Elmore Joann G, Tosteson Anna Na, Pepe Margaret S, Longton Gary M, Nelson Heidi D, Geller Berta, Carney Patricia A, Onega Tracy, Allison Kimberly H, Jackson Sara L, Weaver Donald L
Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, NH, USA Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.
BMJ. 2016 Jun 22;353:i3069. doi: 10.1136/bmj.i3069.
To evaluate the potential effect of second opinions on improving the accuracy of diagnostic interpretation of breast histopathology.
Simulation study.
12 different strategies for acquiring independent second opinions.
Interpretations of 240 breast biopsy specimens by 115 pathologists, one slide for each case, compared with reference diagnoses derived by expert consensus.
Misclassification rates for individual pathologists and for 12 simulated strategies for second opinions. Simulations compared accuracy of diagnoses from single pathologists with that of diagnoses based on pairing interpretations from first and second independent pathologists, where resolution of disagreements was by an independent third pathologist. 12 strategies were evaluated in which acquisition of second opinions depended on initial diagnoses, assessment of case difficulty or borderline characteristics, pathologists' clinical volumes, or whether a second opinion was required by policy or desired by the pathologists. The 240 cases included benign without atypia (10% non-proliferative, 20% proliferative without atypia), atypia (30%), ductal carcinoma in situ (DCIS, 30%), and invasive cancer (10%). Overall misclassification rates and agreement statistics depended on the composition of the test set, which included a higher prevalence of difficult cases than in typical practice.
Misclassification rates significantly decreased (P<0.001) with all second opinion strategies except for the strategy limiting second opinions only to cases of invasive cancer. The overall misclassification rate decreased from 24.7% to 18.1% when all cases received second opinions (P<0.001). Obtaining both first and second opinions from pathologists with a high volume (≥10 breast biopsy specimens weekly) resulted in the lowest misclassification rate in this test set (14.3%, 95% confidence interval 10.9% to 18.0%). Obtaining second opinions only for cases with initial interpretations of atypia, DCIS, or invasive cancer decreased the over-interpretation of benign cases without atypia from 12.9% to 6.0%. Atypia cases had the highest misclassification rate after single interpretation (52.2%), remaining at more than 34% in all second opinion scenarios.
Second opinions can statistically significantly improve diagnostic agreement for pathologists' interpretations of breast biopsy specimens; however, variability in diagnosis will not be completely eliminated, especially for breast specimens with atypia.
评估二次诊断意见对提高乳腺组织病理学诊断解读准确性的潜在作用。
模拟研究。
获取独立二次诊断意见的12种不同策略。
115名病理学家对240份乳腺活检标本进行解读，每个病例一张切片，并与专家共识得出的参考诊断进行比较。
个体病理学家以及12种模拟二次诊断意见策略的错误分类率。模拟比较了单名病理学家的诊断准确性与基于第一位和第二位独立病理学家解读配对后的诊断准确性，其中分歧由第三位独立病理学家解决。评估了12种策略，二次诊断意见的获取取决于初始诊断、病例难度或临界特征评估、病理学家的临床工作量，或者政策是否要求或病理学家是否希望进行二次诊断。240个病例包括无异型性的良性病例（10%为非增殖性，20%为无异型性的增殖性）、异型性病例（30%）、导管原位癌（DCIS，30%）和浸润性癌（10%）。总体错误分类率和一致性统计数据取决于测试集的构成，该测试集包含的疑难病例比例高于典型实践。
除仅将二次诊断意见限于浸润性癌病例的策略外，所有二次诊断意见策略的错误分类率均显著降低（P<0.001）。当所有病例都接受二次诊断意见时，总体错误分类率从24.7%降至18.1%（P<0.001）。从工作量大（每周≥10份乳腺活检标本）的病理学家处同时获取首次和二次诊断意见，在该测试集中错误分类率最低（14.3%，95%置信区间10.9%至18.0%）。仅对初始解读为异型性、DCIS或浸润性癌的病例获取二次诊断意见，可将无异型性良性病例的过度解读从12.9%降至6.0%。异型性病例单次解读后的错误分类率最高（52.2%），在所有二次诊断意见方案中仍超过34%。
二次诊断意见在统计学上可显著提高病理学家对乳腺活检标本解读的诊断一致性；然而，诊断的变异性不会完全消除，尤其是对于有异型性的乳腺标本。
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