Value of pathology review highlighted in node-negative breast cancer

By Laura Cowen

Secondary pathology review results in significant changes in diagnosis and treatment for women with node-negative breast cancer, Canadian researchers report.

Of 405 women who received a pathology review, 81 (20%) had a change in pathology results, which resulted in 27 changes in adjuvant systemic and/or radiation therapy in 25 (6%) women.

Hagen Kennecke and colleagues from the British Colombia Cancer Agency (BCCA) in Vancouver say their findings indicate that pathology review to determine margin and nodal status "remains relevant in the era of gene expression signatures."

The researchers carried out the study to investigate the impact of the BCCA policy that only patients with ductal carcinoma in situ or node-negative breast cancer should undergo routine secondary pathology review of surgical material.

There were a total of 102 pathology changes in the 81 women. The most frequently changed element upon review was tumor grade (40%) followed by lymphovascular invasion (26%), nodal status (15%; six cases from N0 to N1 and nine from N0 to N0i+), and margin status (12%; 11 from negative to positive and one from positive to negative).

Among the 25 women who received treatment modification, systemic therapy was added for 12 patients and modified in three. The most common reason for adding systemic therapy was a change to node-positive status.

Only two treatment changes were related to measurement of tumor biology in women with estrogen receptor-positive, node-negative breast cancer.

The researchers note that despite the BCCA policy recommending pathology review in all node-negative patients, less than half (405 of 906) received it. Furthermore, a higher proportion of patients referred to BCCA full-service centers received a review than did patients initially seen in community clinics. This may reflect a lower familiarity with the policy or decreased accessibility to pathology review at community centers, say the researchers.

The team also found that patients who received a pathology review were significantly younger (58 vs 65 years) and had a higher rate of close pathologic margins on initial pathology review (16 vs 6%) than those who did not have a review, "indicating that clinicians may be selective about which specimens they send for review," Kennecke et al remark.

They conclude in the Journal of Clinical Oncology that their findings "highlight the value of secondary review of pathology materials before final treatment is recommended."

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