Reducing the Discrepancy of
Clinical and Pathological Tumor and Node Evaluation in Patients with Breast
Cancer
Multicenter Cooperative
Collaborative Action Research Study (MCCCARS) Group
Centers that contributed to at least one
action-research objective:
Ospital ng Maynila Medical Center (OMMC), Manila Doctors Hospital
(MDH), Philippine General Hospital (PGH),
Visayas Community Medical Center
(VCMC)
MCCCARS Principal
Investigators:
Reynaldo Joson, MD
(OMMC, MDH, PGH); Rogelio G. Kangleon, Jr. MD (VCMC); Sergio Paguio, MD (OMMC)
OMMC
Residents: Nolim’t Jay Raquel, MD; Miguel Galvez, MD; Rubi Ann Claire Chan, MD;
Oliver Leyson, MD
MDH
Resident: Malou Bastan, MD,
PGH
Resident: Orlino Bisquera, MD
VCMC
Resident: Jerry S. Alinsug, MD
Acknowledgement to
other MCCCAR members who participated in the focused group discussion: Alex
Cerrillo, MD; Alex Tan, MD; Edgardo Penserga, MD; Adrian Yu, MD; Ravel
Bartolome, MD; Roberto Valenzuela, MD
·
Reducing
discrepancy in cTN and pTN in breast cancer
Reducing discrepancy in cTN and pTN in breast cancer 2
ABSTRACT
Literature has shown a significant
discrepancy rate between clinical and pathological tumor and node staging in
patients with breast cancer. A multicenter cooperative and collaborative action
research study (MCCCARS) was established to look into this issue in the
Philippines. An initial retrospective
study confirmed the presence and estimated the extent of discrepancy. The root causes of discrepancy were
identified as absence of a structured training for surgeon-examiner and absence
of an agreed protocol between pathologists and surgeons on how to examine and
report tumor and nodal status. Thus, a
structured training for surgeon-examiner with the use of a report card and a
memorandum of understanding between pathologists and surgeons were formulated
and implemented. Evaluation showed the
strategies to be effective and easy to implement. This study will be used as basis to institutionalize the
strategies in reducing the discrepancy of clinical and pathological tumor and node
evaluation in patients with breast cancer.
Key words: Breast Cancer, Clinical Staging, Pathological Staging
Reducing discrepancy in cTN and pTN in breast cancer 3
INTRODUCTION
Literature has shown a significant discrepancy rate between clinical and pathological TN (Tumor, Node) staging in patients with breast cancer. In a German experience, the pretherapeutically and histologically measured size of the tumor was compared in 2511 cases of breast carcinomas. Breast tumors up to 2 cm in size revealed a correspondence in the histologically and clinically measured tumor size in only 13.6% (1). In a report from the Yorkshire Breast Cancer Group, in 348 patients with operable breast cancer, surgeons, radiologists, and pathologists varied considerably in measuring tumor size (T), with surgeons and radiologists agreeing in only 39% of cases, surgeons and pathologists in 54%, and radiologists and pathologists in 59%. Surgeons and pathologists agreed on the state of the regional lymph nodes (N) in 68% of cases (2).
In the Philippines, there are no published statistics on the discrepancy rate between clinical and pathological TNM staging in patients with breast cancer. However, discrepancy definitely exists as it has been observed by the authors. The junior authors who are surgical residents have observed it in their institutions of training. The senior authors have observed it in various institutions with surgical residency training program and have personally experienced it in their practice.
Discrepancy between clinical and pathological TNM staging in patients with breast cancer certainly has a negative impact in management, particularly in the choice of primary treatment as well as in the advice of patients on extent of cancer prior to treatment. Different clinical stages of breast cancer have corresponding different primary treatment approaches. A patient with an actual clinical stage II who is erroneously categorized as clinical stage III will be erroneously
Reducing discrepancy in cTN and pTN in breast cancer 4
treated as one with clinical stage III rather as one with clinical stage II. Nowadays, with the extensive public health information in trimedia and Internet, patients with breast cancer and their relatives would usually ask what stage they are in prior to treatment. An erroneous clinical staging may be a cause of unnecessary alarm in those with overstaging; a source of unwarranted rejoice in those with understaging, and definitely, a potential factor for patient’s dissatisfaction and complaint.
