Bull A D, Biffin A H, Mella J, Radcliffe A G, Stamatakis J D, Steele R J, Williams G T
Department of Pathology, University of Wales College of Medicine, Cardiff.
J Clin Pathol. 1997 Feb;50(2):138-42. doi: 10.1136/jcp.50.2.138.
To audit the information content of pathology reports of colorectal cancer specimens in one National Health Service region.
All reports of colorectal cancer resection specimens from the 17 NHS histopathology laboratories in Wales during 1993 were evaluated against: (a) standards previously agreed as desirable by pathologists in Wales; and (b) standards considered to be the minimum required for informed patient management.
1242 reports were audited. There was notable variation in the performance of different laboratories and in the completeness of reporting of individual items of information. While many items were generally well reported, only 51.5% (640/ 1242) of rectal cancer reports contained a statement on the completeness of excision at the circumferential resection margin and only 30% (373/1242) of all reports stated the number of involved lymph nodes. All of the previously agreed items were contained in only 11.3% (140/1242) of reports on colonic tumours and 4.0% (40/1242) of reports on rectal tumours. Seventy eight per cent (969/1242) of colonic carcinoma reports and 46.6% (579/ 1242) of rectal carcinoma reports met the minimum standards.
The informational content of many routine pathology reports on colorectal cancer resection specimens is inadequate for quality patient management, for ensuring a clinically effective cancer service through audit, and for cancer registration. Template proforma reporting using nationally agreed standards is recommended as a remedy for this, along with improved education, review of laboratory practices in the light of current knowledge, and further motivation of pathologists through their involvement in multidisciplinary cancer management teams.
审核某国民保健服务地区结直肠癌标本病理报告的信息内容。
对1993年威尔士17家国民保健服务组织的组织病理学实验室的所有结直肠癌切除标本报告进行评估，评估依据为：（a）威尔士病理学家先前商定的理想标准；（b）知情患者管理所需的最低标准。
共审核了1242份报告。不同实验室的表现以及各项信息报告的完整性存在显著差异。虽然许多项目的报告总体良好，但只有51.5%（640/1242）的直肠癌报告包含关于环周切缘切除完整性的说明，所有报告中只有30%（373/1242）注明了受累淋巴结的数量。所有先前商定的项目仅在11.3%（140/1242）的结肠肿瘤报告和4.0%（40/1242）的直肠肿瘤报告中出现。78%（969/1242）的结肠癌报告和46.6%（579/1242）的直肠癌报告符合最低标准。
许多关于结直肠癌切除标本的常规病理报告的信息内容不足以进行高质量的患者管理、通过审核确保临床有效的癌症服务以及癌症登记。建议采用全国商定标准的模板式报告格式作为补救措施，同时加强教育，根据当前知识审查实验室操作，并通过让病理学家参与多学科癌症管理团队进一步激发他们的积极性。
