What Do You Know About The Doctor That Diagnosed Your Breast Biopsy?

If you or someone you know has felt a breast lump or had an abnormal mammogram, you know it can be a very scary situation.  The immediate fear is “I might have breast cancer.” When confronted with a breast health issue, many patients seek out a particular breast center or a breast doctor well-known for their expertise in the field. However, one of the key physicians in your breast care is the pathologist who is the doctor that determines your diagnosis. Unfortunately, many patients know nothing about the background and training of the pathologist who diagnosed their breast biopsy.  So even though you may see a respected surgeon or radiologist for your breast biopsy, your biopsy could be sent out to a lab where someone just out of residency training or someone with no specialization in breast pathology determines your diagnosis. That diagnosis dictates all of your future treatment decisions made by the rest of your medical team.

The Susan G. Komen Foundation published a “white paper” in 2006 advocating changing practice patterns in breast pathology (1).  The paper estimates error rates in breast cancer diagnosis from 2-4%. They go on to say “if accurate, as many as 5,000 to 10,000 patients diagnosed with invasive or in-situ breast cancer each year may have been misdiagnosed and inappropriately treated” (1).

There are many other articles in the medical literature that address the importance of second opinion pathology review by specialists in breast pathology. Below are a few examples:

  • The University of Pennsylvania Multidisciplinary Breast Center reviewed 77 breast lesions in 75 women.  They found disagreement in outside treatment recommendations in 43% of patients, and of those, 9% were due to a major change in the pathology diagnosis (2). This was just over a six-month period!
  • Northwestern University’s Breast Center  published an article reviewing 340 patients presenting for a second opinion over a four-year period.  There was a major change in pathology review altering surgical therapy in 7.8% of patients. Pathology review also added additional prognostic information in 40% of patients (3).
  • The Toronto-Sunnybrook Regional Cancer Centre published an article in which they looked at patients with ductal carcinoma in situ (DCIS). In a four-year period from 1996-2000 they found that second opinion pathology changed the assessment of local recurrence risk in 29% of patients and contributed to a change in treatment recommendations in 43% of patients (4).
  • The Universidade Federal de Minas Gerais in Brazil published an article looking at 329 breast biopsies seen in consultation by breast pathologists. They confirmed malignancy in 82.2% of patients and a benign diagnosis in 85.6% of patients.   That still means an error rate averaging 16%! In addition, they found the highest disagreements were with DCIS and microinvasion (74%), LCIS (70%), and atypical epithelial hyperplasias (61%) (5).

These discrepancies in diagnoses are hardly trivial.  An over-diagnosis of malignancy on a benign breast biopsy not only causes emotional damage to the patient, but can cause physical and monetary damage as well (6).  Additional surgery, chemotherapy, and radiation therapy are not only costly but can have significant side effects.  The opposite is also true.  If a patient is told she does not have cancer because it was missed by the pathologist, that patient is at risk of that cancer metastasizing since it was never appropriately treated at the time of diagnosis.

If you have been accurately diagnosed as having a primary breast cancer, your pathologist still plays an additional role in what therapy you receive based on a panel of breast prognostic markers that are determined by immunohistochemistry.  All invasive breast cancers should be tested for estrogen receptor, progesterone receptor, and HER2/neu.  These are “standard of care” tests performed on any invasive breast cancer. Yet, as with your primary biopsy, these ancillary tests could possibly be interpreted by a non-breast pathologist.  Based on the Susan G. Komen Foundation report, estrogen receptor status can be misclassified in up to 20% of patients, and HER2/neu status can be misclassified in up to 26% of patients (1).

These are unsettling statistics, but they need to be addressed.

So the question remains:  What do you know about the qualifications of the pathologist that determined whether or not you have breast cancer?

 

REFERENCES

 

1.  Susan G. Komen Foundation (White Paper). Why Current Breast Pathology Practices Must be Evaluated. June 2006.

2.  Chang JH, Vines E, Bertsch H, et. al.  The Impact of a Multidisciplinary Breast Cancer Center on Recommendations for Patient Management: The University of Pennsylvania Experience. Cancer 91(7): 1231-1237, 2001.

3.  Staradub VL, Messenger KA, Hao N, et. al.  Changes in Breast Cancer Therapy Because of Pathology Second Opinions.  Ann Surg Oncol 9(10): 982-987, 2002.

4.  Rakovitch E, Mihai A, Pignol JP, et. al. Is Expert Breast Pathology Assessment Necessary for the Management of Ductal Carcinoma in Situ? Breast Cancer Res Treat 87(3): 265-272, 2004.

5.  Salles Mde A, Sanches FS, Perez AA, et. al. Importance of a Second Opinion in Breast Pathology and Therapeutic Implications.  Rev Bras Ginecol Obstet 30(12): 602-608, 2008.

6.  Saul S. Prone to Error:  Earliest Steps To Find Cancer. New York Times (online). July 19, 2010.

 

 

 

 

One Response

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