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Woeste MR, Jacob K, Duff MB, Donaldson M, Sanders MAG, McMasters KM, Ajkay N. Impact of routine expert breast pathology consultation and factors predicting discordant diagnosis. Surg Oncol 2022; 45:101860. [DOI: 10.1016/j.suronc.2022.101860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 09/10/2022] [Accepted: 10/02/2022] [Indexed: 12/05/2022]
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Perrier L, Rascle P, Morelle M, Toulmonde M, Ranchere Vince D, Le Cesne A, Terrier P, Neuville A, Meeus P, Farsi F, Ducimetière F, Blay JY, Ray Coquard I, Coindre JM. The cost-saving effect of centralized histological reviews with soft tissue and visceral sarcomas, GIST, and desmoid tumors: The experiences of the pathologists of the French Sarcoma Group. PLoS One 2018; 13:e0193330. [PMID: 29621244 PMCID: PMC5886412 DOI: 10.1371/journal.pone.0193330] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Accepted: 02/08/2018] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE This study examined the types of discordance occurring in the diagnosis of soft tissue and visceral sarcomas, gastrointestinal stromal tumors (GIST), and desmoid tumors, as well as the economic impact of diagnostic discrepancies. METHODS We carried out a retrospective, multicenter analysis using prospectively implemented databases performed on a cohort of patients within the French RRePS network in 2010. Diagnoses were deemed to be discordant based on the 2013 World Health Organization (WHO) classification. Predictive factors of discordant diagnoses were explored. A decision tree was used to assess the expected costs of two strategies of disease management: one based on revised diagnoses after centralized histological review (option 1), the other on diagnoses without centralized review (option 2). Both were defined based on the patient and the disease characteristics, according to national or international guidelines. The time horizon was 12 months and the perspective of the French National Health Insurance (NHI) was retained. Costs were expressed in Euros for 2013. Sensitivity analyses were performed using low and high scenarios that included ± 20% estimates for cost. RESULTS A total of 2,425 patients were included. Three hundred forty-one patients (14%) had received discordant diagnoses. These discordances were determined to mainly be benign tumors diagnosed as sarcomas (n = 124), or non-sarcoma malignant tumors diagnosed as sarcomas (n = 77). The probability of discordance was higher for a final diagnosis of desmoid tumors when compared to liposarcomas (odds ratio = 5.1; 95%CI [2.6-10.4]). The expected costs per patient for the base-case analysis (low- and high-case scenarios) amounted to €8,791 (€7,033 and €10,549, respectively) for option 1 and €8,904 (€7,057 and €10,750, respectively) for option 2. CONCLUSIONS Our findings highlight misdiagnoses of sarcomas, which were found to most often be confused with benign tumors. Centralized histological reviews are likely to provide cost-savings for the French NHI.
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Affiliation(s)
- Lionel Perrier
- University of Lyon, Léon Bérard Cancer Centre, GATE L-SE UMR 5824, Lyon, France.,Direction of Clinical Research and Innovation, DRCI, Léon Bérard Cancer Centre, Lyon, France
| | - Pauline Rascle
- Direction of Clinical Research and Innovation, DRCI, Léon Bérard Cancer Centre, Lyon, France
| | - Magali Morelle
- University of Lyon, Léon Bérard Cancer Centre, GATE L-SE UMR 5824, Lyon, France.,Direction of Clinical Research and Innovation, DRCI, Léon Bérard Cancer Centre, Lyon, France
| | - Maud Toulmonde
- Department of Medicine, Institut Bergonié, Bordeaux, France
| | | | - Axel Le Cesne
- Department of Medecine, Institut Gustave Roussy, Villejuif, France
| | | | - Agnès Neuville
- Department of Anatomopathology, Institut Bergonié, Bordeaux, France
| | - Pierre Meeus
- Department of Surgery, Cancer Centre Léon Bérard, Lyon, France
| | - Fadila Farsi
- Réseau Espace Santé Cancer Rhône-Alpes, Lyon, France
| | | | - Jean-Yves Blay
- Department of Medicine, Cancer Centre Léon Bérard, Lyon, France
| | - Isabelle Ray Coquard
- Santé-Individu-société EA-INSERM 4129, Cancer centre Léon Bérard, Lyon, France.,Department of Medicine, Cancer Centre Léon Bérard, Lyon, France
| | - Jean-Michel Coindre
- Department of Anatomopathology, Institut Bergonié, Bordeaux, France.,University Victor Ségalen, Bordeaux, France
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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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Romanoff AM, Cohen A, Schmidt H, Weltz CR, Jaffer SM, Nagi CS, Bleiweiss IJ, Port ER. Breast pathology review: does it make a difference? Ann Surg Oncol 2014; 21:3504-8. [PMID: 24859936 DOI: 10.1245/s10434-014-3792-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Breast pathology is a challenging field, and previous work has shown discrepancies in diagnoses, even among experts. We set out to determine whether mandatory pathology review changes the diagnosis or surgical management of breast disease. METHODS Cases were referred for pathology review after patients presented for surgical opinion to the Dubin Breast Center at Mount Sinai Medical Center over the course of 2 years. Surgical pathologists with expertise in breast disease reviewed slides submitted from the primary institution and rendered a second opinion diagnosis. Comparison of these reports was performed for evaluation of major changes in diagnosis and definitive surgical management. RESULTS A total of 306 patients with 430 biopsy specimens were reviewed. Change in diagnosis was documented in 72 (17 %) of 430 cases and change in surgical management in 41 (10 %). A change in diagnosis was more likely to occur in patients originally diagnosed with benign rather than malignant disease (31 vs. 7 %, p < 0.001). Twelve (7 %) of 169 specimens initially diagnosed as benign were reclassified as malignant. A malignant diagnosis was changed to benign in 4 (2 %) of 261 cases. Change in diagnosis was less common in specimens originating from commercial laboratories than community hospitals or university hospitals (8, 19, 21 %, p = 0.023). Change in management was not dependent on initial institution. Type of biopsy specimen (surgical or core) did not influence diagnostic or management changes. CONCLUSIONS We recommend considering breast pathology review based on the individual clinical scenario, regardless of initial pathologic diagnosis or originating institution.
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Affiliation(s)
- Anya M Romanoff
- Department of Surgery, Dubin Breast Center, Mount Sinai Medical Center, New York, NY, USA,
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