AP, radiology talk it out on breast cancer cases

CAP Today

August 2012
Feature Story

Anne Ford

Thousands of breast cancer diagnoses are missed each year, says the U.S. Department of Health and Human Services, because not enough radiologists and pathologists do one thing: Sit down and talk to each other.

Of course, the HHS—whose Office of the Assistant Secretary for Planning and Evaluation released a white paper on this topic in 2010—isn’t suggesting these two groups of physicians just shoot the breeze. Rather, the intent is to encourage “both radiologists and pathologists [to] communicate and correlate their findings in a way that ensures the proper treatment course for a patient,” the paper says. And the panel of experts that created the paper isn’t shy about estimating just how many missed breast cancer diagnoses result annually because radiologists and pathologists don’t routinely review results together: 9,969.

Which leads to the questions: What is that estimate based on? Exactly who is keeping data on how often a lack of radiology-pathology concordance produces a missed or incorrect breast cancer diagnosis?

Pathologist Ossama Tawfik, MD, PhD, and radiologist Mark Redick, MD, PhD, of the University of Kansas Medical Center, Kansas City. That’s who.

As CAP TODAY reported in May 2009 (“Talk to me—AP, radiology meet in virtual middle”), Dr. Tawfik, professor and vice chair of education and outreach and director of anatomic and surgical pathology, and Dr. Redick, assistant professor of radiology in the medical center’s Section of Breast Imaging, have for the past several years been holding weekly one-hour video conferences to correlate tissue and imaging findings for benign breast lesions. As a result, dozens, even hundreds, of patients have received more accurate diagnoses. While other hospitals have begun exploring the possibility of creating their own such radiology-pathology consultations, KUMC may be among the very few institutions, if any, with enough experience in this area to produce hard data on exactly how important these consultations are to patient care.

That’s not surprising, given KUMC’s increasing leadership role in the field of radiology-pathology concordance. Not only do the data of Dr. Tawfik and Dr. Redick show that their weekly consultations dramatically affect the quality of breast care at their medical center, but Dr. Tawfik recently invented a device to improve pathology-radiology correlation. He has also begun to use radiology software that makes it easier for pathologists to view radiology images and reports.

Is this a vision of a world to come—a world in which radiologists and pathologists routinely correlate their findings, and in doing so, increase the accuracy of their diagnoses? One of Dr. Tawfik’s colleagues thinks so. “Pathology-radiology correlation will be the future,” says Fang Fan, MD, PhD, director of cytopathology in KUMC’s Department of Pathology and Laboratory Medicine. “Every place, really, should start to do it.”

A quick review of the program’s beginnings: In 2008, as Dr. Tawfik recalls, “Dr. Redick came to me and said, ‘I need to sit down with you and review all benign breast lesions.’ I said, ‘You’re out of your mind. It’s not going to happen. It’s impossible.’ He said, ‘Trust me.’ I said, ‘No.’”

But then the pathologist reconsidered. Perhaps regular consultations with Dr. Redick would help resolve one of the longstanding frustrations of pathologists—lack of information on radiology reports. “Written words are sometimes very cryptic,” Dr. Tawfik says. “The joke in pathology is that when you receive a requisition, what’s written on it is, ‘57-year-old female with lesion.’ We know it’s a lesion. Can you give me some more? If I don’t know what you are thinking of, there is no way I can answer your question to your satisfaction.”

For his part, Dr. Redick was hoping that correlating results with Dr. Tawfik would help lessen frustration on the radiology end as well. “As the field of imaging has advanced, we’re finding smaller and smaller abnormalities to biopsy,” he explains. Those lesions sometimes are a very small part of the core specimens that are submitted. “Occasionally we’ll have cases where we’re looking for ductal carcinoma in situ, and the pathologist will see a microcalcification and say, ‘This is benign.’ Then, after we correlate the specimen x-rays with the pathology images, we find out they haven’t seen the right calcification. In fact, sometimes it’s never even been cut; it’s still in the block.”

