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KUGEL medical GmbH & Co. KG Hermann-Köhl-Straße 2a DE-93049 Regensburg · Germany Phone +49 (0) 9 41/20 86 48-0 Fax +49 (0) 9 41/20 86 48-29 E-Mail info@kugel-medical.de MADE IN GERMANY WE CREATE SOLUTIONS FOR HISTO-PATHOLOGY LABS www.KUGEL-medical.de Join us in Düsseldorf Hall 3 Booth 3E92 Azg_European_Hospital_Magazine_103x133.indd 1 15.09.14 08:17 EUROPEAN HOSPITAL Vol 23 Issue 5/14 PATHOLOGY The 2014 European Society of P Surveying discrepancies The righ The issue is not over-diagnosis but over-treatment Mismatched reports from clinicians and pathologists Low-grade ductal cancer in situ A limited survey of patients who died soon after being discharged from hospital found that almost a quarter had an undiagnosed co-morbidity with a potentially avoidable cause of death. Lukasz Adamczyk, a pathologist in training at Southmead Hospital, Bristol, UK, presented the find- ings at the European Congress of Pathology in London. Adamczyk and his colleagues looked at 8,971 adult deaths record- ed in the Bristol area between 2012 and 2013, focusing on 123 patients who passed away within 30 days of being discharged from hospi- tal. From the available information they found that, in almost 25% of cases, there was a major dis- crepancy between the clinical diag- nosis recorded on the discharge summary and the findings of an autopsy [http://www1.esp-congress. org/guest/ID730f32b5450d8a/ AbstractView?ABSID=8142]. The data was drawn from several locations, as autopsies in the region are conducted in a central mortuary. Kathy Oliver, Chair co-director of the International Brain Tumour Alliance (IBTA [www.theibta.org]), was speaking at a ‘Pathology, Patients and the Public’ workshop at the European Congress of Pathology in London. Han van Krieken, presi- dent of the European Society of Pathologists, and Suzy Lishman, president-elect of the Royal College of Pathologists, chaired the session. Oliver, whose son Colin was diag- nosed with a brain tumour in 2004, drew attention to rare cancers – affecting fewer than six in 100,000 people, they nonetheless make up 22% of cancers diagnosed in Europe [http://www.cancerresearchuk.org/ about-cancer/type/rare-cancers/ about/what-is-a-rare-cancer/], affect- ing over four million people. She called for these patients to receive greater access to their medical records, especially pathology test results, and promoting the right of patients to seek a second opinion. The IBTA was formed in 2005 to raise awareness of the needs of brain tumour patients and their families, and to build greater links In addition to the two main hospi- tals in Bristol, deaths in the commu- nity that fell onto other hospitals in the wider Avon area were included. In the majority of cases, death was directly related to previously record- ed risk factors, or the cause of most recent hospital admission – nearly half of the patients studied were over 80. In 38% of cases, some dis- crepancy was discovered between the clinical notes and the results of an autopsy. ‘The main finding is that, in our cohort, where patients die within the 30 days of discharge the major- ity of cases are in full agreement between what the clinicians have diagnosed and what was found in the autopsy,’ commented Adamczyk, noting that malignant diseases were rarely missed. ‘Our findings broadly reflect what is already recorded in the litera- ture,’ he added. ‘About thirty per- cent of the time, there’s a mismatch between what the pathologists says and what the clinician says, which has been studied and meta-analysed for quite a few years now.’ Why these discrepancies occur is very difficult to assess, Adamczyk explained. ‘This is the first such sur- vey, and our goal was to determine the proportion of discrepancies and to subtype them. Finding out the cause of discrepancies would need a more extensive study.’ He pointed out that at the time of autopsy, a full background medical history of the deceased might not be available. Often it is also not included in the discharge summaries. Cases such as these are more challenging to cor- relate. ‘The interesting finding is the 25% figure. If those people had received different treatment, knowing what the pathologist knew, it would have changed their outcome.’ ‘It’s seems like a big number,’ admitted Adamczyk. ‘But overall it’s a very small proportion of patients.’ Nonetheless, Adamczyk empha- sised the importance of carrying out autopsies whenever there is doubt over the cause of death. Adamczyk said the study would have to be carried out within a much larger cohort of patients before stat- ing specific conclusions, but high- lighted the importance of providing the pathologist with the full medical history. ‘A relatively small propor- tion of patients die after being discharged, and autopsy confirms clinical diagnosis, these are the main features here. Further studies are required to determine why some diagnoses are missed.’ Undiagnosed co-morbidities were found in a quarter of deaths following recent discharge Patients are no longer content to be passive re ing a more active role in their treatment, says We desperately need a ‘no treatment’ trial for DCIS Lukasz Adamczyk MD is a specialist trainee in histopathology. He works in the Department of Cellular Pathology at the Southmead Hospital in Bristol, UK. Adamczyk graduated the Medical University of Gdańsk, Poland, in June 2007. His current research is on ‘Large cell neuroendocrine carcinoma of the urinary bladder – a morphometric, clinicopathological and immunohistochemical study focusing on a large-cell subtype’. He is a member of Royal College of Pathologists, the British Division of the International Academy of Pathology and Pathological Society of Great Britain and Ireland. Clive Wells MD qualified from Cambridge University in 1978 having attended clinical school at St. George’s Hospital in London, and trained in histopathology at Oxford. He was appointed Consultant in Histopathology and Cytopathology at St Bartholomew’s Hospital in London in 1989 and worked there for 20 years until moving to University College Hospital in October 2009. He is now a Consultant and Honorary Senior Lecturer in Histopathology and Cytopathology. Dr Wells publishes widely on breast pathology and is Chairman of European Commission Working Group for Breast Screening Pathology (EBCN). Clive Wells is Chairman of the European Working Group on Breast Cancer Pathology, and London Regional Co-ordinator for the United Kingdom’s National Health Service (NHS) National Breast Cancer Screening Programme. During the European Congress of Pathology he used his lecture to speak out about the risks facing healthy women who were found to have low-grade tumours during screening programmes. Frank Swain: Your lecture at the recent congress on pathology focused on the issue of over-diag- nosis. Tell us more. ‘Over-diagnosis in breast screen- ing is the big issue that’s becoming a problem in the literature. The phrase suggests to the general pub- lic that the doctors have diagnosed benign issues as cancer, but in gen- eral that is not true. ‘What over-diagnosis describes is the detection of cancers by screen- ing that would have never been otherwise recognised during the patient’s lifetime, or would never have killed the patient. Screening is great and can and does save lives, but some women will be found to have cancer that wouldn’t have been an issue in their lifetime.’ Why does it matter if we find can- cer in otherwise healthy women? ‘Estimates of the rate of over-diagno- sis are around one and 10 percent. Ten percent is a lot, and significant- ly tips the balance between benefit and harm. For those women, screen- ing has been a disaster, because they’ve been diagnosed with can- cer and had treatment, and yet they would never have known they had a tumour if they hadn’t been screened.’ What’s the root of the problem? ‘Lead-time is the time between the cancer diagnosis by screening, and when it would have become symp- tomatic. Current estimates suggest lead-time is two years on average. Length bias is the detection by screening of a tumour that is so slow growing that it never would have become symptomatic within a patient’s lifetime. Therefore, length bias also contributes to this over- diagnosis, as does the detection of tumours that, even if you hadn’t screened for them and detected them, could have been effectively treated anyway when they surfaced two years later. ‘You have to ask if we are doing harm to women by detecting these kinds of tumour. We are detecting things we call cancer, which are cancer by all current criteria, and yet they’re not going to kill the patient. So we’re doing the patient a disser- vice by saying, “You’ve got cancer, you need treatment”.’ How can those running screening programmes overcome this issue? ‘You say we need a test for aggres- siveness of tumours. Studies have shown that screening-detected can- cers have a less aggressive molecu- lar signature than interval cancers. These low-grade tumours could be responsible for the over-diagnosis we see. We are in an awkward situ- ation where we don’t know which cancers will recur and which will not, so we must treat them all. The issue is not really over-diagnosis but over-treatment.’ What is the next step? ‘Adequate funding of research and universities is needed to uncover new molecular markers of aggres- siveness. It’s much more expensive to treat a patient with chemotherapy than it is to apply a test for aggres- siveness of the cancer. ‘There are tests for long-term recurrence, such as EndoPredict. However, these tests are not seen to be cheap in the first instance, so aren’t always carried out. ‘We also desperately need a trial of “no treatment” for low-grade DCIS (ductal cancer in situ) cancers. The planned LORIS study by researchers at the University of Birmingham is one example. ‘Of course, it will be difficult to recruit enough people – not a lot of women would say they don’t want treatment for precancerous tumours.’ 18 Phone +49 (0) 941/208648-0 Fax +49 (0) 941/208648-29 Azg_European_Hospital_Magazine_103x133.indd 115.09.1408:17

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