Pathologists Do Not Agree on Breast Diagnoses 25% of the Time

Summary and Comment |
March 17, 2015

Pathologists Do Not Agree on Breast Diagnoses 25% of the Time

  1. Henry Mark Kuerer, MD, PhD, FACS

Underinterpretation of biopsy specimens occurred in 4% of invasive cancers and 13% of DCIS cases.

  1. Henry Mark Kuerer, MD, PhD, FACS

About 1.6 million breast biopsies are performed in the U.S. each year. Although criteria for interpreting the results of a breast biopsy are well established, the extent to which pathologists agree on the final diagnosis is unclear.

To investigate potential observer variability and potential ambiguity in breast disease and cancer diagnoses, investigators sent 60 breast biopsy slides — with a diagnosis unanimously agreed upon by three expert breast pathologists — to 115 practicing pathologists in eight states with at least 1 year of experience. Most of the participants (93%) reported confidence in interpreting breast pathology.

Overall concordance of diagnosis between the participants and expert pathologists was 75.3%. Concordance by diagnosis was 96% for invasive cancer, 84% for ductal carcinoma in situ (DCIS), 48% for atypical hyperplasia (atypia), and 87% for benign lesions without atypia. Underinterpretation potentially resulting in undertreatment occurred in 4% of invasive cancers, 13% of DCIS cases, and 35% of atypia cases. Disagreement with expert diagnosis occurred more often among pathologists who worked in smaller or nonacademic practices with lower case volumes or when biopsies were from women with dense breast tissue.


The entire practice of treating patients with benign and malignant breast disease depends on reaching the correct pathologic diagnosis. One limitation of this important study is that participants had to make diagnoses without consulting colleagues or without reviewing multiple biopsy sections, often a routine practice with complex breast cases. Overdiagnosis of atypia can lead to unnecessary surgery, and underdiagnoses can lead to lost opportunities for chemoprevention or to missed cancers in nonsurgical patients. About 17% of patients in this study could have been seriously undertreated without necessary surgery, radiotherapy, or endocrine therapy. These results clearly imply that a pathologist with expertise in breast diseases should be consulted if there is concern by a pathologist with limited breast practices. At MD Anderson, pathology rereview identifies diagnostic disagreement that significantly affects patient management in about 11% of patients (J Surg Oncol 2015 Feb; 111:192). It is hoped that molecular classification may soon help pathologists make the correct diagnosis.

Editor Disclosures at Time of Publication

  • Disclosures for Henry Mark Kuerer, MD, PhD, FACS at time of publication Speaker's bureau Physicians’ Education Resource, LLC Grant / Research support Susan G. Komen Breast Cancer Foundation Editorial boards Annals of Surgical Oncology Leadership positions in professional societies Alliance for Clinical Trials in Oncology (Chair, Education Committee); Society of Surgical Oncology (Chair, Curriculum Ad Hoc Committee, Breast Program Directors


Reader Comments (3)

Shibichakravarthy Kannan Physician, Oncology, Hyderabad, India

In this post genomic era, with the advent of targeted therapies transforming conventional healthcare into a personalized medicine approach, why should pathologists be left behind. Digital Pathology is gaining momentum and rapidly transforming the oncology treatment landscape. By automating the slide staining, image capture and software guided analysis the chances of misdiagnosis or erroneous calculations of tumor percentage are vastly minimized. Plus we get consistent results every time. Currently digital pathology has been hugely successful in three major cancers - breast, lung and colon. But we need more R&D to expand the scope to all pathology.

Victor Kantariya Physician, Family Medicine/General Practice

Overdiagnosis and overtreatment, underdiagnosis and undertreatment in Cancer! That is the problem. Getting a Second Opinion is essential. In the future, the blood-based testing (liquid biopsies) can replace the tissue-based aproach. This is not science fiction, it`s reality. V.Kantariya MD

William Rutenberg MD Physician, Other, Office

So now I understand it's not mammography that results in too many false positives, it's our pathologists arriving at too many false negatives. We need to stop opining like experts on utilization and consequences of testing when the evidence base is insufficient To validate the guideline.

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