Pathology Best Practice Reporting

The pathology report is often the main communication tool between pathologist and clinician. It should provide all essential information on the resected specimen which will be used to guide patient treatment. With increasing complexity of diagnostic criteria and adjuvant testing, especially in oncology, the volume of required information steadily rises.

Writing reports is absolutely central to pathology practice and a task undertaken numerous times a day. The vast majority of reports are produced in traditional narrative style, following the loose structure of ‘macroscopic description; microscopic description; conclusion’. Given the core nature of the pathology report, it would be tempting to think the majority contain all necessary information. However, sadly the data do not support this idea. In 2006 an audit from France found that the majority of over 200 reports were missing key information—for example 33% were missing data on pTNM staging [1]. Many other reports have echoed these findings. Across clinical practice there is an increasing awareness of ‘human factors’, how these lead to errors and what might be done to minimise their impact [2].

Pathology Best practice Guidelines

In recognition of the importance of the pathology report, in 2004 the American College of Surgeons Commission on Cancer mandated that at least 90% of pathology reports should contain all pertinent information for that patient [3]. To aid in this the College of American Pathologists (CAP) have produced multiple checklists for cancer reporting, detailing all relevant information across a variety of diagnoses [4]. Use of such checklists is now widely recognised as best practice for generating pathology reports, helping to increase accuracy and reduce omissions.

Synoptic reporting

An example of synoptic pathology reporting with Synoptec.

This style of reporting is known as synoptic reporting and in its most complete form uses a series of checklists with pre-defined responses aimed at standardising information and ensuring completeness. What evidence do we have that synoptic reporting works? In 2015 a systematic review of reports into synoptic reporting was published [5]. The authors identified 33 reports on the changes resulting from switching from traditional narrative reporting to synoptic reporting. The reports covered eleven countries and ten different cancer types. All but one demonstrated increased completeness of reporting after implementation – for example in the universal inclusion of tumour margins or evidence of neurovascular invasion. The one report that did not demonstrate increased completeness attributed this to the lack of appropriate parameters on the checklist – factors which were therefore excluded on the synoptic reports but had been previously included in narrative reports. However, as discussed in a 2009 Canadian report, this issue can and should be tackled by  adapting synoptic reporting templates to fit with local practices and specialisms [6].

In addition to helping meet best practice guidelines, synoptic reporting has been shown to improve clinical performance. A 2007 paper from Australia showed among other things reduced non-diagnostic rates and false-negatives from FNA thyroid biopsies following the introduction of synoptic reporting [7].

Barriers to implementation

Introducing synoptic reporting represents a huge change for many pathology departments. So, what might be the barriers to implementation of synoptic reporting? A 2014 paper identified several key factors, such as stakeholder engagement, administrative support and training which were central to the process [8]. Many may fear that reporting will take longer, adding stress to an already pressured department. Whilst this does seem to be true during the implementation phase, in fact longer term reporting is quicker for the pathologist and reports become available to the clinical team in a much more timely fashion [9]. Whilst much of this may be due to improvements in IT and process, there is little doubt that removing the need for transcription and checking of report accuracy should enhance efficiency. In addition, reports with a standard formula allow quicker extraction of information by the clinical team and facilitate interrogation of data for future research projects.

Summary

The traditional narrative report has been the mainstay of pathological reporting, allowing the pathologist to express uncertainty and place emphasis. However with the ever-increasing volume of information required, such as genotype and biological markers it becomes all too easy to miss information which may be crucial to patient care. Implementation of synoptic reporting should facilitate compliance with best practice standards from professional bodies such as CAP and Royal College of Pathologists as well as producing reports in a standardised format which allow the efficient extraction of pertinent information by the clinical team. When considering implementing synoptic templates it is crucial to ensure they align with best practice templates [4], as well as allowing adaptability to local specialisms. After training report generation is quicker for the pathologist and seems to be preferred both by pathologists and clinical teams [10].

 

References:

  1. Quality and completeness of histopathology reports of rectal cancer resections. Results of an audit in Brittany. Eon Y, Le Douy JY, Lamer B, Battini J, Bretagne JF. Gastroenterol Clin Biol. 2006 Feb;30(2):235-40. https://www.ncbi.nlm.nih.gov/pubmed/16565656
  2. Integrating human factors research and surgery: a review. Shouhed D, Gewertz B, Wiegmann D, Catchpole K. Arch Surg. 2012 Dec;147(12):1141-6. https://dx.doi.org/10.1001/jamasurg.2013.596
  3. Commission on Cancer, American College of Surgeons Cancer program standards 2004. American College of Surgeons Web site. https://www.facs.org/quality-programs/cancer/coc/standards
  4. College of American Pathologists Protocol Templates – accessed Feb 2017 http://www.cap.org/web/oracle/webcenter/portalapp/pagehierarchy/cancer_protocol_templates.jspx?_afrLoop=98267439371548#!%40%40%3F_afrLoop%3D98267439371548%26_adf.ctrl-state%3Dqrfcsoeyu_30
  5. The effects of implementing synoptic pathology reporting in cancer diagnosis: a systematic review. Caro E. Sluijter CE, van Lonkhuijzen LRCW, van Slooten HJ, Nagtegaal ID, Overbeek LIH. Virchows Arch. 2016; 468: 639–649. https://dx.doi.org/10.1007/s00428-016-1935-8
  6. Usefulness of a Synoptic Data Tool for Reporting of Head and Neck Neoplasms Based on the College of American Pathologists Cancer Checklists. Kang HP, Devine LJ, Piccoli AL,et al. Am J Clin Pathol 2009;132:521-530 https://dx.doi.org/10.1309/AJCPQZXR1NMF2VDX
  7. The impact of synoptic cytology reporting on fine-needle aspiration cytology of thyroid nodules. Tsan CJ, Serpell JW, Poh YY. ANZ J Surg. 2007 Nov;77(11):991-5. https://dx.doi.org/10.1111/j.1445-2197.2007.04297.x
  8. Multi-level factors influence the implementation and use of complex innovations in cancer care: a multiple case study of synoptic reporting. Urquhart R, Porter GA, Sargeant J, Jackson L, Grunfeld E. Implement Sci. 2014 Sep 16;9:121. https://dx.doi.org/10.1186/s13012-014-0121-0
  9. A synoptic reporting system for bone marrow aspiration and core biopsy specimens. Murari M, Pandey R. Arch Pathol Lab Med. 2006 Dec;130(12):1825-9. https://dx.doi.org/10.1043/1543-2165(2006)130[1825:ASRSFB]2.0.CO;2
  10. Standardized synoptic cancer pathology reports – so what and who cares? A population-based satisfaction survey of 970 pathologists, surgeons, and oncologists. Lankshear S, Srigley J, McGowan T, Yurcan M, Sawka C. Arch Pathol Lab Med. 2013 Nov;137(11):1599-602. https://dx.doi.org/10.5858/arpa.2012-0656-OA