Category Archives: Pathology

Young Women With Breast Cancer Are Increasingly Being Tested For BRCA Mutations

percent_cancer_riskUS News & World Report (2/11, Esposito) reports that research published online in JAMA Oncology indicates “testing for BRCA1 and BRCA2 gene mutations, which significantly increase a woman’s risk of getting breast cancer and ovarian cancer, is on the rise among women ages 40 and under who’ve been diagnosed with breast cancer.”

HealthDay (2/11, Norton) reports that investigators “found that of nearly 900 women who developed breast cancer at age 40 or younger, most had undergone BRCA testing within a year of their diagnosis.” The data indicated that “the percentage went up over time: By 2013, 95 percent had been tested.”

The Cancer Network (2/11, Levitan) reports that the researchers “noted that the high frequency of testing in this cohort likely reflects the fact that most women were insured, educated and treated at major cancer centers.”

Giving Bad News by Phone May Be the Better Way

Communicating the news that a biopsy result indicates malignancy by telephone may be better than delivering the news in person, a team of researchers from the University of Michigan, in Ann Arbor, suggests. Two outside experts do not altogether agree.

“Telemedicine approaches can potentially relieve much of the anxiety associated with in-person consultations while delivering bad news in a timely, compassionate, and patient-centered manner,” write Naveen Krishnan and colleagues in a viewpoint published in the November issue of JAMA Oncology.

Getting the bad news over the telephone can give patients time to absorb their diagnosis and take greater advantage of their next in-person consultation, Krishnan and colleagues write.

“The initial in-person office visit to communicate malignant biopsy results is arguably less interactive than expected. Patients are not only trying to absorb devastating news but also engage in challenging conversations,” they write. “On the other hand, communication of biopsy results through telecommunication can serve as a buffer to the initial in-person visit and provide time for patients to process the results alone or with family.”

The authors cite examples of oncologic services delivered through telemedicine.

One is the Arizona Telemedicine Program’s Telehealth Rapid Breast Care Process, which lets patients receive their breast cancer diagnosis the same day as their biopsy. The program is conducted under the auspices of the University of Arizona.

Another example is the Ontario Telemedicine Network, located in Canada. With more than 1600 sites and 3000 systems, the OTN is the largest teleoncology service in North America, according to the authors.

“The Ontario Telemedicine Network has overcome a number of barriers, including cost, physician compensation, and resistance to telehealth technology adoption,” they write. “In fact, telehealth technology is now an everyday part of health care delivery in Ontario.”

Krishnan and colleagues claim that for patients, message content and timeliness are the two most important factors in relaying biopsy results. Patients are less interested in nonverbal communication on the part of the physician delivering the bad news, they say.

“In this respect, telemedicine allows physicians to focus on content rather than nonverbal communication that patients may not appreciate at the initial in-person visit,” the authors write.

“With increasing clinical time constraints and the shock of hearing a cancer diagnosis in person, telemedicine encounters can facilitate more meaningful future in-person discussions of complex therapeutic options and their adverse effects,” the authors write.

Read more.

 

4 Lessons I Learned From My Cancer Scare

home-advocateIn my original post, going back to June, I mentioned that I had received a positive PET scan.  I met with 4 of the top gynecologic oncologists in the Chicagoland area, and each one was consistent in telling me that I had metastatic breast cancer to my ovary that would require a full hysterectomy and bilateral oophorectomy. Divorce? Cancer-again? Surgery? Loose my uterus and ovaries? Was this really happening to me, right now?

With the best opinions in the area from top gyn oncs, I proceeded to surgery, prepared for the next chapter of my life, without estrogen and more surgery and potentially more chemotherapy if the surgery found additional sites of disease.

I was angry & fearful, and could not believe this was happening again.

On the day of surgery I had asked that if the growth was not cancerous to keep my uterus and other ovary. Despite support for that plan pre-operatively,  I was actually in the pre-op holding area and my surgeon was recommending the initial plan of full hysterectomy and to remove both tubes & ovaries. What was going on here? We prepare for weeks and on the morning of surgery we change the entire game plan?

