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Video: Ideally, Only A Pathologist Can Judge The Malignancy Of A Neoplasm
Ideally, only a pathologist can judge the malignancy of a neoplasm
According to various estimates, the discrepancy between clinical and morphological diagnosis in oncology is up to 30-40%. The most serious mistakes are those when cancer is “found” where it does not exist, or, conversely, a malignant tumor is missed. They tried to find out what to do with cancer patients without morphological verification of the diagnosis and stage of the disease at the Chelyabinsk Center for Oncology and Nuclear Medicine.
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According to various estimates, the percentage of discrepancy between clinical and morphological diagnosis in oncology is up to 30-40%. There are no official statistics on this issue. The most serious mistakes are those when cancer is “found” where it does not exist, or, conversely, a malignant tumor is missed. There are fewer such cases, but the consequences are the same - the wrong treatment tactics and a sad outcome. At the same time, the farther the patient is from the central clinics, the less chances he has for an adequate diagnosis.
Who are they - cancer patients without morphological verification of the diagnosis and stage of the disease, and what to do with them, tried to find out in the Chelyabinsk Regional Clinical Center of Oncology and Nuclear Medicine. The first results of the study, presented at the International Forum of Oncology and Radiology held in Moscow, were told to MedNews by the head of organizational and methodological cabinet and registry office Irina Aksenova.
Irina Alekseevna, what is happening now with "unverified" patients?
- This is a very big problem that is faced all over the world. Existing standards for the treatment of cancer do not apply to patients who have not established the stage of the prevalence of the malignant process. In the last decade in Russia, the proportion of such patients has fluctuated annually within 5-8%. And the attending physician is faced with a difficult question: how to treat such a patient, what approaches to apply to his management?
Like everywhere else, cancer incidence is growing in our region, which is a serious problem for society - huge costs, disability, loss of a large number of lives. And one of the sources of growth in mortality rates is cases without morphological confirmation of the diagnosis or stage of the disease. And the goal that we set when starting this study is to determine at least with large smears what these groups of patients are. And as a result of the research - to develop an algorithm for observation, examination and possible treatment of such patients.
We conducted an analysis of survival rates based on the database of the population cancer registry of the Southern Urals, the quality of which was highly appreciated at the international level. Since 2017, the Chelyabinsk Population Cancer Registry (under the leadership of the Academician of the Russian Academy of Sciences, Professor, Doctor of Medical Sciences, Chief Physician of the Chelyabinsk Center of Oncology and Nuclear Medicine, Andrey Vladimirovich Vazhenin) is a member of the International Association of Cancer Registries.
In 2017, about 10% of newly diagnosed cases of malignant neoplasms were recorded posthumously. This means that the disease was detected shortly before death during hospitalization or autopsy. The leaders in this anti-rating were lung cancer, pancreatic cancer and colon cancer. In total, we analyzed the one-three-five-year survival rate of patients with malignant neoplasms of the lungs, breast, prostate, colon and stomach (these diseases are leading in the structure of cancer incidence), based on the database of the Chelyabinsk population cancer registry for 2005-2012 - about 50 thousand medical records.
And what did this analysis show?
- The worst situation is with lung cancer. In the group of patients who did not have the stage of the disease - and there were about 5% of them - survival rates were two times lower than the average for the population. More than half of the patients with this localization (almost 7 thousand people) did not have a morphologically verified diagnosis. Today there are much fewer such patients, but in general this problem is difficult to solve due to the difficulty in some cases to take material for histological examination. Finally, about 20% of lung cancer cases in 2017 were diagnosed posthumously.
Among patients with colon cancer, 3% were stageless, and about 5% were without morphological verification. The survival rate of both is much lower than the average for the population. Patients without a verified diagnosis of gastric cancer had half the chances of survival. And the picture looked just as sad in other localizations, even in those that today are quite successfully amenable to early diagnosis and treatment. For example, even at the first stage of breast cancer, the survival rate of patients without morphological verification of the diagnosis was lower than in the entire group.
What often does not allow you to establish the stage of the disease or even the diagnosis itself?
- Our study covered the period starting from 2005, at that moment it was far from everywhere possible to carry out clarifying diagnostic methods, and the first PET scanner appeared in the Chelyabinsk region in 2010. Most likely, a decisive role in such low survival rates of cancer patients is played by severe concomitant pathology (heart disease, etc.), which does not allow for a full diagnosis and special treatment. For the same reason, it is not possible in some cases to establish the stage of the disease.
A common problem both in our region and in other regions of Russia is the lack of an oncologist at the place of residence, especially in rural areas. The shortage of pathologists also affects. An urgent problem when conducting an autopsy in order to establish the cause of death (to establish the histological type of tumor) is a violation of Federal Law No. 323-FZ, namely, the refusal of relatives to carry out an autopsy on religious grounds.
How can your findings help clinicians and their patients?
- We analyzed the survival rates of stageless patients and saw that they are between the rates of III and IV stages of the disease. And, therefore, in such patients, most likely, the corresponding stage of the malignant process, and they should be treated in the same way as the recommendations for these stages. The tactics of managing patients without morphological verification, but with an obvious clinical and laboratory picture for the council of doctors, should be similar to the tactics used in the general population. As for patients without morphological verification of the diagnosis, we realized that the stage they were trying to establish was not entirely correct and had to be increased by 1 or 2. But here, too, there are some nuances for different localizations . Thus, unverified gastric cancer should most likely be treated as in IVstages of this disease.
But what if the clinical picture is not obvious, and the diagnosis itself is questionable?
- This is a very difficult situation. One must be very careful with the diagnosis of a malignant neoplasm; we must not “diagnose” it, but exclude it from the patient. Because, for example, formation in the liver is not always liver cancer. Such a patient may have anything - a benign tumor, a parasitic disease and a number of other diseases.
Ideally, only a pathologist can judge the malignancy of the formation based on the results of the histological examination. There is also a list of examinations that allows with a high probability (but not 100%) to establish whether neighboring organs are involved in the process or whether there are metastases there. The same PET CT scan indicates a malignant tumor when contrast accumulates in the corresponding place. And if the oncologist has sufficient grounds, he has the right to establish a diagnosis even without morphological verification. However, it is worth remembering that radiation diagnostic methods do not have 100% sensitivity and specificity and leave a certain amount of doubt about the correctness of the diagnosis.
Several years ago, MedNovosti told the story of a man who died without waiting for treatment: the oncological diagnosis was made only posthumously. Are doctors afraid to treat patients without verified diagnoses?
- There are many doubts about the correctness of the diagnosis. We have also encountered cases when a patient who was diagnosed with pancreatic cancer without morphological verification did not have a malignant tumor as a result. At the same time, in the results of CT studies, metastases to the brain were even described. The patient received expensive treatment, but after death, an autopsy revealed that he was being treated for the wrong disease. (In accordance with Article 67 of the 323rd Federal Law, a patient who died of cancer must be sent for an autopsy to clarify the histological type of tumor).
On the other hand, a lot of patients who are registered without morphological verification, with an incorrectly established stage of the disease, die within three months. In fact, the patient had a more severe stage of the disease, and the tactics of treatment in this case should have been different. And the number of such cases is actually significant.
There is no ready-made solution to this problem, and to begin with, we just wanted to outline it. At the same time, we understand that in the realities of our life, a doctor in such a situation is completely unprotected. In the near future, the results of a scientific study will be formulated and a clear algorithm for observation, diagnosis and further tactics of managing this category of patients will be proposed. The practical significance of this study is very high: the algorithm will be introduced into the practical work of oncologists in primary oncology offices in the region, and we hope it will reduce the loss of lives of our patients.
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