Globally, more than one million new cases of cancer are diagnosed in a year and approximately 23 per cent of all new cancer cases diagnosed are breast cancers1,2. With an incidence of 22.2 per cent, and a mortality of 17.2 per cent, it is pegged as the second most commonly occurring cancer in women in India3. Among males and females, breast cancer cases are expected to cross the figure of 100,000 in India, by the year 20204.
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Dr Anurag Bansal
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In the US, about 89 per cent of women diagnosed with breast cancer are likely to survive for at least five years5. There are barely any similar statistics for India available, but rough estimates from the Population Based Cancer Registry (PBCR) and Hospital Based Cancer Registries (HBCR) reports state that this figure is less than 60 per cent. When detected at an early stage and aggressively managed using a multimodal approach, breast cancer displays significantly reduced morbidity and mortality 6,7. In India, a lack of an organised screening programme, scarcity of diagnostic aids, failure to act on symptoms, delay in consulting the specialist and lack of awareness of new screening tests may be some of the reasons that breast cancer does not get diagnosed and treated as effectively as in the US.
To add to the complexity is the fact that breast cancer is not a single disease entity, but is a conglomeration of morphological subtypes with different clinical outcomes. Diagnosing and staging accurately is another challenge faced by clinicians. Despite training and experience of pathologists, diagnostic discrepancies are bound to occur, as a result of inherent practice-related difficulties, as well as differences in the abilities and personal interpretations concerning tissue changes. Another important challenge is the interpretation of the ER-PR (estrogen or progesterone receptor) status and HER2/neu amplification and over expression. These tests help in the right classification of breast cancer and provide the clinician with information about how the tumour acts and what kind of therapy may promote a favourable response. Although there are several guidelines, these tests are performed and interpreted differently by different laboratories and clinicians resulting in further difference of opinion8. It has therefore been noted that breast pathology is one of the areas within surgical pathology that often yields differences of opinion.
As other fields of medicine have become increasingly sub-specialised, so too has surgical pathology. There is an increasing trend toward sub-speciality diagnosis of surgical pathology cases in academic settings; that is, breast cancer case reports are often signed out only by pathologists with expertise in breast pathology to avoid any misdiagnosis resulting in wrong therapy.
In the US, there is now a growing trend to obtain a second opinion from an expert breast pathologist and there are published studies highlighting the same. One such study showed that post second review, major changes that altered surgical therapy occurred in 7.8 per cent of cases, and in 40 per cent of the cases the second opinion provided additional prognostic information.9
In India, a study of this kind was done by a reference lab in its clinical laboratory in Gurgaon. A retrospective analysis of 51 breast cancer patients, who were referred for second opinion between 2011 and 2013, was done to understand the level of diagnostic discrepancies. The specialist breast pathologists of the reference lab expert medical team conducted the consultative diagnosis for these cases.
Out of the 51 cases, aged between 27 and 77 years, diagnostic insights provided by a specialist breast pathologist changed or impacted the therapy in almost 43 per cent of the cases. Out of the 43 per cent, the diagnosis was discordant from primary diagnosis in 27.5 per cent of the cases. In 15.6 per cent of the cases, the diagnosis from the breast pathologist provided ‘additional insight’ that impacted the clinical management of the patient (selection of therapy and/or understanding on prognosis).
In conclusion, a second opinion by a specialist pathologist can provide insights to the clinician to help guide diagnosis and treatment. With this team approach, more patients may be spared the potential emotional, physical and economic toll that comes from late or misguided diagnosis or treatment of breast cancer.
References:
1. Pakseresht, S., et al. Risk factors with breast cancer among women in Delhi. Indian J Cancer. 2009;46:132-138.
2. Jemal, A., et al. Global cancer statistics. Ca Cancer J Clin.2011;61:69–90.
3. GLOBOCAN.(2008) [Online] Available from: http://globocan.iarc.fr/factsheet.asp. [Accessed on: 21stAugust, 2013].
4. Projections of Cancer Cases in India (2010-2030) by Cancer Groups. Asian Pacific J Cancer Prev, 11, 1045-1049
5. American Cancer Society. Breast Cancer facts and figures 2007-2008.
6. Yenidunya, S. et al. (2011) Predictive value of pathological and immunohistochemical parameters for axillary lymph node metastasis in breast carcinoma. [Online] Available from: http://www.diagnosticpathology.org/content/6/1/18. [Accessed on: 21st August, 2013.
7. Patil, VW.,et al. (2011) Triple-negative (ER, PgR, HER-2/neu) breast cancer in Indian women. [Online] Available from: DOI: 10.2147/BCTT.S17094. [Accessed on: 21st August, 2013].
8. Kleer, CG. Pathology re-review as an essential component of breast cancer management. CurrOncol. 2010;17(1):2-3.
9. Staradub VL et al. (2002) Changes in breast cancer therapy because of pathology second opinions, Ann Surg Oncol. 2002 Dec;9(10):982-7.