Nonetheless, my wishes were followed and the involved ovary was sent for a frozen section which was read as a benign cyst. The surgeon removed both of my Fallopian tubes, and a small piece of my liver, which also turned out to be benign.

NO CANCER! NO EVIDENCE OF DISEASE! I felt like I was just given another chance at life, for the third time.

This specific experience taught me many very valuable lessons.

Multiple opinions are better than one. If I had stopped at the first or second consultation I may have had radical surgery for a benign disease. This is because PET scans can be very non-specific. Every “hot spot” is not the same, particularly in this disease and in the ovaries for pre-menopausal women, as in my case. While PETs can be “positive” or “negative” they can also be “in-between” and depending on the organ involved, may have differing sensitivities (probability disease is present if test is positive) and specificities (probability disease is absent if test is negative).

Secondly, physicians will advise you of what they think is best for you based on the evidence, literature and their experience with similar patients or “cases”. You have to remember your “case” may be different. In reality, my PET scan was “hot” but could have been “hotter” and because of the differences in how the test is performed, it may not have been as “hot” somewhere else.

Thirdly, no single test, as in PET scan, or anyone’s opinion may be that accurate and should not alone guide what YOU want to do. Physicians are trained to battle disease and as medicine has become more sub-specialized with physicians focused in narrower areas, it becomes harder for them to consider the person in as much as the disease or the psychologic impact their recommendations may have for the patient.

Lastly, be your own best advocate. Get multiple opinions, read up on what tests can and can’t tell physicians, search the literature to see the best approach to similar “cases” and finally, read first-person testimonials from other patients about their experiences, treatment and post-operative feelings.

I sincerely appreciate all the support, prayers, and kind words of encouragement. I am fully recovered, and ready to continue enjoying life, while doing the work that I have so much passion for.

 

ASCO Breast Cancer Symposium 2015 News Roundup

MRI improved breast cancer detection in average risk women

Oncology Practice reports that research suggests that “MRI-screening may improve the detection of biologically relevant breast cancer in women who are at average-risk, and reduce the interval-cancer rate down to 0%, at a low false-positive rate.” In the “cohort of heavily pre-screened women at average risk, the additional cancer yield achieved through MRI was high, at 15.8 cases per 1,000 women screened, and the added cancers diagnosed by MRI tended to be of high nuclear grade.” The findings were presented at the 2015 ASCO Breast Cancer Symposium.

Use Of Aromatase Inhibitors In The Adjuvant Setting May Delay Development Of Contralateral Breast Cancer

Oncology Practice reports that research suggests “the use of aromatase inhibitors (AIs) in the adjuvant setting appears to delay the development of contralateral breast cancer.” The “effect was particularly prevalent among breast cancer patients who were BRCA positive.” The research was presented at the 2015 ASCO Breast Cancer Symposium.

Age At Biopsy and Number Of Atypical Hyperplasia Foci May Be Good Predictors Of Risk For Subsequent Breast Cancer

Oncology Practice reports that research suggests that “a woman’s age at biopsy and the number of atypical hyperplasia foci appear to be good predictors of risk for subsequent breast cancer.” The “review of pathology records and medical history on more than 13,000 women with benign breast disease showed that a predictive model including age and atypia effectively identified those women with atypical hyperplasia at highest risk for developing breast cancer.” The findings were presented at the ASCO Breast Cancer Symposium.

Radiotherapy not needed for all women post mastectomy

Oncology Practice reports that research suggests that “postmastectomy radiotherapy should not be routinely recommended for breast cancer patients with microscopic nodal metastases (N1mic) and T1-2 tumors.” Investigators found that “in patients with T1-2, N1 disease who were treated with standard therapies, the study authors found that overall, there were low rates of locoregional failure.” The findings were presented at the 2015 ASCO Breast Cancer Symposium.