Realizing the importance of discrepancy in the clinical-pathological staging in the management of patients with breast cancer and experiencing the existence of such discrepancy, the authors decided to conduct an action research study on this topic with the goal of reducing the discrepancy and, therefore, improving patient care.
The general objective of the study is to reduce the discrepancy of the clinical and pathological tumor (T) and node (N) evaluation in patients with breast cancer.
The specific objectives of the study are:
Reducing discrepancy in cTN and pTN in breast cancer 5
METHODS:
General Methods:
The concept and methodology of an action research was utilized (3,4), namely: analysis of the problems, research designs on how to solve the problems; implementation of action plan; and evaluation of results of implementation. Multicenter cooperation and collaboration was tapped for data gathering, patient accrual, and validity testing of proposed solutions. (Multicenter cooperation and collaboration does not necessary mean that all centers were accomplishing the same thing at the same time and all the time. Cooperation and collaboration was utilized when some centers could not, because of logistic and technical problems, accomplish certain research objectives while some centers could.) Tools for data gathering included literature search using evidence-based approach, focused group discussion among the members of the multicenter cooperative collaborative action research study (MCCCARS) group, retrospective chart reviews, and prospective data accrual. Focused group discussion done mainly through email was the tool used for consensus gathering for problem-solving and decision-making. Appropriate statistics, both descriptive and analytical, were used as needed.
Specific Methods for Each Objective:
Objective 1:
To determine the extent of discrepancy of clinical-pathological TN staging in patients with breast cancer in the focal institution.
Methods:
A retrospective chart and record review was done on all breast cancer patients who underwent total mastectomy and axillary dissection (usually modified radical mastectomy) and with documentation of clinical and pathological TN determination. Excluded were patients with post-excision-section-biopsy status.
The retrospective chart and record review was done only in Hospital X , Hospital Y and Hospital W. The other centers and members of the MCCCARS group had difficulty gathering data on baseline discrepancy rate because of chart and record problems.
Objectives 2 and 3:
To determine the root causes of the discrepancy, if discrepancy is present and needed to be diminished further.
To formulate strategies to reduce the discrepancy based on identified root causes.
Methods:
Focused group discussion among members of MCCCARS group and dialogue with pathologists of focal institution were done.
Objective 4:
To implement and then evaluate the strategies.
Methods:
Implementation of strategies was done in multiple centers particularly among surgical residents. Evaluation was done on the effectiveness of strategies based on the results seen in the report
Reducing discrepancy in cTN and pTN in breast cancer 7
cards submitted by the residents that showed comparison of cT (clinical tumor size) with sT (tumor size on operation) and pT (tumor size determined by the pathologist) on one hand and comparison of cN (clinical nodal status) with sT (nodal status) and pT (histopathological status) on the other hand. The residents were also asked to give feedback on the training program.
RESULTS:
Objective 1:
To determine the extent of discrepancy of clinical-pathological TN staging in patients with breast cancer in the focal institution.
A total of 82 charts of breast cancer patients who have undergone total mastectomy and axillary dissection in Hospital X from January 1997 to June 2001 were reviewed. The age of the patients included in the review ranged from 24 to 49 with a mean of 49. All the patients were female. The clinical-pathological T discrepancy rate was 17%, while the N discrepancy was 52 %. The overall T and N discrepancy rate was 70%. See Tables 1 to 3.
A total of 84 charts of breast cancer patients who have undergone total mastectomy and axillary dissection in Hospital Y from January 2001to December 2001 were also reviewed. All the patients were female. The clinical-pathological T discrepancy rate was 15%, while the N discrepancy was 39 %. The overall T and N discrepancy rate was 54%. See Tables 4 to 6.
A total of 85 charts were also reviewed in Hospital W from January 2000 to July 2002. The age of the patients ranged from 31 to 82 with a mean of 54. All were females. 50 charts were excluded because of the following reasons; incomplete charts, incomplete pathology report, and
excision biopsies were done as outpatient. The clinical-pathological T discrepancy rate was 54%, while the N discrepancy was 29 %. The overall T and N discrepancy rate was 83%. See Tables 7 to 9.
