The recent New York Times article regarding an error in breast cancer diagnosis, commented upon in several of my earlier blogs, continues to draw attention to the poorly understood fields of pathology and cancer biology. Quite a few of you have commented to me privately about the issues involved and you also should feel free to post comments here.
Dr. Diane Schecter, a pathologist in White Plains, NY, has tried to formally respond to the New York Times article in several venues, as of yet without success. This is unfortunate as a number of the issues in the article clearly need clarification or refutation. She has written an Op Ed piece which I sincerely hope finds publication in the NYT, but even if it doesn't she has allowed me to share it here. It is an excellent summary of who we are, what we try to do and the problems created by bad nomenclature leading to bad medicine.
Although this op-ed is obviously in response to your front page piece "Prone to Error: Earliest Steps to Find Cancer" by Stephanie Saul, it provides information and and opinions that deserve to be heard. I am a surgical pathologist with 25 years experience. I attended Cornell University Medical College followed by seven years of residency in surgical pathology. Women need to know this.
To the Op-Ed Editor:
Although I do not believe the op-ed page of the New York Times is the most appropriate forum for a discussion of the complex issue of pre-cancerous breast lesions, recent negative press directed at general surgical pathologists compels me to make my voice heard. And the lack of an adequate response from leading pathology organizations has added to my determination to clarify several issues for the public.
First, some basic facts: Pathologists are physicians who render diagnoses based on microscopic examination of cells and tissues. It is the pathologist, not a surgeon or oncologist, who performs this vital task. A pathlogist attends medical school, followed by at least four years of residency. For most cancers, a patient's diagnosis is based largely on the pathologist's findings.
With the advent of mammography, pre-cancerous lesions of the breast became an increasingly important category of breast pathology. Ductal lesions can roughly be categorized along a continuum from duct hyperplasia (benign) through atypical duct hyperplasia (ADH - a borderline lesion) to ductal carcinoma in situ ( DCIS, a cancer confined to the breast ducts, meaning it is not invasive.) Seems straightforward right? In practice it is not. That is the truth, although it is uncomfortable for both patients and surgeons to accept. Yes, many cases are straightforward, but many are not. In this, the work of the pathologist does not differ from that of colleagues in clincal medicine. A pathologist's diagnosis is based on knowledge and experience applied to a specific patient.
Numerous studies have shown that even the most experienced pathology experts disagree on the diagnosis of pre-cancerous breast lesions in a significant proportion of cases. Yet, the medical community continues to treat these lesions as totally distinct entities with radically different therapies. Too little attention has been paid to the controversy over how some of these borderline breast lesions should be treated and the suggestion by some that they are over treated. Currently, ADH and low-grade DCIS are treated in radically different ways. Clinical medicine needs to accept the reality of grey-zone (borderline) diagnoses and modify therapy accordingly. This is an aspect of breast cancer care that the public needs to know about and which, ultimately, is much more important than any erroneous perception of pathologist "error."
Meanwhile, surgeons need to explain to patients the continuum concept and emphasize that pre-cancerous lesions are just that: they are not invasive cancer. There is a pervasive hysteria and panic in this country about breast cancer that is fueled in part by advocacy groups. This hysteria has found its way to patients with pre-cancerous lesions as well. This hysteria is harmful to patients. Surgeons need to send their cases to pathologists they trust, based on experience, and they need to communicate that trust to their patients. Patients should be encouraged to speak to their pathologists if there are questions not answered by their surgeons. Pathologists need to be more visable and accessible.
It is not my intention to deny that occasionally pathology mistakes are made. But the insinuation that pathologists regularly misdiagnose pre-cancerous breast lesions is unfounded. There are scattered studies, some by individual pathologists, indicating "misdiagnoses" and others indicating differences of opinion. Other studies indicate a high level of agreement when breast cases are reviewed. Heresay, "personal communications" and "estimates" of error rates are not the way medicine is evaluated.
Pathologists are not known to be an outspoken group. In fact, they are so quiet most patients do not even know they exist. But everyone has their limit. And this was mine.
Diane J. Schecter, M.D.
White Plains Hospital Medical Center
White Plains, New York