Pathology review underused in node-negative breast cancer

Issue: June 25, 2012

A second review of the pathology slides of women diagnosed with node-negative breast cancer resulted in a statistically significant change in diagnosis, according to the results of a recently published study.

“This study finds that, in the setting of limited pathology resources, patients with node-negative breast cancer or ductal carcinoma in situ may represent a particularly relevant subgroup to consider for routine pathology review,” Hagen Kennecke, MD, a clinical oncologist and researcher with the British Columbia Cancer Agency, and colleagues wrote.

A change in the pathology of the disease may significantly alter the therapy used to treat it because women with node-negative disease are not always offered chemotherapy or postmastectomy radiation, according to background information in the study.

Researchers identified 906 women with node-negative, invasive or in situ breast cancer between 2004 and 2007. Of those women, 45% had received a pathology review.

Hagen Kennecke

In the study, pathologists conducted a second review of the pathology to determine whether it had changed from that which was originally reported, and if that change would affect treatment.

Women whose pathology was reviewed were more likely to have been younger (P<.001) and more likely to have had close margins by initial pathology report (P<.001).

Of the 405 women who had pathology information, 20% had at least one significant change upon second review. Change in pathology occurred commonly for grade (40%) or for lymphovascular (26%), nodal (15%) and margin status (12%).

Based on these results, treatment was changed in 25 patients (6%).

“It is noteworthy that, despite a policy recommending pathology review of all node-negative patients, review was conducted in fewer than half of all patient cases,” Kennecke and colleagues wrote. “Review remains relevant in the era of gene expression signatures to determine margin and nodal status, which may result in significant changes in systemic, radiation or surgical management.”

In an accompanying editorial, Ira J. Bleiweiss, MD, and George Raptis, MD, both of The Mount Sinai School of Medicine in New York, said the study clearly has direct implications for patient care.

“Is routine second-opinion breast pathology therefore necessary for everyone, regardless of whether they have been diagnosed with carcinoma or not? Clearly this is not possible, given the number of patients, specimens, slides, and available specialized breast pathologists,” Bleiweiss and Raptis wrote. “Some sort of selection of cases is possible and needed. … All treating physicians involved in breast cancer care must ultimately determine for which patients a second pathologic opinion is likely to make a difference.”

References:

Kennecke HF. J Clin Oncol. 2012;doi:10.1200/JCO.2011.38.9247.