Many women with triple-negative breast cancer aren’t screened for BRCA

Oncology Practice reports that research indicates that “many younger women diagnosed with triple-negative breast cancers do not get tested for BRCA, despite guideline recommendations.” Researchers found that “among 173 women with triple-negative tumors – lacking the HER2, estrogen and progesterone receptors –17% of those who should have been tested for BRCA according to National Comprehensive Cancer Network (NCCN) guidelines, were not tested.” The findings were presented at the ASCO Breast Cancer Symposium.

“Mommy, are you going to die?”

picture2On May 28th, Thursday, it was the last day of school. I purposely scheduled my quarterly PET Scan, knowing how busy the day was going to be, with all the kids coming over to celebrate with their moms and friends. The anxiety and fear never leaves your mind, and the uncertainty overwhelms you. I tried my best to stay busy, but as the day and night progressed, I could feel my mind wonder. Conversations seemed to be less engaging for me, and all I wanted to do was call my oncologist to hear the results.

I had a big oncology conference the next morning in the city, and I was planning on driving that night after my parents arrived to relieve me. Than, the call came in, 9pm. There was an area, in my left adnexal, near my left ovary and fallopian tube that showed suspicious activity that needed to be further evaluated. All I could think of was, how in the world would I even have the time to find a gynecologic oncologist with my schedule so packed morning till night for the next 7 days. But, I had to do what women do best – put on my work hat, and place this to the back burner to focus on what the priority was at that moment. I had no choice. What I was able to do, and I realize how blessed I am, was the ability to access the top oncologists from all over the world. Professionally, I have the most amazing support network, and I asked every one I knew what this could be, and how to best proceed. The overall suggestion was to undergo surgery to remove this and get the pathology to determine if this was truly ovarian cancer as they suggested on the report, or the return of metastatic breast cancer.

When I arrived home from my trip, I had 3 names of the top gynecologic oncologists in my area. I scheduled my first appointment with a local doctor from Hinsdale Hospital. I went alone thinking I would hear the same suggestions from my connections. But, that was not the case. After my exam, and review of films, and tests, the doctor looked at me and said, “Ms. Jewett, I think you have metastatic breast cancer that has went to your ovary. We are going to need to perform a full hysterectomy. Now, keep in mind this could be benign, or it could also be a new primary, such as ovarian cancer. But, in my professional opinion, I think we are dealing with MBC.” As tears started to roll down my face, all I could think of was how much more could I possibly handle on my plate? Divorce? Cancer? Surgery?

The second opinion was the same recommendation. This doctor was the top gyn-onc from Northwestern. When I heard his thoughts on MBC, I cried and put my hand in his face and asked him to just stop talking. I could not hear anymore of his thoughts. Much less how he was going to take my uterus out through my vagina! I am 38 years old, cancer has taken my breasts, taken my ability to have any more children, and now it is going to take my remaining female parts next? When do I say enough is enough?

Cancer is an evil Bitch.

After that appointment, I had to meet with my attorney that is handling my divorce case. I remember sitting in the waiting room, thinking was this really my life? Not only did we have to discuss my financial concerns surrounding the divorce, but it was also time to consider a Will and Power of Attorney. And, I needed this information in place before my surgery date. I was sick to my stomach. All I wanted to do was to go home and hold my kids so tight and forget this was all happening.

My last appointment was with a female gyn-onc, on Thursday, who had a much more compassionate perspective and approach. She was able to confirm that this was not a mass, it was my ovary that was enlarged, and had some suspicious activity going on. She did agree that the best option would be a full hysterectomy. However, she understands that as a young woman, who is cycling every month, this would not be an easy journey. I asked if it was possible to leave my right ovary, at least until I was ready to let it go. She said she was open to that suggestion, but if I were to test positive for cancer, whether that was metastatic breast or ovarian, it would need to come out, no matter what. I like to think and believe there is hope. And, I like that she is a female doctor who has compassion, and understanding to do what is best for me in the midst of all the uncertainty and anxiety. I have come to realize that with a diagnosis like cancer, patients need to feel as if they have some form of control. It truly does help with the decision making.

