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CMAJ
CMAJ - June 2, 1998JAMC - le 2 juin 1998

More on breast cancer guidelines

CMAJ 1998;158:1426

See response from: M. McGregor
In the guideline "The management of ductal carcinoma in situ (DCIS)" (CMAJ 1998;158[3 Suppl]:S27­34 [full text / text complet]), I had difficulty following the logic in the explanation for the last recommendation in the section on diagnosis (page S30). Citing the multicentre clinical trial by Fisher and colleagues,1 in which problems in standardizing the interpretation of DCIS specimens were described, the guideline authors state that "a similar or even higher rate of misinterpretation could be expected from general pathologists working in the community" and go on to recommend that "whenever the pathologist is not highly experienced, the biopsy specimen be reviewed by a pathology service with special expertise in this area." However, this is only level V evidence, the opinion of the guideline authors.

As a "general pathologist working in the community," I find this blanket recommendation unwarranted. The DCIS cases I see form a spectrum from low to high grade. Most cases are fairly obvious and present the straightforward cytoarchitectural features of DCIS. The problem occurs in the small subset of cases at the low-grade end of the spectrum, where the distinction between DCIS and atypical ductal hyperplasia (ADH) can be difficult because of ill-defined or arbitrary criteria that may not be very reproducible. Fisher and colleagues1 stated that 7% of the cases were reclassified as ADH rather than DCIS on the basis of the authors' rather subjective definition of ADH as "ductal epithelial alteration approximating but not unequivocally satisfying the criteria for a diagnosis of DCIS," rather than the more quantitative but arbitrary criteria used by others.2,3

The 2% of cases that were reclassified as invasive and "undercalled" DCIS raise the question of whether all breast biopsy results that might be undercalled but never referred to a cancer centre (e.g., radial scars, sclerosing adenosis, ductal epithelial hyperplasia) should be reviewed by experts.

I believe that, in signing a surgical pathology report, the pathologist must take responsibility for its accuracy and should therefore determine which cases require expert consultation.

Mark Rieckenberg, MD
Staff Pathologist
Thunder Bay Regional Hospital
Thunder Bay, Ont.

References

  1. Fisher ER, Costantino J, Fisher B, Palekar AS, Redmond C, Mamounas E. Pathologic findings from the National Surgical Adjuvant Breast Project (NSABP) Protocol B-17. Intraductal carcinoma (ductal carcinoma in situ). The National Surgical Adjuvant Breast and Bowel Project Collaborating Investigators. Cancer 1995;75:1310-9.
  2. Tavassoli FA, Norrish HJ. A comparison of results of long-term follow-up for atypical intraductal hyperplasia and intraductal hyperplasia of the breast. Cancer 1990;65:518-29.
  3. Page DL, Anderson TJ. Diagnostic histopathology of the breast. Edinburgh: Churchill Livingstone; 1988. p. 137.

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