Pathology Diagnosis: What You Don’t Know Can Hurt You
(From CancerWire July 2005) For cancer, a pathological diagnosis is the gold standard that indicates the presence or absence of cancer, the type of cancer, and its classification. Unfortunately, medical studies over the last two decades have demonstrated that this gold standard is not consistently reliable. In fact, studies have demonstrated discrepancy rates of up to 30%.
(PRWEB) July 22, 2005 -- Pathology is the medical specialty that deals with
the examination of tissues and cells under the microscope in order to arrive at
a diagnosis. When it comes to cancer, a pathological diagnosis is the gold
standard that indicates the presence or absence of cancer, the type of cancer,
and its classification. Because therapeutic decisions are based on the presumed
reliability of the pathology diagnosis, a misdiagnosis can result in
unnecessary, harmful and aggressive therapy or inadequate treatment.
Unfortunately, medical studies over the last two decades have
demonstrated that this gold standard is not consistently reliable. In fact,
multiple studies have demonstrated discrepancy rates of up to 30% with an
average of approximately 10%. A “discrepancy” happens when one pathologist
renders a diagnosis and another pathologist looks at the same material and
renders a different opinion. See for example, Gupta D, Layfield LJ. Am J Surg
Pathol. 2000 Feb;24(2):280-4. Prevalence of inter-institutional anatomic
pathology slide review: a survey of current practice.
Here are some
examples from the medical literature:
* Bladder Cancer
– Wrong Pathology Would Have Led to Five Unnecessary Cystectomies: The pathology
of 97 patients (131 specimens) with suspected urothelial carcinoma of the
bladder was reviewed. Twenty-four of the 131 specimens "exhibited significant
discrepancies." This included two patients who showed no evidence of tumor. As a
result of the review, five radical cystectomies were avoided.
Coblentz TR,
Mills SE, Theodorescu D. Cancer. 2001 Apr 1;91(7):1284-90. Impact of second
opinion pathology in the definitive management of patients with bladder
carcinoma.
* Brain Tumors – Pathologists Often Disagree
With Themselves or Others Pathologists agreed with their original diagnosis only
51.43% for anaplastic astrocytomas, 74.73% for glioblastoma multiforme, and
65.22% for low-grade astrocytomas. Pathologists agreed with other pathologists
only 62.41% for glioblastomas, 36.04% for AA, and 57.14% for low-grade
astrocytomas.
Mittler MA, et al., J Neurosurg. 1996 Dec;85(6):1091-4.
Observer reliability in histological grading of astrocytoma stereotactic
biopsies.
* Breast Cancer – Different Treatment
Recommendations 43% of the Time: Seventy-five women with a total of 77 breast
lesions were examined. The reviewing panel disagreed with the treatment
recommendations 43% of the time (32 cases). The disagreements included
breast-conservation therapy instead of mastectomy (13 patients) and different
treatment based on a "major change in diagnosis on pathology review.
(3.9%)."
Chang JH, et al., Cancer. 2001 Apr 1;91(7):1231-7. The impact of a
multidisciplinary breast cancer center on recommendations for patient
management: the University of Pennsylvania
experience.
* Ovarian Cancer – 12.7% Did Not Have
Ovarian Cancer
The medical records and pathology slides of 339 women
diagnosed with ovarian cancer were reviewed. Forty-three women (12.7%) were
discovered not to have ovarian cancer. (28 had other types of cancer and 15 had
benign tumors.)
McGowan L, Norris HJ. Surg Gynecol Obstet. 1991
Sep;173(3):211-5. The mistaken diagnosis of carcinoma of the
ovary.
* Prostate Cancer – Wrong Pathology Would Have
Led to Six Unnecessary Prostatectomies: A total of 535 men referred for radical
prostatectomy were reviewed. Seven (1.3%) of the men were found to have a benign
pathology. “Upon subsequent clinical work up, six of seven men were considered
not to have adenocarcinoma, and their surgery was cancelled.”
Epstein JI, et
al., Am J Surg Pathol. 1996 Jul;20(7):851-7. Clinical and cost impact of
second-opinion pathology. Review of prostate biopsies prior to radical
prostatectomy.
* Soft Tissue Lesions – Benign
Considered Malignant and Malignant Considered Benign: In this study 266 cases of
soft tissue lesions were reviewed. A major discrepancy was found in 25% of
cases. Of these discrepancies, 45% consisted of benign lesions diagnosed as
sarcomas, and 23% were sarcomas diagnosed as benign tumors.
Arbiser ZK,
Folpe AL, Weiss SW. Am J Clin Pathol. 2001 Oct;116(4):473-6. Consultative
(expert) second opinions in soft tissue pathology. Analysis of problem-prone
diagnostic situations.
Getting the pathology wrong is not limited to the
U.S. Other countries have found similar problems. For example, in the United
Kingdom, 413 cases of sarcoma were reviewed and the diagnosis was confirmed only
76% of the time. The study concluded that "second opinion is essential in cases
of presumed sarcoma…to ensure that appropriate treatment is selected." Harris M,
Hartley AL, et al., Br J Cancer. 1991 Aug;64(2):315-20. Sarcomas in north west
England: I. Histopathological peer review
Do You Need a Second
Opinion?
The vast majority of pathologists are excellent physicians and that
the diagnoses they render are correct. However, a minority of cases benefit from
a second opinion. The problem, of course, is accurately identifying which cases
should get a second opinion. To read the rest of the story go to http://www.cancermonthly.com
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Source : http://www.prweb.com/releases/2005/7/prweb263907.htm