When I arrived home from that appointment, my kids were very aware with what was going on. I had tried my best to keep them from all of this until I had a better idea what was going to happen. But, they had to know the reality, it was time. I sat them both down, alone. I explained to them that I had a PET scan, just as I always do every quarter, but this time something showed up that needed further evaluation.

My daughter, Kalli, immediately got upset and told me I was lying and she knows it was cancer. I told her we really did not know that, but I would need to have surgery to take out that “suspicious area” and some other parts to ensure we minimized my risk.

My son, Tyler, looked at me with tears in his eyes and said, “Mommy, are you going to die of cancer?” At this point, I could no longer hold back my emotions, and I simply told them both that I did not have that answer. What I could promise them was, I fought cancer twice now, and that I would do everything I could to fight it again. And this surgery was part of that process. I explained that we had some time until surgery, and that I wanted to take a vacation with them before, so we could enjoy the rest of their summer vacation before school started.

It has been the worst 3 weeks of my life. I have cried so much, felt the anxiety in my chest, and have feared what lies ahead. What I am so grateful for in the midst of this uncertainty is the overwhelming support, love, and compassion from all my friends and family, near and far, personally and professionally. I have gotten emails, calls, text messages, and cards, that fuel my strength to know we are not alone. There is an army with a lot of gear fighting this battle with us, and I will overcome this next chapter of my life.

So, for now I need time to process the reality. In the meantime, I am going to continue to focus on doing the work I love, embrace every moment of every day, and spend time with the people I love so much.

Life truly has a lot of challenges lately, but there is not a single moment that goes by that I do not count my blessings for the life I have been given.

From the bottom of my heart, THANK YOU for the support, and most of all, the love and compassion you have shown the kids and I.

Why Digital Pathology?

Digital pathology is a dynamic environment by which glass pathology slides are converted into a digital format for viewing, sharing and archiving for later use.

Before my cancer diagnosis and trying to retrieve my pathology slides, tissue cassettes and pathology reports for second and third opinions, I, like most patients had no idea how cancer diagnoses were made and where treatment algorithms are derived from.

As a patient advocate, I was asked to speak at a Key Opinion Leader dinner for a large healthcare company involved with digital pathology. In the course of my research on pathology, histology and digital pathology technologies, I came across Dr. Keith Kaplan’s widely read and respected Digital Pathology Blog at tissuepathology.com. At the time of my research last Summer, there were 100s of articles dealing with different technologies, companies and use cases for digital pathology in both clinical and research settings in addition to a mix of Dr. Kaplan’s own observations and lessons learned being involve with digital pathology for 15 years.

They say in research “go to the source”- so I did. Through Dr. Kaplan’s blog, we originally connected on Twitter, then by phone and within a week, in person at the annual College of American Pathologists meeting in Chicago last Fall. Dr. Kaplan was speaking at the meeting on digital pathology for a luncheon seminar and invited me to listen to a presentation sponsored by Leica Biosystems.

I met representatives from Leica Biosystems, toured their booth and saw several digital pathology products, that go by the name Aperio ePathology Solutions. Attending my first pathology meeting and exhibit floor, I was impressed by not only the dedication pathologists have to their specialty but the personal stories shared by those who are in healthcare industry.

I also recognized pathologists are very much “behind the scenes” not being at the bedside, but have a very direct and important impact on patient outcomes.

Many of the people I met have a personal reason for producing, distributing, marketing and selling what they do – a close relative who had cancer, a personal battle, or the recognition they could help millions of people with their products and services.

I am honored and grateful to have this opportunity to help share information about technology that positively impacts the work of pathologists, globally, from companies such as Leica Biosystems that are providing solutions to help patients everywhere. People just like me.

Second Look Alters 20% of Breast Biopsy Conclusions

second-opinionMedscape Medical News recently published an article with the above title about a study from Roswell Park Cancer Institute showing that 20% of cases examined there resulted in a change from the prior diagnosis.

This comes on the heels of a recent JAMA study that has been widely discussed in the pathology and popular press about the discordance among practicing pathologists in primary breast diagnosis.

