Breast Pathology Second Review Identifies Clinically Significant Discrepancies in Over 10% of Patients LAILA KHAZAI, MD, LAVINIA P. MIDDLETON, MD,* NAZLI GOKTEPE, BENJAMIN T. LIU, AND AYSEGUL A. SAHIN, MD Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas Background: Patients seeking a second opinion or continuation of care at our hospital will routinely have their pathology reviewed prior to initiating treatment. To assess the relevance of this review in patients with breast cancer, we compared original pathology reports submitted during the referral with second‐review reports issued at our institution. We also assessed compliance with College of American Pathologists (CAP) requirements regarding inclusion of scientifically validated data elements (SVDE) in these pathology reports. Methods: We retrospectively studied all 1,970 breast pathology referral cases reviewed during one calendar year. The variables studied were histologic classification; tumor grade, necrosis, size, margin status, lymphatic/vascular invasion, dermal involvement, and biomarker profile (ER, PR, and Her‐2). Each variable was rated as “agree,”“disagree,”“missing information,” or “not applicable.” Results: A significant discrepancy, defined as a disagreement that affected patient care, was found in 226 cases (11.47%). Additionally, in 418 resection cases (31.6%), some CAP‐checklist specific required information was missing. The most common areas of significant discrepancy were histologic category (66 cases; 33%) and biomarker reporting (50 cases; 25%). The most problematic diagnostic categories were intraductal lesions, lobular carcinoma, metaplastic carcinomas, and phyllodes tumors. Most disagreements in the biomarker‐profile category were interpretive, but in 20% of discrepant cases, findings were supported by repeat immunohistochemical analysis. Conclusions: Our results confirm the value and utility of obtaining a second opinion to optimize patient care. Changes in diagnoses obtained after second review should be interpreted and reported in a collaborative fashion, noting the benefit of a review from second pair of experienced eyes. Our results support the use of second review to ensure inclusion of CAP‐required data elements in pathology reports. J. Surg. Oncol. 2015;111:192–197. ß 2014 Wiley Periodicals, Inc. KEY WORDS: breast pathology; quality; second opinion; error INTRODUCTION Accurate histologic assessment is the foundation on which treatment decisions are made and therapeutic responses measured. When patients seek a second opinion or transfer of their care, the pathology report is an essential element of their continuum of care. In the early 1990s, the Association of Directors of Anatomic and Surgical Pathology (ADASP) recommended routine review of outside pathologic interpretation when patients are referred to another institution for further treatment [1]. Despite this call, no consensus has emerged for the adoption of a mandatory second review policy, and debate remains regarding the value of such a practice; some studies have suggested that only selective review is necessary, for cases with high‐risk of diagnostic error (e.g., tumors of certain anatomic sites such as the ovary, soft tissue, and lymph nodes) [2]. In a survey published in 2000, only 50% of 126 participating hospitals, mostly academic health centers, had a mandatory second review policy [3]. Various factors are thought to be responsible for institutions’ reluctance to adopt a mandatory policy, including workload constraints, the financial cost of a second opinion, challenges in doctor‐ patient communication, and potential treatment delays [4–7]. It has been routine practice to review the histopathologic material accompanying all patients referred to our tertiary care center. The review is carried out by a pathologist with subspecialty expertise prior to the clinician developing a treatment plan and initiating therapy. Recently we have demonstrated the value that is added by providing precise pathologic diagnoses to clinicians formulating evidence‐based treatment plans [8]. The aim of this retrospective study was to determine the rate of concordance in all referral pathology reviewed by a breast pathologist with subspecialty expertise. MATERIALS The pathology database at The University of Texas MD Anderson Cancer Center was searched for all referred patients seeking a medical second opinion to the Breast center whose specimens were received during calendar year 2010. Consultation cases, defined as cases for which the primary pathologist was seeking an “expert” opinion before rendering the final diagnosis, were excluded from the study. The referral basis included community hospitals, commercial laboratories and academic centers. One pathologist with breast sub‐specialty expertise compared scanned copies of contributors’ pathology reports with reports issued at our institution, all of which were prepared by the subspecialist breast pathology group. The subspecialty breast pathologists in our group number 12, are fellowship trained, and have been in practice from 5 to Disclosure: There are no financial disclosures. Precis: There is a significant rate of discrepancy (11.47%) comparing outside pathology reports of patients with breast diseases seeking a second opinion or transfer of care. Second review of breast pathology is a quality and patient safety mechanism that reduces error, not only in the setting of complicated/ unusual cases, but also through capturing uncomplicated but simply overlooked diagnostic errors. *Correspondence to: Lavinia P. Middleton, MD, Department of Pathology, UT MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, Texas 77030. Fax: 713‐745‐5709. E‐mail: lpmiddleton@mdanderson.org Received 15 July 2014; Accepted 20 August 2014 DOI 10.1002/jso.23788 Published online 1 October 2014 in Wiley Online Library (wileyonlinelibrary.com). Journal of Surgical Oncology 2015;111:192–197 ß 2014 Wiley Periodicals, Inc.