Today, cancer is one of the leading causes of death in the United States. 1 The initial diagnosis of cancer is a complex process involving many healthcare specialists. Two physician specialties often at the center of this initial cancer diagnosis are radiology and pathology. While neither radiologists nor pathologists are usually involved in direct patient care, their collective findings and interventions are responsible for subsequent cancer patient treatment and outcome. A patient with radiology findings suggestive of malignancy is sent for biopsy to confirm or negate the diagnosis. These tissue specimens are sent to pathology where a definitive diagnosis is given based on the submitted material.
Unfortunately, not all institutions correlate suspicious radiology and subsequent negative pathology findings. As a result, there are instances when a radiologist issues a report stating a high degree of suspicion for malignancy, but, through sample or processing error, the material reviewed by a pathologist is not representative of the suspicious area detected in radiology. As a result, a negative for malignancy pathology report is issued. In order to avoid such false negative cancer diagnosis, it is imperative that both radiologists and pathologists communicate and correlate their findings in a way that ensures the proper treatment course for a patient. The workflow of reports originating in radiology and subsequently made available to pathology, as well as the reverse process, is essential to ensure that real time correlation of findings is maintained throughout the patient’s encounter. The issue of workflows between radiology and pathology and the need for communication, correlation and resolution of discordant findings between the two groups to reduce diagnostic errors is the focus of this report.
The Office of the Assistant Secretary for Planning and Evaluation (ASPE) commissioned SciMetrika to conduct a series of discussions with representatives from several groups to determine the current workflow practices between radiology and pathology and ways communications can be improved. The panel experts consisted of pathologists, radiologists, medical informaticists and cancer registrars involved in the delivery of healthcare or the study of the flow of health information.
In order to best illustrate the essential workflow needed to foster the relationship between radiologists and pathologists, the decision was made to study the processes involved in the diagnosis of breast cancer as a preeminent example. The panel focused on mammography studies, reviewing the roles and responsibilities of both radiologists and pathologists in the diagnosis of breast cancer and the current interactions between the two specialties. It became apparent through discussion and literature review that radiology and pathology often operate in different and distinct areas of a hospital or institution (or in differing institutions) with varying degrees of interaction. 2 This isolation increases the risk of radiologic-pathologist discordance, i.e., histologic findings that do not substantiate imaging findings. Reviewed studies assessed the frequency of radiologic/pathologic discordance of percutaneous breast biopsies from 1 percent to 6 percent. 3 These discordance rates have serious consequences if left unresolved. Based on a pilot study conducted by one panel member, we estimated that approximately 10,000 breast cancer cases may be under diagnosed per year due to the failure to resolve discordant radiology and pathology findings. It is obvious that any improvements in the process of communicating findings between radiology and pathology to ensure timely exchange of clinical information could reduce these false negative reports.
The panel developed a series of workflows to support optimal communication efforts to reduce discordant rates, not only for mammography studies, but also applicable across all cancer types. These workflows and the critical components of each stage are examined in detail. An idealized workflow model that not only includes radiology and pathology but also illustrates the importance of data flow between other disciplines is presented in this document. This report also addresses some of the limitations for the proposed solutions as well as the efforts of two institutions ( Kansas University Medical Center and the University of California Los Angeles) to resolve discordant findings between radiology and pathology. Included in these recommendations is the need to standardize the terminology of the reports to reduce misinterpretations as well as to expedite the flow of clinical information between radiology and pathology. This standardization is carried over to include the development of standardized requisition forms that accompany the specimen sent to pathology as well as the use of standardized messaging formats between information systems.
Both pathology and radiology organizations recognize the gaps in workflows that might hinder optimal communication of patient data, and progress is being made to resolve these critical issues and concerns. This report concludes with opportunities for both radiology and pathology to improve workflow processes that would improve communication and resolution of discordant findings. Suggestions include efforts to develop quality assurance programs and best practice guidelines that meet not only the needs of pathologists and radiologists but most importantly, provide optimal patient care.