Breast cancer pathology reporting practice ang guidelines

The article by Wilkinson and colleagues in this issue of the Journal, evaluating use of guidelines for reporting of breast cancer by the College of American Pathologists (CAP), is a welcome exercise. We need to continuously review our practices to gauge improvement in this area and to focus understanding on the utility of more uniform reporting. This is also an opportune time to note that there have been minor modifications to the specific elements covered in the 1998 guidelines of the CAP, but the major lesson remains: the necessity for clear and consistent reporting of necessary elements for prognostication of breast cancer. Basically, the guidelines provided by the CAP for reporting of breast cancer specimens in 1998 are precisely that: suggestions for practice, because there are no methods for implementing and testing these as requirements for practice. In some measure, though, these guidelines will be reviewed in the American College of Surgeons’ evaluation of hospital-based cancer programs in the near future. Pathologists and other clinicians on the committee that produced these guidelines would support their use. But in some practices they will not be completely used, for a variety of reasons. The strongest stimuli for changing surgical pathology practice are requests by the clinicians the pathologists serve. Studies done by the CAP indicate different variables linked to the acceptance of newer guidelines and techniques, and many of these involve the size of the practice and the specialty expertise of the clinical practitioners. I hope to emphasize here the importance of some prognostic elements and the belief that publications such as this will drive their wider acceptance and adoption. A rigorous checklist is not necessary in all cases, but the current information has become sufficiently complex that some indication of a list of essential, clearly stated information should be considered in reports to foster both clarity and consistency. There are some changes that have been made, even in these guidelines from 1998 to 2001 that will be reflected in the next publication of the protocols and checklists currently under preparation. This is closely correlated with the 6th edition of the American Joint Committee on Cancer’s TNM Staging Manual. Specifically, grade, discussed below, and tumor size have been altered. Tumor size measurements in three dimensions are no longer called for specifically; rather, at least two dimensions are requested, and it emphasizes that size of smaller breast cancers is best determined microscopically from tissue slides. A major addition to practice is the rigorous approach to histologic grading of breast cancers and adoption of a combined system that includes differentiation, nuclear patterns, and mitotic counts. Even in a minimal sampling, such as needle biopsy, the newer aspects of histopathologic grading have been shown to be extremely useful clinically. We should note that the system promoted currently by the CAP is a modified one of the Scarff Bloom Richardson system. Indeed, the modifications produced by the group at Nottingham have been so great during several decades of modification, education, and verification, that the preferred name for the grading system is the Nottingham Histopathologic Grade. Developed by Chris Elston and Ian Ellis of the Nottingham Institutions, its importance is strongly supported by the guidelines that aid in interpersonal verification and agreement in the evaluation of gland formation and in the evaluation of mitotic counting—quite changed from the older system. Mitotic counting has been shown to be one of the most important indicators of shortterm survival in breast cancer, when the counts are done in a somewhat rigorous fashion. A recent study from Guy’s Hospital found that restratifying breast cancer patients in the intermediate-stage category by mitotic counts produced useful, predictive information. The institution of any new technique in medicine, be it therapeutic or diagnostic, takes a prolonged trail. There is the original presentation, and then the verification, followed by the introduction into general practice. The last phase is usually institutionalized within some professional society. At one point, the article editorialized here discusses the use of guidelines for reporting what the results were