Thus, based on data from 3
local hospitals, the overall T and N discrepancy rate ranged from 54% to 83%
with the cT-pT discrepancy ranging from 15% to 54% and the cN-pN discrepancy
ranging from 29% to 52%.
Through a focused group discussion among MCCCARS members, the consensus was that the discrepancy needed to be improved. The cT-pT discrepancy rate of 15% to 54% was considered not acceptable. The consensus was that the discrepancy rate could be reduced to about 5%. Likewise, the cN-pN discrepancy rate of 52% was not acceptable if 32% is to be taken as the standard based on the Yorkshire Breast Cancer Group (2).
Objective 2:
To determine the root causes of the discrepancy, if discrepancy is present and needed to be diminished further.
The consensus of MCCCARS members was that the discrepancy rate in Hospital X , Hospital Y and Hospital W was most probably true in other centers and that the discrepancy rate needed to be diminished.
Possible sources of error and discrepancy were arrived at from a focused group discussion among MCCCARS members and dialogue with pathologists (Table 10). As to the root causes, the consensus consisted of the following: 1) Absence of structured training for the surgeon-
Reducing discrepancy in
cTN and pTN in breast cancer 9
examiner on evaluation of cT and cN and 2) lack of communication between surgeons and pathologists on how to examine and report the tumor and nodal status (Table 11).
Objective 3:
To formulate strategies to reduce the discrepancy based on identified root causes.
The following strategies were formulated:
1. Communication and cooperation between surgeons and pathologists to come out with a mutually agreed protocol on the determination and reporting of T and N (memorandum of cooperation). See Memorandum of Cooperation in appendix A.
2. Structured training for surgeons to develop accuracy in clinical determination of T and N and to implement the mutually agreed protocol with the pathologists. See Structured Training Program in appendix B.
Objective 4:
To implement and then evaluate the strategies.
The Memorandum of Cooperation with the pathologists was implemented so far only in Hospital X and Hospital W on a pilot basis.
The structured training for residents is being implemented in Hospital X ,Y and Z on a pilot basis. Preliminary results show the following:
In Hospital Z, two residents participated with seven and six subjects respectively (Table 12A). Later, one of these two residents continued to evaluate 5 more subjects (Table 12B).
In Hospital X, eight residents participated with eleven subjects each (Tables 13A and 13B). In Hospital Y, seven residents participated with one resident having eleven subjects and the rest having eight subjects each (Table 14).
Reducing discrepancy in
cTN and pTN in breast cancer 10
In Hospital Z, the cT-pT discrepancy rate was 23% and the cN-pN discrepancy rate was 30% (Table 12A). In the subsequent 5 patients evaluated by one of the residents, the discrepancy rates for both T and N were zero.
In Hospital X, after 5 patients, the cT-pT discrepancy rate was 95% and the cN-pN discrepancy rate was 0% (Table 13A). The unusual discrepancy for T led to a review which subsequently revealed that the surgeons and pathologists had different reference points in measuring the T size. Desmoplastic change around the tumor was pointed out as the reason for discrepancy in
measuring the tumor size. The measurement for pT for the succeeding subjects was done by the surgeon and the pathologist agreeing on the reference point.
Table 13B shows the succeeding results of implementation of the structured training program including 6 more subjects in Hospital X. The cT-pT discrepancy rate was lowered down from 95% to 31.25% and the cN-pN discrepancy rate was increased from 0% to 33%.
In Hospital Y, the cT-pT discrepancy rate was 62.7% and the cN-pN discrepancy rate was 42.37% (Table 14).
Based on interview with the surgical residents in Hospital X, Y and Z, the training program and the report card were said to be easy to implement. The report card served as a constant reminder of the importance of developing competency in determining cT and cN so as to reduce the discrepancy rate. The report card likewise gave feedback on how they fared. Such feedback promoted improvement of accuracy in determining cT and cN.
