Reaction to New JAMA Breast Cancer Study Misses the Mark

Curtis Stratman

Recently, there has been significant media coverage about pathologists, the physicians who diagnose all cancers. On March 17, the Journal of the American Medical Association (JAMA) published a report concluding that nearly 25% of breast biopsies were incorrectly diagnosed.1 And, on April 14, actress Rita Wilson shared statements with People magazine that she had undergone a double mastectomy. In her statement, she elaborated on how the original diagnosis from her breast biopsy was negative, but after seeking a second opinion, cancer was found and reconfirmed.2

This publicity has brought forth much discussion—and criticism—of the accuracy of pathology diagnoses. However, little of it has truly educated the public on how cancers are diagnosed and the challenges facing pathologists on a day-to-day basis.

Patients and physicians want a cancer diagnosis that clearly states “positive” or “negative” when making their treatment decisions. However, many diagnoses are in fact not binary. There are the clearly positives and the clearly negatives, but there is also a gray area that patients are often not familiar with. Pathology researchers do an incredible amount of work to best categorize these gray areas, document their findings, and educate those practicing medicine. But with over three hundred types of known cancers, and more continually being identified, there is simply much knowledge still to be shared and learned.

For cases in these gray areas, the weight of making the best diagnostic determination falls to the pathologist. This is why second opinions are so important to those suspected of having cancer, but where the diagnosis is not clear cut. When cases fall into the gray area mentioned, more opinions and experience can often alter the conclusion.

To put the findings from the JAMA article into this context, one should not conclude that 25% of breast cancer diagnoses are wrong. The study was designed to measure diagnostic agreement among pathologists who read cases on their own. However, pathologists as standard practice do seek second opinions frequently from their peers on cases where they have uncertainty. What the JAMA article demonstrates is that the gray area of diagnosis does exist and is significant.

The bigger concern is the trends creating challenges for pathologists.  In the U.S. from 2000 – 2010, the number of new cancers needing diagnoses increased by 25%3,4 while the number of practicing pathologists decreased by 7%.5 The workload per pathologist has increased significantly, and this trend is continuing.

Pathologists primarily still use glass slides to diagnose cancer by looking at the tissue under a microscope. For those working in locations with a limited number of other pathologists, seeking a second opinion is time consuming. Doing so requires that they package the slides, mail them to another pathologist, and wait for the other pathologist to re-read the case. With the trends in growing workloads, pathologists have less and less time available to manage this administrative work, along with the extra work of reading cases twice. If these trends continue without providing pathologists tools to streamline their work, then for second opinions either the wait times will have to increase, or the number of patients receiving them will have to decrease. Given the importance of second opinions, allowing this to happen should be alarming patients and care providers.

One of the answers to this challenge lies in precision digital tools. Digital pathology streamlines lab workflows, enables integration of additional diagnostic methodologies like genomic and molecular testing, and most of all, it facilitates collaboration between pathologists and other members of the care team. Rather than shipping glass slides, pathologists can easily share images of the tissue with peers at different locations with minimal effort and time. By helping make the process easy and efficient, second opinions can be made available to more patients.

The recent media should highlight how valuable pathologists are to patient cancer care and the importance for providing them the tools to enhance their practice.


 

  1. Elmore JG, Longton GM, Carney PA, et al. Diagnostic Concordance Among Pathologists Interpreting Breast Biopsy Specimens. JAMA. 2015;313(11):1122-1132. doi:10.1001/jama.2015.1405.
  2. http://www.people.com/article/rita-wilson-breast-cancer-double-mastectomy-reconstruction
  3. Greenlee, Robert t., et al. Cancer Statistics, 2000. Ca Cancer J Clin 2000;50:7-33.
  4. American Cancer Society. Cancer Facts & Figure 2010.
  5. Association of American Medical Colleges Center for Workforce Studies. 2012 Physician Specialty Data Book.

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