Improving Cancer Diagnosis and Care Patient Access to Oncologic Imaging and Pathology Expertise and Technologies: Proceedings of a Workshop (2018) / Chapter Skim
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Current Diagnostic Challenges in Cancer Care
Current Diagnostic Challenges in Cancer Care
Pages 6-15
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agenda is provided in Appendix B Speakers' presentations and the webcast have been archived online.4 CURRENT DIAGNOSTIC CHALLENGES IN CANCER CARE "Good care starts with a good diagnosis," said Hricak, who added that an estimated 60 to 70 percent of all decision making in health care is influenced by diagnostic testing (Dzau et al., 2016; Forsman, 1996)
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However, a number of workshop speakers described challenges to ensuring high-quality diagnosis in cancer care, such as • Diagnostic uncertainty and the potential for diagnostic errors; • The rapidly changing landscape of oncologic imaging, pathology, and precision oncology care;
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In the pathology specialty, additional contributing factors included insufficient communication to the ordering clinician and poor technique; in radiology, 5 Accordingto Improving Diagnosis in Health Care, a diagnostic error is "the failure to (a) establish an accurate and timely explanation of the patient's health problem(s)
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. Otis Brawley, chief medical officer of the American Cancer Society, added that a study of diagnostic concordance in breast pathology found that the overall agreement among individual pathologists and consensus panel reference diagnoses was approximately 75 percent (Elmore et al., 2015)
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"Uncertainty in medicine is just not appreciated and everybody thinks everything is binary," he said, adding that many molecular tests for predicting cancer recurrence divide patient populations into low, middle, or high risk of recurrence, but the thresholds for these categories can be difficult to determine and may not always reflect clinical differences among the population subgroups. Brawley said there also can be differences in the performance of a diagnostic test within clinical trials that have highly selected populations compared to its performance in clinical practice settings.
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approved the first digital pathology system to review and interpret whole-slide images prepared from biopsied tissue.10 Jeremy Warner, associate professor of medicine and biomedical informatics at Vanderbilt University, said the goal of precision oncology care is to ensure the delivery of the right care to the right patient at the right time. Precision oncology therapies target specific abnormalities in a patient's cancer, facilitated by diagnostic testing that characterizes that cancer.
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He added that the FDA approval of the cancer immunotherapy pembrolizumab14 for patients whose cancers harbor biomarkers indicating high microsatellite instability or mutations in mismatch repair genes, rather than on where a cancer originated in the body, signaled a new era of biomarker-based treatment assignment. Also in 2017, the FDA approved the first in vitro diagnostic test capable of detecting genetic mutations in 324 genes and 2 genomic signatures in any solid tumor type.15 Warner said this will prompt a "vastly increased uptake of these large gene panels in the coming year." Michael Becich, chair and distinguished university professor in the department of biomedical informatics at the University of Pittsburgh School of Medicine, noted that computational pathology -- which he described as an approach to diagnosis that incorporates multiple sources of data (e.g., hematoxylin and eosin staining, immunohistochemistry, immunofluorescence, and genomic data)
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Hricak suggested that there is a need to facilitate the development of AI and machine learning to take over some relatively straightforward repetitive tasks, such as tumor measurement and summarizing pertinent history, in order to give radiologists the time to focus on more challenging diagnostic tasks. Given the rapid growth in complexity in imaging and pathology, several speakers said that a major challenge is how to convey complex diagnostic testing results to clinicians who are unfamiliar with emerging technologies.
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For example, when mammography was first introduced, Brawley said that women with non-invasive breast lesions unnecessarily received mastectomies; in addition, after introduction of the Pap smear,16 some women with mild cervical dysplasia received radical hysterectomies or radiation therapy because it was not well understood that the majority of these cervical abnormalities regress without treatment. "We need to be very careful in how we disseminate these new technologies into the community," said Brawley.
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Brawley added that inadequate examination of lymph nodes was associated with the hospital where care was received, suggesting that understaging was related to workload, or inadequate time for lymph node examination during surgery. Both Brawley and Richard Schilsky, senior vice president and chief medical officer of ASCO, noted that the introduction of innovative technologies can exacerbate health disparities because of the lag in their adoption in cancer care facilities with limited finances.
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