Reducing discrepancy in cTN and pTN in breast cancer 11
DISCUSSION:
Discrepancy in the clinical and pathological tumor and node evaluation in patients with breast cancers do exist in the Philippines as evidenced by the retrospective chart review and prospective performance monitoring through a report card. The retrospective chart reviews from three centers showed the cT-pT discrepancy rate ranging from 15 to 54 per cent with tendency of the error in overestimation of T size and the cN-pN discrepancy rate ranging from 29 to 57 per cent with tendency of the error in detecting an axillary lymph node. Assuming that an acceptable cT-pT discrepancy rate is 5% and an acceptable cN-pN discrepancy rate is 30%, the rates as gathered from the chart reviews are considered not acceptable and need to be reduced.
Two strategies to reduce the discrepancy were formulated and piloted in 3 centers. In one center, there was a memo of understanding (MOU) between the pathologists and surgeons and a structured training program with a prospective performance monitoring report card. In the other 2 centers, there was no MOU and just a prospective performance monitoring report card.
In the center where there was a MOU, it was evidently shown that communication with the pathologists was very important. Despite a memo of understanding, misunderstanding still occurred on the reference points for measuring T between the surgeons and the pathologists in Hospital X resulting in a 95% discrepancy rate for cT-pT. With further communication between the two specialists, the discrepancy improved in the subsequent batch of patients.
In 2 of the 3 pilot centers, training came in 2 batches for some of the residents, meaning after one batch of patients, there was evaluation and resolution to improve before proceeding to the second batch of patients. There was improvement in the second batch of patients (Tables 12A and 12 Bl
Reducing discrepancy in
cTN and pTN in breast cancer 12
Tables 13A and 13 B). In these two centers, it was evidently shown that a structured training with provisions for evaluation and follow-through for improvement was very important. In the third center, a follow-through is needed to improve on the unacceptable discrepancy rates.
With the fluctuating cTN-sTN-pTN discrepancy per examiner, this experience has shown that 100% accuracy can never be achieved at all time by the surgeon-examiner in the clinical examination of the breast tumor and axilla. There will always be situation where there will be uncertainties of findings and difficulty in determining the exact tumor size and nodal status. In other words, there will always be occasions where discrepancy will occur because of surgeon’s or clinician’s limitations in physical examination, not to say, patient’s unique situation. This was vividly shown in the experience in Hospital X. There was fluctuation in the accuracy rate from one batch of patients to another batch, from high to low for T and low to high for N.
The way to deal with this problem is not complete surrender and do nothing anymore to achieve and improve accuracy in physical examination. Although such limitation is a reality, all surgeons should still strive to achieve and improve accuracy at all times, 100% if possible, if not, at least within the acceptable discrepancy rate. In this study, the standards set by the members of the MCCCARS group are 5% for the cT-pT discrepancy and 30% for the cN-pN discrepancy. The report card used in this study seemed to be an effective strategy in reducing the discrepancy rate between cTN and pTN by improving the accuracy of physical examination skills of the surgical residents. As gotten from the feedback, the report card made the residents more conscious of the need for accuracy in their physical examination. It also made them more aware of the consequences of an inaccurate physical examination. Furthermore, with the intraoperative and histopathologic correlation, they were able to check on the accuracy of their clinical
Reducing discrepancy in
cTN and pTN in breast cancer13
examination. If there were discrepancy, they would analyze and make resolve to improve in subsequent patients.
Thus, basically, the strategies used in reducing the discrepancy in the cTN and pTN evaluation include a communication between surgeons and pathologists on a cooperative effort as well as a training program for surgeons (residents) for improvement. Both strategies are relatively simple to implement and can be adopted as a model by other institutions all other the country. Crucial to the sustenance of these strategies, especially, the report card system is the constant awareness by the surgeons and surgical trainees of the importance of accurate clinical staging and to be constantly on the look out for possible errors and to acquire an attitude or habit of continual improvement.
The results of this study will now serve as a basis for institutionalizing the strategies in reducing the discrepancy of tumor and nodal evaluation in patients with breast cancer. This has been done in Hospital X. Hopefully, the other centers in the MCCCARS will follow suit.
REFERENCES:
1. Leonhardt A. Observations and problems in the TNM classification of breast cancers.
Geburtshilfe Frauenheilkd 1988;48(5):318-21.
