improvement for breast cancer reporting in Australia. Research evidence suggests that multifaceted strategies are needed to assist practitioners with implementing more uniform reporting standards.