The weekly conferences—held for one hour via videoconference, since the offices of Dr. Redick and Dr. Tawfik are located a mile and a half apart—allow both physicians to look at a patient’s radiology imaging and pathology digital slides at the same time. “We can take the mouse and show each other the areas we’re looking at and question this, question that,” Dr. Redick says. “It’s very bidirectional. We’ll review every benign breast biopsy and be certain there is a concordance, and then we make an additional, amended report and a final recommendation back to the referring physician.”

Within a month of beginning the conferences, Dr. Tawfik became convinced of their value. “Lo and behold, we found out we were giving up to 25 percent of women an inaccurate benign diagnosis,” he says. Not only that, but one year later, in a study of 122 biopsies from 106 patients, he and Dr. Redick found their initial reports agreed on only 80 diagnoses. Of the rest, 42 required further intervention (such as lesion excision, re-biopsy, or x-ray of tissue blocks) before a concordance report could be issued.

Dr. Redick remembers one of the more dramatic instances of diagnosis conversion that the pathology-radiology concordance procedure sparked: “There was a patient who presented with an intraductal mass under the nipple, and we biopsied it. The original diagnosis came back as completely benign papilloma. At the time of our conference, we reviewed the slides and compared them with the radiology imaging, and the diagnosis converted to atypical papilloma with cellular atypia. We took that to surgery and did a wider resection, and it converted again to invasive papillary carcinoma. That’s a very significant jump.” (“I don’t want to give the impression that we have one every week like that,” he hastens to add.)

Click image to enlarge

Soon the medical community outside KUMC began to take notice. In 2009, Dr. Redick and Dr. Tawfik spoke about their project at the Dark-Report-sponsored Molecular Summit. The following year, Dr. Tawfik got a call from the HHS. “They heard about our consultations, and I received a call from them saying, ‘We need to know what you guys are doing. We’re looking into improvement in diagnoses by integrating pathology and radiology. We looked around, and the only place doing something like that is you.’ So they invited me and Dr. Redick to join an ASPE [Assistant Secretary for Planning and Evaluation] committee and go to Washington, DC, and meet with them,” he says. “Their charge was to look into generalized pathology-radiology integration, but they lacked data. And we had data. So they used our data as proof that there is a need for integrated pathology-radiology initiatives.”

Specifically, the committee (formally the ASPE Technical Expert Panel on Improving Cancer Policy Research through Information Technology) was interested in KUMC’s findings that of 321 benign breast cancer biopsies, radiology-pathology concordance found 61 discordant results and four malignant cases. The white paper the committee produced said, “Using these results and projecting on a population level (based on approximately one million needle biopsies performed per year in the US for the diagnosis of breast cancer with approximately 200,000 positive cases), we can estimate that approximately 9,969 missed cancer diagnoses per year could be treated earlier if radiology-pathology concordance processes were implemented nationwide” (“The Importance of Radiology and Pathology Communication in the Diagnosis and Staging of Cancer: Mammography as a Case Study,” November 2010). Comparable data reported between 2007 and 2010 in European Radiology and European Journal of Radiology led the panel to a range of between 5,000 and 10,000 per year, the paper says.

Another result of Dr. Tawfik and Dr. Redick’s consultations: A new type of tissue tray, which Dr. Tawfik invented to facilitate radiology-pathology diagnosis concordance by making it easier to correlate histologic findings with mammographically detectable calcifications. The tray has four slots; when a radiologist obtains a core-needle biopsy, he or she places individual core specimens into the separate slots, so the tissue maintains its orientation and integrity. The biopsies undergo x-ray imaging, after which the tray is secured in a standard specimen cassette and submerged in formalin. The pathology laboratory then fixes and embeds the samples in the same exact orientation as the radiologist imaged the samples.

