A recent article in the New York Times about errors being made by pathologists in the diagnosis of ductal carcinoma in-situ (DCIS) of the breast has been very controversial (see: Prone to Error: Earliest Steps to Find Cancer). Here's a passage from the article with a short summary of DCIS:
D.C.I.S., which is also called Stage 0 or noninvasive cancer, was a rare diagnosis before mammograms began to be widely used in the 1980s. Until then, breast pathology typically involved reading tissue from palpable lumps....Today, D.C.I.S. is diagnosed in more than 50,000 women a year in this country alone....Concerned about the accuracy of breast pathology, the College of American Pathologists said it would start a voluntary certification program for pathologists who read breast tissue. Among its requirements is that the pathologists must read 250 breast cases a year.
There's no question but that the diagnosis of DCIS can, in some cases, be a very tough call. This is in part because of the variability of the lesion and the lack of broadly-accepted criteria for the diagnosis. The diagnostic error rate for the lesion was emphasized in another portion of the NYT article:
In 2006, Susan G. Komen for the Cure, an influential breast cancer survivors’ organization, released a startling study. It estimated that in 90,000 cases, women who receive a diagnosis of D.C.I.S. or invasive breast cancer either did not have the disease or their pathologist made another error that resulted in incorrect treatment....For the medical community, the Komen findings were not surprising, since the risk of misdiagnosis had been widely written about in medical literature. One study in 2002, by doctors at Northwestern University Medical Center, reviewed the pathology in 340 breast cancer cases and found that 7.8 percent of them had errors serious enough to change plans for surgery.
A partial solution to this problem, in my mind, is a relatively simple one and stated explicitly in a comment by Dr. Mary Edgerton to an on-line health column in the NYT that followed the publication of the main article above (see: Doubt About Pathology Opinions for Early Breast Cancer), Here is her advice:
I am a breast pathologist at a world renowned cancer center. There are many mimics to breast cancer and I recommend that all women send their biopsies for a second opinion. An accessible resource to find a center to send a biopsy to would be the list of top cancer centers from the US News and World Report or the list of NCI designated/ comprehensive cancer centers. I also encourage the practice of getting a second opinion even more so when the diagnosis is DCIS and not invasive cancer because that diagnosis is even more difficult.
Here, then, is some simple advice. For all cases of breast cancer and particularly for DCIS, the patient should request a second opinion from a pathologist who "reads" at least 250 breast cases per year. Such pathologists are most likely to work in large hospitals, particularly academic medical centers, and comprehensive cancer centers. The more breast cases read by the pathologist per year the better. For a member of my family, I would go even further and recommend seeking treatment in a cancer hospital. Here's my opinion about this from a January, 2009, note (see: Some Tips for Selecting a "Good" Doctor and a "Good" Hospital):
If I were personally seeking care for cancer, I would get myself to a specialized cancer hospital or clinic, even if it involved some travel. In my personal opinion, there are four criteria to keep in mind when seeking the best cancer treatment: (1) physicians and staff at the facility should treat many patients per week with the same or similar diagnosis as yours; (2) the physicians should pride themselves on being up-to-date on the latest research and treatment of your disease as well as available clinical trials; (3) there should be little or no direct connection between the treatment being offered to you and the salary of the treating physicians, and (4) your treatment plan should be developed by a multi-specialty panel of physicians working in the facility, resulting in a more nuanced and balanced approach.
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