A paper published in Modern Pathology in August 20191 called attention to the lack of standardized reporting practices that pathologists use to evaluate postneoadjuvant chemotherapy specimens. 

The findings were born from research for a talk that coauthor Susan Fineberg, MD, was asked to give to fellow members of the New York Metropolitan Breast Cancer Group. Dr Fineberg, a pathologist at Albert Einstein College of Medicine’s Montefiore Medical Center in The Bronx, New York, wanted to focus her speech on different ways that breast cancer practitioners might receive pathology reports. To prepare, she read a 2015 Modern Pathology paper2 by representatives of the Residual Disease Characterization Working Group of the Breast International Group-North American Breast Cancer Group (BIG-NABCG) that offered recommendations for how reports should be written when pathologists assess postneoadjuvant chemotherapy breast specimens. Dr Fineberg hypothesized that the recommendations came from a desire to facilitate more coherent communication between pathologists and clinicians when they encounter complicated specimens demonstrating variable treatment response patterns.  

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But a recommendation is only effective if it is properly communicated and received, and Dr Fineberg wondered whether physicians were following the standards of best practice across local academic hospitals. To find out, she sent a survey of 6 yes or no questions, drawn from the 2015 study’s recommendations, to institutions such as Cornell University, Mount Sinai, and New York University. The data were eye-opening and showed a number of differences in reporting methods, inspiring her to send the survey more broadly. Ultimately, 23 breast pathologists across 19 institutions participated. 

Although a lack of standardization in disclosures about the specimens emerged as she reviewed the responses, some questions did show the group leaning more in a particular direction. For example, 74% of pathologists surveyed said they grade tumors after neoadjuvant chemotherapy, while 26% said they do not. Other questions showed real ambivalence among participants, however: when asked whether they report cases that include features of tumor regression or tumor bed at the margin (despite the absence of actual tumor at the margin), 48% responded yes, while 35% said no.

Pathologists at many institutions follow reporting guidelines from the College of American Pathologists (CAP), but on the topic of postneoadjuvant chemotherapy specimens, the group is pretty mum. The collective suggests that pathologists only seek to answer 2 questions: In the breast, is there a response, a probable response, or no definite response? And in the lymph nodes, is there a response, a probable response, or no definite response? Dr Fineberg said that while this might be a sufficient line of questioning for other types of breast specimens, the lack of nuance can be problematic for postneoadjuvant specimens.

“You’re not required to report the fact that a tumor is scattered over a very large area, you’re only required to report the largest contiguous focus of tumor, which can be much smaller than the actual extent of residual tumor spread,” Dr Fineberg said. “That’s something that a clinician could potentially miss” if pathologists use the current, less-detailed CAP reporting guidelines as a template.

Jane Brock, MD, PhD — who did not herself take the survey, but who works as a pathologist at Brigham and Women’s Hospital in Boston, Massachusetts, with pathologists who did — said that Dr Fineberg’s survey has highlighted crucial discrepancies in how cases are described. She agreed that with postneoadjuvant specimens, looks can be deceiving, and current CAP guidelines are often not detailed enough to capture subtle differences.

Dr Brock characterized this diversity in reporting practices as a historical artifact: until approximately 10 years ago, pathologists were mostly evaluating breast cancer response to neoadjuvant chemotherapy treatment within the confines of clinical trials.

“When you look at the number of pathologists in the country who actually evaluate clinical trial-type pathology, it’s very few,” she noted. “So the way we approach evaluating neoadjuvant chemotherapy specimens has really never had to be standardized in any way outside of the clinical trials.”

In other words, there is no gold standard for logging and describing these specimens today because it wasn’t standard practice to even encounter them in the lab until fairly recently.

But Dr Brock is hopeful that as more of these specimens make their way to regular laboratory benches, more and more pathologists will seek out papers like Dr Fineberg’s in search of information, and that CAP — purveyors of the most widely disseminated pathology guidelines — will eventually fill the knowledge gap with its own recommendations.

“These guidelines get updated regularly,” Dr Brock said. “I think there will be an improvement to the next iteration.”

References

  1. Lanjewar S, Patil P, Fineberg S. Pathologic reporting practices for breast cancer specimens after neoadjuvant chemotherapy — a survey of pathologists in academic institutions across the United States. Mod Pathol. August 2019. doi: 10.1038/s41379-019-0326-5
  2. Provenzano E, Bossuyt V, Viale G, et al. Standardization of pathologic evaluation and reporting of postneoadjuvant specimens in clinical trials of breast cancer: recommendations from an international working group. Mod Pathol. 2015;28(9):1185-1201.