2. Anonymous. Critical assessment of the clinical TNM system in breast cancer. Report from the
Yorkshire Breast Cancer Group. Br Med J 1980;281(6233):134-6.
3. Cohen L, Manion L. Research Methods in Education. London, Croom Helm, 1980.
4. Marguiles N. Managing change in health care organization. Medical Care 1977;15:693-704.
Table 1. Clinical-Pathological T Staging (Hospital X).
|
Clinical Staging |
Pathological Staging |
|||
|
cT |
No. |
Discrepancy # (%) |
Upstaged # (%) |
Downstaged # (%) |
|
T1 |
7 |
2(29%) |
2(100%) |
0 |
|
T2 |
38 |
4(11%) |
3(75%) |
1(25%) |
|
T3 |
27 |
7(26%) |
1(14%) |
6(86%) |
|
T4 |
10 |
1(10%) |
0 |
1(100%) |
Table 2. Clinical-Pathological N Staging (Hospital X)
|
Clinical Staging |
Pathological Staging |
|||
|
cN |
No. |
Discrepancy # (%) |
Upstaged # (%) |
Downstaged # (%) |
|
N0 |
47 |
26(55%) |
26(100%) |
0 |
|
N+ |
35 |
17(49%) |
9(53%) |
8(47%) |
Table 3. Overall Clinical-Pathological TN Staging Discrepancy (Hospital X).
|
Clinical Staging |
Pathological Staging |
|||
|
cTN |
No. |
Discrepancy # (%) |
Upstaged # (%) |
Downstaged # (%) |
|
cT |
82 |
14(17%) |
6(43%) |
8(57%) |
|
cN |
82 |
43(52%) |
35(81%) |
8(19%) |
Table 4. Clinical-Pathological T Staging (Hospital Y).
|
Clinical Staging |
Pathological Staging |
|||
|
cT |
No. |
Discrepancy # (%) |
Upstaged # (%) |
Downstaged # (%) |
|
T1 |
1 |
0 |
0 |
0 |
|
T2 |
32 |
6(19%) |
4(67%) |
2(33%) |
|
T3 |
22 |
7(32%) |
0 |
7(100%) |
|
T4 |
29 |
0 |
0 |
0 |
Table 5. Clinical-Pathological N Staging (Hospital Y).
|
Clinical Staging |
Pathological Staging |
|||
|
cN |
No. |
Discrepancy # (%) |
Upstaged # (%) |
Downstaged # (%) |
|
N0 |
54 |
30(55%) |
30(100%) |
0 |
|
N+ |
30 |
3(10) |
0 |
3(100%) |
Table 6. Overall Clinical-Pathological TN Staging Discrepancy (Hospital Y).
|
Clinical Staging |
Pathological Staging |
|||
|
cTN |
No. |
Discrepancy # (%) |
Upstaged # (%) |
Downstaged # (%) |
|
cT |
84 |
13(15%) |
4(31%) |
9(69%) |
|
cN |
84 |
33(39%) |
30(91%) |
3(9%) |
Table 7. Clinical-Pathological T Staging (Hospital W).
|
Clinical Staging |
Pathological Staging |
|||
|
cT |
No. |
Discrepancy # (%) |
Upstaged # (%) |
Downstaged # (%) |
|
T1 |
0 |
0 |
0 |
0 |
|
T2 |
5 |
0 |
0 |
0 |
|
T3 |
21 |
11 (52%) |
5 (45%) |
6 (55%) |
|
T4 |
9 |
8 (89%) |
0 |
100% |
Table 8. Clinical-Pathological N Staging (Hospital W).
|
Clinical Staging |
Pathological Staging |
|||
|
cN |
No. |
Discrepancy # (%) |
Upstaged # (%) |
Downstaged # (%) |
|
N0 |
17 |
7 (41%) |
7 (100%) |
0 |
|
N+ |
18 |
3 (17%) |
1 (33%) |
2 (67%) |
Table 9. Overall Clinical-Pathological TN Staging Discrepancy (Hospital W).
|
Clinical Staging |
Pathological Staging |
|||
|
cTN |
No. |
Discrepancy # (%) |
Upstaged # (%) |
Downstaged # (%) |
|
cT |
35 |
19 (54%) |
5 (26%) |
14 (74%) |
|
cN |
35 |
10 (29%) |
8 (80%) |
2 (20%) |
Table 10. Possible sources of error and discrepancy.
