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    Women's Health Update: Breast biopsies read as atypia may warrant a second look

    Breast biopsies read as atypia may warrant a second look

    A multicenter study of breast biopsy interpretation that compared diagnoses by an expert consensus panel and pathologists in clinical practice found that they disagreed in 52% of cases involving atypia.

    The research, based on data from pathologists who interpret breast biopsies in 8 states, suggests that a second opinion may be warranted for women diagnosed with atypia before they begin intensive surveillance or treatment to reduce risk.

    Published in JAMA, the analysis focused on independent interpretation of slides from 60 breast biopsies (240 cases, 1 slide per case) and spanned November 2011 to May 2014. Included were 23 cases of invasive breast cancer, 73 ductal carcinoma in situ (DCIS), 72 atypical hyperplasia (atypia), and 2 benign cases without atypia. The cases were randomly identified from a cohort of nearly 20,000 in pathology registries affiliated with the Breast Cancer Surveillance Consortium and from core needle and excisional biopsies. Nearly half of the specimens were from women aged 40 to 49.

    First all 240 cases were reviewed independently and rated for difficulty by each of 3 pathologists who are internationally recognized as experts in diagnostic breast pathology. In the 25% of cases in which the diagnosis was not unanimous, consensus was reached via discussion.

    Pathologists in 8 states who had interpreted breast biopsies for at least 1 year were then invited to review the same specimens. Of the 115 who participated, 50.5% said that breast pathology was challenging and 44.3% said it made them more nervous than other types of pathology, but more than half (51%) said they had seen cases of the type presented. 

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    For the atypia cases (2070 interpretations), the rate of concordance between the diagnoses of the expert panel and the community pathologists was 48% (95% CI, 44%-52%), 35% (95% CI, 31%-39%) were under-interpreted, and 3% (95% CI, 2%-4%) were over-interpreted. The rate of concordance was 84% (95% CI, 82%-86%) for DCIS cases (2097 interpretations), with 13% (95% CI, 12%-15%) under-interpreted and 3% (95% CI, 2%-4%) over-interpreted. For cases of invasive carcinoma (663 interpretations), the concordance rate was 96% (95% CI, 94%-97%) and 4% (95% CI, 3%-6%) were under-interpreted.

    The authors found that pathologists were statistically significantly less likely to agree with the diagnosis of the expert panel if they were from outside academic settings, interpreted low weekly volumes of breast cases, or were from small practices. “The variability of pathology interpretations,” they concluded, “is relevant to concerns about over-diagnosis of atypia and DCIS.

    When a biopsy is over-interpreted (eg, interpreted as DCIS by a pathologist when the consensus-derived diagnosis is atypia), a woman may undergo unnecessary surgery, radiation, or hormonal therapy.”

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    Judith M. Orvos, ELS
    Judith M. Orvos, ELS, is a a BELS-certified medical writer and editor and an editorial consultant for Contemporary OB/GYN.
    Miranda Hester
    Ms. Hester is Content Specialist with Contemporary OB/GYN and Contemporary Pediatrics.


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