The tissue blocks and their corresponding histologic slides exist in identical orientation, “allowing detailed evaluation and comparison of microcalcifications by histologic and imaging modalities,” Dr. Tawfik and colleagues wrote in an article published recently (Gallagher R, et al. Microcalcifications of the breast: a mammographic-histologic correlation study using a newly designed Path/Rad Tissue Tray. Ann Diagn Pathol. 2012 Jun;16(3):196–201). The article notes that radiologists and pathologists identified and localized targeted microcalcifications in 68 of 71 cases when using the tissue trays, as opposed to 292 of 369 without the trays.

“The trays have improved our correlation with the radiologists tremendously,” Dr. Tawfik says. “They make it very, very easy for the radiologist and the pathologist to compare the site and the number of calcifications that are in each core in a very accurate way. You eliminate the guessing game completely. It works like a charm.”

For their part, the radiology department “put the tray through its paces and helped Dr. Tawfik test it,” Dr. Redick says. “We helped research the different components in terms of how much radiographic continuation there was from different materials so that it was x-ray friendly, so you could x-ray the core specimens inside it and not suffer loss of constituency of the lesion.”

Another stride forward in pathology-radiology relations is Dr. Tawfik’s new use of software called Softek Illuminate to access radiology reports more easily. Rather than force him to exit the Sunquest CoPath AP system, the Softek product allows him to view radiology reports directly from CoPath.

“When Dr. Tawfik pulls up a case,” says Matt McLenon, CEO of Softek in Prairie Village, Kan., “Illuminate automatically brings up all of the patient’s clinical pathology and anatomic pathology data as well as the radiology reports. So if he wants to know what the radiologist saw, what the tumor looked like prior to the biopsy or surgery, he can instantaneously access that exact set of images with a single click, or he can just read the report. It gives the pathologist a much richer picture of the patient’s state so he can really give the best possible interpretation and understand the reason the patient was biopsied.”

As for why a radiology software company would expand into pathology, Softek client services director Christine Rorie says, “The feedback we hear from people like Dr. Tawfik is that because the pathology and radiology departments are on their own separate systems, the primary place to share information is in the EMR. The clinicians have to leave their workflow and go to the EMR. There they have to select the correct patient and study. Our analysis shows this can take five to seven minutes per patient.” Illuminate is an application that’s connected to the system they’re working in. “It’s the same information that goes to the EMR, but we’re making it available to them right there on the desktop.” Dr. Tawfik is the first to have this from a pathology standpoint, Rorie says.

Dr. Tawfik and Dr. Redick say colleagues at other institutions, most recently Stanford and Case Western, have told them they want to start their own radiology-pathology correlation initiatives. The idea “is starting to get more press,” Dr. Redick says. “Still, the vast majority of radiology practices across the country do not do this, even though, if you look at the guidelines from the American College of Radiology, you see very clearly that it is listed under the obligations of the radiologist performing a biopsy to do a pathology-radiology correlation and submit an amended report. It’s one of those things that has just never caught on as a common standard of practice.”

Perhaps that’s in part because “of course, there’s no reimbursement for any of this,” he continues. “This is all dead time in terms of revenue. So it’s an uphill battle in some ways.”

Implementing a video conference procedure was made easier at KUMC, Dr. Tawfik points out, since the pathology department had already gone digital. “The biggest thing is, you need to get into the digital pathology world,” he says. “You need to scan the slides so you can broadcast them by Web to other places. That takes time, and it can get expensive. I just happened to have that available.”

Dr. Redick agrees: “There are some pathology departments that do not have this kind of digital archive system, such as the Aperio system we use here. That’s a significant impediment to doing this electronically.” Institutions without that kind of digital capability, he says, “are probably thinking, ‘We’ve got to get the pathologists together, gather up all the glass slides, travel there [to the radiology department], find a microscope, then the radiologist has to come, and we have to project the image.’” Whereas with digital pathology slides, he says, “the process can be made to be not so disruptive to normal practice.”

Anne Ford is a writer in Evanston, Ill.