· Error in determination of size of primary tumor
· Wrong estimate because did not use ruler (Pathologists use ruler)
· Error in determination of presence or absence of axillary node
· Error lies in determining clinical T and N in those with previous open biopsy
· Error lies in the surgeon during operation intended for modified radical mastectomy
· No nodes were removed in patients with actually cN+ leading to pN0
· Innate discrepancy since surgeons during the clinical breast examination measure what is palpable which includes the mass and the overlying skin and subcutaneous tissue while on post operative measurements the surgeon and pathologist measure the mass itself.
· Pathologist missed detection of lymph node in axillae during cutting of specimen in patients with actual cN+
· What happen before, during and after operation
· Distortion of specimen created by surgeon during and right after the operation, such as cutting the specimen
· Distortion of specimen when fixed in preservative solution
· Distortion of specimen when squeezed into container to be sent to pathologist
· No mutually agreed or standardized way of measuring T
· No mutually agreed or standardized way of determining N
Table 11: Possible root causes of discrepancy.
· Axilla not laxed during palpation
· Too light pressure during palpation
· Not sweeping down the chest wall
· Not reaching the apex
· Not covering the whole area of the axilla
· No side to side palpation of the axilla
· Not conscientious or thorough in examining axillae
· Not knowing how to interpret finding
· Neurovascular bundle and ribs may be mistaken for nodes
Table 12A. Report cards of residents in Hospital Z (1st batch).
|
Surgical Resident |
No. of subjects |
T discrepancy |
N discrepancy |
||
|
|
|
cT-sT |
cT - pT |
cN-sN |
cN-pN |
|
1 |
7 |
1 |
2 |
0 |
0 |
|
2 |
6 |
1 |
1 |
0 |
4 |
|
Discrepancy rate |
|
|
23%(3/13) |
|
30% (4/13) |
Table 12B. Report cards of
residents in Hospital Z (2nd batch).
|
Surgical
Resident |
No.
of subjects |
T
discrepancy |
N
discrepancy |
||
|
|
|
cT-sT |
cT - pT |
cN-sN |
cN-pN |
|
1 |
5 |
0 |
0 |
0 |
0 |
|
Discrepancy rate |
|
|
0% |
|
0% |
Table 13A. Report cards of residents in Hospital X (1st batch).
|
Surgical Resident |
No. of subjects |
T discrepancy |
N discrepancy |
||
|
|
|
cT-sT |
cT - pT |
cN-sN |
cN-pN |
|
1 |
5 |
0 |
4 |
0 |
0 |
|
2 |
5 |
1 |
5 |
0 |
0 |
|
3 |
5 |
2 |
4 |
0 |
0 |
|
4 |
5 |
1 |
5 |
0 |
0 |
|
5 |
5 |
0 |
5 |
0 |
0 |
|
6 |
5 |
0 |
5 |
0 |
0 |
|
7 |
5 |
0 |
5 |
0 |
0 |
|
8 |
5 |
1 |
5 |
0 |
0 |
|
Discrepancy Rate |
|
|
95% (38/40) |
|
0% (0/40) |
Table 13B. Report cards of residents in Hospital X (2nd batch).
|
Surgical Resident |
No. of subjects |
T discrepancy |
N discrepancy |
||
|
|
|
cT-sT |
cT – pT |
cN-sN |
cN-pN |
|
1 |
6 |
0 |
1 |
0 |
2 |
|
2 |
6 |
1 |
2 |
0 |
2 |
|
3 |
6 |
0 |
1 |
0 |
2 |
|
4 |
6 |
1 |
2 |
0 |
2 |
|
5 |
6 |
2 |
3 |
0 |
2 |
|
6 |
6 |
1 |
2 |
0 |
2 |
|
7 |
6 |
1 |
2 |
0 |
2 |
|
8 |
6 |
1 |
2 |
0 |
2 |
|
Discrepancy Rate |
|
|
31.25% (15/48) |
|
33% (16/48) |
Table 14. Report cards of residents in Hospital Y.
