The Dartmouth Institute for Health Policy and Clinical Practice, Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, One Medical Center Drive Level 5 WTRB, Lebanon, NH, 03756, USA.
The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA.
Breast Cancer Res Treat. 2018 Jan;167(1):195-203. doi: 10.1007/s10549-017-4432-0. Epub 2017 Sep 6.
To estimate the potential near-term population impact of alternative second opinion breast biopsy pathology interpretation strategies.
Decision analysis examining 12-month outcomes of breast biopsy for nine breast pathology interpretation strategies in the U.S. health system. Diagnoses of 115 practicing pathologists in the Breast Pathology Study were compared to reference-standard-consensus diagnoses with and without second opinions. Interpretation strategies were defined by whether a second opinion was sought universally or selectively (e.g., 2nd opinion if invasive). Main outcomes were the expected proportion of concordant breast biopsy diagnoses, the proportion involving over- or under-interpretation, and cost of care in U.S. dollars within one-year of biopsy.
Without a second opinion, 92.2% of biopsies received a concordant diagnosis. Concordance rates increased under all second opinion strategies, and the rate was highest (95.1%) and under-treatment lowest (2.6%) when all biopsies had second opinions. However, over-treatment was lowest when second opinions were sought selectively for initial diagnoses of invasive cancer, DCIS, or atypia (1.8 vs. 4.7% with no 2nd opinions). This strategy also had the lowest projected 12-month care costs ($5.907 billion vs. $6.049 billion with no 2nd opinions).
Second opinion strategies could lower overall care costs while reducing both over- and under-treatment. The most accurate cost-saving strategy required second opinions for initial diagnoses of invasive cancer, DCIS, or atypia.
评估替代第二意见乳腺活检病理解读策略的潜在近期人群影响。
决策分析，在美国卫生系统中检查 9 种乳腺病理解读策略的 12 个月乳腺活检结果。将 115 位执业病理学家的诊断结果与参考标准共识诊断进行比较，有无第二意见。解读策略的定义是是否普遍或选择性地寻求第二意见（例如，如果是浸润性的，则进行第二次意见）。主要结果是在活检后 1 年内预期的一致乳腺活检诊断比例、涉及过度或低估的比例以及以美元计算的护理成本。
如果没有第二意见，92.2%的活检得到了一致的诊断。在所有第二意见策略下，一致性率都有所提高，当所有活检都有第二意见时，一致性率最高（95.1%），过度治疗最低（2.6%）。然而，当对初始浸润性癌、DCIS 或非典型性诊断进行选择性第二意见时，过度治疗最低（1.8%比无第二意见时的 4.7%）。该策略还具有最低的 12 个月预计护理成本（59.07 亿美元，无第二意见时为 60.49 亿美元）。
第二意见策略可以降低整体护理成本，同时减少过度和不足治疗。最准确的节省成本策略需要对浸润性癌、DCIS 或非典型性的初始诊断进行第二意见。
