I NTRODUC T I ON
The Pathologist as a Specialist in Breast Carcinoma Care
The development and application of a concept of localized
pathology laid the groundwork for modern specialism by
providing a number of foci of interest in the field of medicine.
Each such focus of interest, that is, a disease or the diseases
of an organ or region of the body, provided a nucleus around
which could gather the results of clinical and pathological
investigation
.
—From
The Specialization of Medicine
by
George Rosen, MD
, 1944.
Impressive advances have been made in the past 60 years
to detect, treat, and cure breast carcinoma. Major milestones
include the development of mammography for early detec-
tion, the refinement of image-based needle biopsy of non-
palpable lesions, the introduction of computed tomography
(CT) and magnetic resonance imaging (MRI) of the breast,
the shift from mastectomy to breast conservation therapy
for almost all patients, technologic advances in radiotherapy,
improved chemotherapy regimens for primary treatment
and as an adjuvant modality, the demonstration that anti-
estrogenic compounds can inhibit the development and
progression of breast carcinoma, the introduction of sentinel
lymph node mapping for axillary staging, and technologic
advances that make gene expression profiling possible. The
growth of medical specialization in the last half of the 20th
century has had a profound influence on these accomplish-
ments by fostering multidisciplinary clinical practice and
research.
Specialism in all aspects of medical care has revolution-
ized the role of the surgical pathologist. Rather than foster-
ing professional independence, specialization in medicine
has created circumstances in which the specialist, delivering
a limited segment of medical care, is increasingly dependent
on the assistance of colleagues who have acquired comple-
mentary expertise. This situation is epitomized by the mul-
tidisciplinary approach that is now standard for treating
breast diseases. Inherent in this circumstance is the expecta-
tion that each member of the team is capable of delivering
optimal specialty care. A corollary effect is the growing pres-
sure for subspecialization in diagnostic pathology in aca-
demic centers and in large community hospital centers. This
process will be furthered by growing awareness on the part
of patients and patient advocacy organizations that accurate
and comprehensive pathology diagnosis is fundamental to
effective treatment and research in breast diseases.
Even when considered in the context of advances in
diagnosis that have been facilitated in recent decades by
immunohistochemistry and molecular analysis, micro-
scopic examination of hematoxylin and eosin–stained tis-
sue sections combined with gross inspection remains the
most cost-effective diagnostic procedure for breast diseases.
Pathologists generate an important part of the information
used for therapeutic decisions. The complex multifacto-
rial description of breast pathology now considered to be
standard practice has expanded the diagnostic report from a
brief one- or two-line statement to a catalog of data that may
be several pages in length. Immunohistochemistry makes it
possible to determine whether prognostic and therapeutic
markers are present by microscopic examination, and these
observations are part of the pathologist’s report. The ex-
panded role of pathologists in the management of breast dis-
eases requires their active participation as part of the clinical
care team. Pathologists who diagnose breast specimens need
to be aware of how various components of their reports are
relevant to treatment decisions.
Coincidental with these medical developments has been
the growing involvement of patients in making decisions
about their treatment. This, in turn, has led to greater pub-
lic awareness of the importance of information contained
in pathology reports. For the untrained layperson to read
and interpret a pathology report, it is necessary to learn
and understand a new vocabulary, a daunting task that is
not necessarily made easier by the frequently conflicting
and unfiltered information available from the Internet.
Surgeons, oncologists, and radiotherapists are experts at
interpreting pathology reports for their patients and at
explaining the significance of the data. Nonetheless, a sub-
stantial number of patients with breast diseases want an
explanation from the pathologist who issued the report or
they seek out another pathologist, often with specialized
expertise, for a second-opinion review. In this way, patholo-
gists increasingly participate in direct patient care and pa-
tient education, a vital public service.
Second Opinions in Breast Pathology
Surgical pathologists in general practice provide accurate
diagnoses for the great majority of the breast specimens they
encounter without the assistance of intramural or extramu-
ral consultation. Nonetheless, pathology departments that
do not have a dedicated breast pathology subsection should
have a built-in mechanism for obtaining second opinions
internally through conferencing or other quality assurance
programs. As evidenced by a number of papers published in
recent years, there is growing recognition of the importance
of having an intradepartmental peer-review quality assur-
ance program in order to minimize diagnostic errors.
1–3
Procedures have been described for internal review shortly
after the diagnosis was officially reported
4
and for pre-sign-
out review.
5
For detailed discussions of quality assurance
issues in surgical pathology, the reader should consult the
aforementioned articles and references cited therein.
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