I think the bottom line here is that review of pathology slides can have a significant impact on patient care and you owe it to yourself to insure that a breast specialist or second opinion from an individual/institution with expertise reviews your slides.

The second opinion about a suspected breast cancer should be in the form of an “interinstitutional pathology consultation” (IPC) that includes a review by a specialized breast pathologist, the authors say.

“Specialized pathology is very important these days because there are so many advances in the field of pathology, and if you are not specialized, you will miss many of the new technologies and morphologies, new entities, etc, etc,” author Thaer Khoury, MD, from Roswell Park Cancer Institute, Buffalo, New York, told Medscape Medical News.

In his study, a second look at the pathologic samples from needle biopsies that were sent to Roswell Park by outside institutions resulted in a change in 20% of the cases that were examined.

“These results underscore the need for a second review of the original pathologic material by a pathologist who specializes in breast cancer prior to the implementation of breast cancer therapy,” he said.

The study was published online April 15 in the Breast Journal.

“At Roswell Park Cancer Institute, it is a routine practice to review the outside pathology slides and reports of all patients referred from different health institutions for further treatment,” Dr Khoury said.

“This type of review is a required part of our quality assurance policy, but it has never been formally evaluated in terms of the discordance rate and the subsequent clinical impact on patient care.”

Consequently, Dr Khoury and colleague Yousef Soofi, MD, sought to evaluate the impact of IPC for breast core needle biopsies received at their institution.

They retrospectively reviewed 502 breast core biopsy cases provided by referring institutions during a 1-year period (2012).

Surgical pathology follow-up was available for 25 (62.5%) cases with major discordance and for 13 (20.3%) cases with minor discordance.

The resulting interpretation changed management in 15 patients (3%); 25 patients (5%) had a potential of management change.

The most common reason for major discordance was in interpreting biomarkers, such as the estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor type 2 (HER- 2).

Breast J. Published online April 15, 2015. Abstract

Live Webinar: Leveraging the Cloud to Improve Pathology TAT

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Presented by Ramu Sheshadri, Product Manager, SaaS Solutions Leica Biosystems
Date: 07 May 2015 – Time: 9:00 AM CST

Register Now!

 

Learn how Aperio ePathAccess from Leica Biosystems can improve pathology secondary case review.
We invite you to attend this live webinar, where we will discuss the benefits of the solution, including:

* Faster total turnaround time (TAT) for pathology cases
* Easy & Secure access to subspecialist pathology expertise
* Reduce time and cost associated with shipping glass

 

Review of Whole Slide Imaging for Pediatric Specimens Advances Validation Process

Interesting study in pediatric pathology showing high concordance in review of 60 surgical pathology cases. Using the College of American Pathologists guidelines, of the 60 surgical pathology cases, which included 130 specimens, and 473 slides, only 1 case was found discordant. This study within pediatric specimens, supports the feasibility of this technology and supports the validation model proposed by the College of American Pathologists.

Whole slide imaging is an emerging technology that is poised to impact the practice of medicine by extending the virtual reach of pathologists. A study in the new issue of Pediatric and Developmental Pathology offers guidance for further development of whole slide imaging systems and advances the technology toward regulatory approval for use in primary diagnosis.

(PRWEB) April 20, 2015– Pediatric and Developmental Pathology —Whole slide imaging is an emerging technology that is poised to impact the practice of medicine by extending the virtual reach of pathologists. Classified as a medical device by the U.S. Food and Drug Administration, whole slide imaging must be validated and approved before use in primary diagnosis. The College of American Pathologists has published guidelines for this validation, and a new study applies those guidelines specifically to specimens in the pediatric population.

The journal Pediatric and Developmental Pathology reports results of a whole slide imaging review of 60 surgical pathology cases and an attempted review of 21 cytopathology cases. This study, undertaken at Nationwide Children’s Hospital in Columbus, Ohio, offers guidance for further development of whole slide imaging systems and advances the technology toward regulatory approval for use in primary diagnosis.

