104 Impact of diagnostic advices in cancer care in Aquitaine

Autor: Sébastien Lepreux, Marie Parrens, Simone Mathoulin-Pélissier, Jean Michel Coindre, Merlio Jean Philippe, Brigitte Le Bail, Isabelle Soubeyran, Antoine de Mascarel, Béatrice Vergier, Nadège Lapeyrere
Rok vydání: 2010
Předmět:
Zdroj: BMJ Quality & Safety. 19:A62-A63
ISSN: 2044-5423
2044-5415
DOI: 10.1136/qshc.2010.041624.16
Popis: Context, objectives Treatments and prognosis for patients with cancers are most often based on histological and/or cytological diagnoses performed by pathologists. Errors are probably the most harmful and expensive types of diagnostic errors, especially for cancer, so an expert second opinion on lesions which are difficult to analyse can be particularly valuable for pathologists (and patients). Such expert review can lead to confirmation or revision of the initial diagnosis and greatly impact the therapeutic management and prognosis of patients. To our knowledge, little is known about the impact of pathology review on patient care. The objective of our study was to focus on the voluntary sending of specimens by pathologists for a second opinion to evaluate its impact on the management of cancer patients in Aquitaine, a region of France. Program The study was first quantitative performed retrospectively on all cases of cancer, voluntary sent in 2006 by a pathologist located in a French region (Aquitaine) to an expert pathologist for a second opinion. We excluded samples sent only for specific additional analyses or submitted by clinicians. Secondly we restricted the study to lymphoid, melanocytic and soft tissue tumours sent for second opinion in order to analyse their diagnostic, therapeutic and prognostic impact. The initial diagnosis was compared to the expert diagnostic. We considered that the expert review had an important diagnosic impact either when the initial pathologist sent the specimen to identify or classify malignant tumour, or hesitated between benign and malignant tumour or had no hypothesis, or if there were discordant diagnoses (malignant/benign) between the two pathologists. We considered that the expert review had a high therapeutic impact if the disagreement between initial and expert diagnoses induced a complete modification in therapy. Results Thousand three hundred thirty six out of all 3781 second opinion cases were sent by pathologists in Aquitaine: 751 samples (56%) were submitted for lymphoid (55%), melanocytic (15%) or soft tissues tumours (30%). There was an important diagnostic impact for 75% of the sample since the expert pathologists identified or classified malignant tumours (60%), made a diagnosis different from the initial diagnosis (9%), or provided a complete diagnosis (6%). The impact of the expert review on patient management was considered high for 46% of specimens (50% for lymphoid, 44% for melanocytic and 39% for soft tissue tumour), resulting in clinically relevant changes. Among the 706 specimens for which there was an initial diagnosis, the expert diagnosis modified the clinical prognosis in 40% of the specimens (similar proportions for better or worse prognosis). Discussion and conclusion This study emphasises the importance of expert pathological second opinion in cancer pathology. But, our study is interested only on lymphoid, melanocytic and soft tissue tumours, samples more complex than others tumours. So, the question remains regarding which slides should be reviewed. Nevertheless, a high therapeutic impact justifies the needs for a second opinion in problematic cases because a correct diagnosis with adapted treatment is preferable to a false diagnosis with inappropriate management. Contexte, objectif La prise en charge et le pronostic de patients atteints de cancer sont determines par le diagnostic histologique et/ou cytologique etablis par les pathologistes. Les erreurs diagnostiques sont certainement les plus dangereuses et les plus couteuses, notamment dans le domaine du cancer; une expertise des lesions les plus difficiles a analyser doit etre valorisee pour les pathologistes. Ainsi, des relectures par des experts peuvent etre effectuees pour confirmer ou preciser le diagnostic initial ce qui peut avoir un impact sur la prise en charge du patient. Toutefois, dans la litterature, nous retrouvons peu d9etudes menees sur l9impact d9un second avis. L9objectif de cette etude etait d9evaluer l9impact therapeutique des avis en cancerologie donnes en Aquitaine. Programme Une etude quantitative retrospective a ete effectuee sur tous les avis et relectures, envoyes volontairement en 2006 par un pathologiste de la region Aquitaine a un expert referent. Ont ete exclus les relectures demandees par un clinicien et les avis adresses uniquement a but technique. Un echantillon des avis regionaux adresses pour tumeurs lymphoides, melaniques et conjonctives a ete selectionne afin d9analyser l9impact diagnostique, therapeutique et pronostique. La proposition diagnostique du pathologiste initial a ete comparee au diagnostic du pathologiste expert. L9impact diagnostique etait determine majeur lorsque l9avis etait envoye pour tumeur maligne a typer ou a identifier, doute benin/malin, diagnostic non precise ou si les diagnostics etaient discordants (malin/benin). L9impact therapeutique etait juge fort si l9avis engendrait une modification radicale du traitement. Resultats Sur 3781 avis recus, 1336 etaient envoyes par un pathologiste aquitain (75%); 751 (56%) correspondaient a des tumeurs lymphoides (55%), conjonctives (30%) et melaniques (15%). L9avis donne par l9expert a induit un impact diagnostique majeur dans 75% des cas regroupant 60% de tumeur maligne a typer ou a classer, 9% de discordance majeure benin/malin et 6% de diagnostic initial non precise. L9avis donne par l9expert a eu un impact therapeutique fort dans 46% des cas (50% pour les tumeurs lymphoides, 44% pour les melaniques et 39% pour les tumeurs conjonctives) resultant a une modification « radicale » du traitement suite a cet avis. Parmi les 706 cas pour lesquels il y avait un diagnostic initial precise, l9avis de l9expert a modifie le pronostic clinique pour 40% d9entre eux (cet impact est meilleur pour la moitie de ces avis). Discussion et Conclusion Cette etude souligne l9importance des avis diagnostiques dans le domaine de la cancerologie. Mais cette etude s9est interessee uniquement aux avis envoyes pour tumeurs lymphoides, melaniques et conjonctives, qui sont des tumeurs complexes. Une question reste donc en suspend concernant les cas qui doivent etre envoyes pour second avis. Toutefois, un fort impact therapeutique justifie la necessite de demander un second avis pour des cas problematiques car un diagnostic correct avec un traitement adapte est preferable a un diagnostic errone qui amene a une prise en charge inappropriee.
Databáze: OpenAIRE
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