|
Surgical Resident |
No. of subjects |
T discrepancy |
N discrepancy |
||
|
|
|
cT-sT |
cT - pT |
cN-sN |
cN-pN |
|
1 |
11 |
4 |
5 |
0 |
4 |
|
2 |
8 |
3 |
3 |
0 |
4 |
|
3 |
8 |
5 |
5 |
1 |
4 |
|
4 |
8 |
4 |
7 |
1 |
3 |
|
5 |
8 |
3 |
5 |
0 |
3 |
|
6 |
8 |
5 |
6 |
0 |
3 |
|
7 |
8 |
7 |
6 |
1 |
4 |
|
Discrepancy Rate |
|
|
37/59 62.7% |
|
25/59 42.37% |
APPENDIX A
Hospital X
between Department of Surgery and Department of Pathology
in an effort to reduce the discrepancy rate in the clinical and pathological tumor and node evaluation in patients with breast cancer
Whereas, there exists a significant discrepancy rate in the clinical and pathological tumor and node evaluation in patients with breast cancer which needs to and can be reduced to within acceptable limits;
Whereas, an acceptable discrepancy rate is a parameter of quality patient care;
Whereas, one of the root causes of the discrepancy is lack of communication and understanding between the staff of the Department of Surgery and that of the Department of Pathology;
Be it resolved, and hereby resolved, that a memorandum of understanding and cooperation be forged between the Department of Surgery and the Department of Pathology with the following stipulations:
I. In the clinical examination, surgeon will
A. Measure the size(s) of the primary breast tumor(s) using a stiff ruler.
B. Note down presence or absence of palpable axillary lymph nodes; if present, note the
size of largest node palpated.
C. The clinical T and clinical N data should be noted down in the pathology
request.
II. After the total mastectomy and axillary dissection, surgeon will do the following:
A. Measure the tumor (sT)
1. In tumor with no previous open biopsy or frozen section biopsy, cut the
tumor along the widest diameter in one direction only and then using a stiff ruler measure the length of the widest diameter in cm. Note down size (length) of sT in pathology request.
2. In tumor with frozen section biopsy, determine the sT in its widest
diameter using a stiff ruler taking into consideration the size of the specimen removed and submitted for frozen section. Note down size (length) of sT in pathology request.
B. Identify and isolate nodes in the axillary dissection specimen.
Note down in pathology request number of grossly palpable nodes isolated
and their sizes in greatest diameter using stiff ruler.
III. Role of the pathologists after receiving the specimen and request:
A. Study the pathology request of surgeon.
1. Take note of the clinical and surgical T and N.
2. Verify the sTN data.
Make the necessary adjustment and corrections for sT and sN.
C. Make a histopathological report after conducting a microscopic examination of
all specimens submitted.
1. Include the data submitted by surgeon in the report (cTcN and sTsN)
2. Place a pTpN report.
The pT and sT should gibe. The cT may not gibe with the sT or
PT depending on the accuracy of clinical measurement of T by the surgeon.
The pN and cN and sN may not gibe.
SSSSS, MD PPPPPP, MD
Chair Chair
Department of Surgery Department of Pathology
Date: Date:
APPENDIX B
Structured training program for surgeons to develop accuracy in clinical determination of T and N and to implement the mutually agreed protocol with the pathologists.
1. Developing accuracy in clinical determination of T and N
Training program with the following main learning strategy: Plan - Do - Check - Improve
Plan:
1. Creation of awareness of importance of accurate clinical staging
2. Structured training on
physical examination of the primary breast tumor and axillae (demo-return demo
on 2 patients one with and one without axillary nodes)
a. How to determine the clinical T (see details below)
b. How to do the physical examination of the axillae with emphasis on how to determine the presence and absence of lymph nodes (see details below)
3. Do - Check - Improve (with inculcation of importance of continual self-improvement):
Each surgeon do (cTcN) - check (sTsN - pTpN) - improve on at least 10 patients for and undergoing modified or classical radical mastectomy.