Whole slide imaging is a digital scan of an entire glass slide, allowing the digital file to be viewed on a computer monitor rather than through a microscope. The College of American Pathologists points out that it has the advantages of accessibility, portability, and easy archiving as well as the use of computer-aided diagnostic tools. Validation will determine whether whole slide imaging can replace the light microscope as the method pathologists use to review specimens and render diagnoses.

In accordance with the College of American Pathologists guidelines, this study reviewed varied specimens, including complex and less common diagnoses. Results of whole slide imaging were compared with the original glass slide diagnoses. Essentially identical results or those with only minor differences that would not affect diagnosis were considered concordant while major differences or slides that were unsatisfactory for evaluation were deemed discordant.

Of the 60 surgical pathology cases, which included 130 specimens in 473 slides, only 1 was found discordant. Review of cytopathology cases proved more difficult, with a discordant rate of 33.3 percent. Nucleated red blood cells and eosinophilic granular bodies were particular challenges when using whole slide imaging for pediatric specimens. The authors noted that image capture in multiple focal planes is likely needed to successfully review cytopathology specimens.

This first review of exclusively pediatric specimens confirms the feasibility of this technology. “Our experience with whole slide imaging extends the possibilities for this technology further into the field of pediatric pathology and supports the validation model proposed by the College of American Pathologists,” said author Michael A. Arnold.

Full text of “The College of American Pathologists Guidelines for Whole Slide Imaging Validation Are Feasible for Pediatric Pathology: A Pediatric Pathology Practice Experience,” Pediatric and Developmental Pathology, Vol. 18, No. 2, 2015, is now available.

About Pediatric and Developmental Pathology
Pediatric and Developmental Pathology is the premier journal dealing with the pathology of disease from conception through adolescence. It covers the spectrum of disorders developing in utero (including embryology, placentology, and teratology), gestational and perinatal diseases, and all diseases of childhood. For more information about the journal or society, please visit: http://www.pedpath.org

Diagnosis in Eye of Beholder and the ‘Rita Wilson’ Effect

Since Angelina Jolie’s public statements about her testing for BRCA and subsequent surgeries including bilateral mastectomies and removal of her fallopian tubes and ovaries, many oncologists and laboratories have mentioned reports of an increase in BRCA testing across North America. Her awareness of her personal health and potential risk combined with her celebrity status raised awareness of need for early diagnosis and treatment. This is part of the ‘Angelina Jolie’ effect.

Another star, Rita Wilson, has also made headlines recently with her own call to action about the need for second opinions in breast pathology if you have a biopsy. According to one pathology blog, Dr. Keith Kaplan mentions the need for some form of second opinion in questionable cases to ensure patient safety and quality. Pathologists have many quality assurance processes in place and collaborate with one another on challenging cases. Check out this resource on Understanding Your Pathology Report.”

Yesterday I read a post from Dr. Susan Love on The Huffington Post that detail a little more than initial reports about Rita Wilson’s own breast cancer journey.

The takeaway message from Ms. Wilson’s situation is this: Individuals read pathology slides. And the diagnosis is often in the eye of the beholder. We encourage second opinions about treatment, but most people don’t realize that when they ask for a second opinion on the diagnosis, the opinion should be based on examination of the actual biopsy slides, not simply the original pathology report. Some cases are clear-cut but if there is any question, the more eyes looking at the tissue, the more accurate the diagnosis, and the more confident a woman can feel in the decisions she makes.

Too often, celebrities who publicly share their health stories leave out key information, which in turn can cause confusion and sometimes stimulate people to take action that may not be necessary or advised. We applaud Ms. Wilson’s willingness to include the details of her specific situation so that other women can better understand the rationale that drove her personal treatment decision.

Having traveled to many hospitals and cancer centers, I know this process all too well with many delays by both the referring and receiving hospitals to get my slides for review. I would also like to leverage the future vision of digital pathology that can help all of us ensure that our slides are read accurately and in a short amount of time by many pathologists. This technology can make the diagnostic process much easier for patients as well. The time is now for second opinions enabled by digital pathology.

Who is ready to stand alongside of me to make it happen?