For each patient, the surgeon fills up the form below:
Resident’s Report Card on
Improving accuracy of Clinical Determination o T and N in Patients with Breast Cancer
Name of resident:
Instructions:
1. Competency to develop: accuracy in clinical determination of T and N in patients with breast cancer
2. Main learning activity:
Do-Check-Improve (with inclusion of importance of continual self improvement):
Each resident do (cTcN) – check (sTsN – pTpN) – improve on at least 10 patients for and undergoing modified or classical radical mastectomy.
3. Fill-up table below and submit on agreed date to facilitator.
4. Target standards:
1-cm discrepancy rate of cT and sT (=pT)/surgeon should be 5% or less.
Discrepancy rate of cN and sN/surgeon should be 30% or less.
Or there must at least be signs of definite improvement in each surgeon until he reaches a constant acceptable discrepancy rate.
|
|
cTcN |
STsN |
pTpN |
Discrepancy |
|
Pt 1 Age/sex |
cT=cm |
sT= cm |
pT cm |
|
|
cN= (+/-) Size= cm |
sN= (+/-) Size=cm |
pN= (+/-) |
|
|
|
Pt 2 Age/sex |
cT=cm |
sT= cm |
pT cm |
|
|
cN= (+/-) Size= cm |
sN= (+/-) Size=cm |
pN= (+/-) |
|
|
|
Pt 3 Age/sex |
cT=cm |
sT= cm |
pT cm |
|
|
cN= (+/-) Size= cm |
sN= (+/-) Size=cm |
pN= (+/-) |
|
|
|
Pt 4 Age/sex |
cT=cm |
sT= cm |
pT cm |
|
|
cN= (+/-) Size= cm |
sN= (+/-) Size=cm |
pN= (+/-) |
|
|
|
Pt 5 Age/sex |
cT=cm |
sT= cm |
pT cm |
|
|
cN= (+/-) Size= cm |
sN= (+/-) Size=cm |
pN= (+/-) |
|
|
|
Pt 6 Age/sex |
cT=cm |
sT= cm |
pT cm |
|
|
cN= (+/-) Size= cm |
sN= (+/-) Size=cm |
pN= (+/-) |
|
|
|
Pt 7 Age/sex |
cT=cm |
sT= cm |
pT cm |
|
|
cN= (+/-) Size= cm
|
sN= (+/-) Size=cm
|
pN= (+/-) |
|
|
|
Pt 8 Age/sex |
cT=cm |
sT= cm |
pT cm |
|
|
cN= (+/-) Size= cm |
sN= (+/-) Size=cm |
pN= (+/-) |
|
|
|
Pt 9 Age/sex |
cT=cm |
sT= cm |
pT cm |
|
|
cN= (+/-) Size= cm |
sN= (+/-) Size=cm |
pN= (+/-) |
|
|
|
Pt 10 Age/sex |
cT=cm |
sT= cm |
pT cm |
|
|
cN= (+/-) Size= cm
|
sN= (+/-) Size=cm
|
pN= (+/-) |
|
How to determine the clinical T:
· Patient in supine position
· Locate the mass by palpation
· Determination of edges of tumor for measurement (induration vs erythema)
· use ballpen to mark the edges
· use stiff ruler (not tape measure) to measure widest diameter in cm
How to determine the clinical N
· Patient in sitting position facing surgeon examiner
· Surgeon promotes laxity of axillary fold
· Palpation of axilla for nodes
· Gentle and adequate palpating pressure (light to firm) on the lateral chest wall
· Palpation of entire axilla up to apex and anterior and posterior parts
· Interpretation of findings
· Elongated structures palpated: NOT lymph nodes
· Round or oval structures palpated in axilla (not on epidermis and dermis): lymph nodes
· Determine size of largest node
· < 1 cm
· 1 - 2 cm
· > 2 cm
· End-point of examination
· Repeat and repeat until convinced of NO nodes or presence of nodes
All surgical residents will examine patients for modified radical mastectomy (all or some residents per patient)
At least 10 patients per residents, preferably more.
Check accuracy of clinical evaluation with operative findings.
Timetable: 2 months depending on prevalence of patients for modified radical mastectomy