Cancer diagnosis: the price of error

Irina Reznik, Mednovosti 

Errors in the diagnosis of cancer, according to independent experts, occur in almost 40% of cases. There are no official statistics on this issue. The most serious mistakes are those when cancer is "found" where it does not exist, or, on the contrary, a malignant tumor is missed. The most common mistakes are made when typing a tumor – morphological determination of the type of cancer. As a result – incorrectly chosen treatment tactics and a sad result. 

Here are some messages from there. "I had a mistake in the type of cancer, and my friend's repeated IHC (immunohistochemistry) did not confirm the diagnosis at all. I retook in Israel." "In one place – one result of IHH, in another – there was another. How to understand where the correct analysis is? Where is the guarantee that no mistake was made in the second place?". Patients and their relatives from all over the country also tell the Movement coordinators about how things are with diagnostics: "The diagnosis was made without establishing a focus, now the symptoms have worsened, a diagnosis was made in another city for a fee and a focus was found. I returned home – the treatment was changed", "IGH was not done and a biopsy was not taken, the treatment was picked up at random."

At the same time, the further the patient is from the central clinics, the less chance he has of an adequate diagnosis. And this situation has not changed for decades. As a health care veteran from a remote region told Mednovosti, when her colleagues diagnosed her with breast cancer back in the mid-70s, she took the glasses to Moscow by the first plane. As a result, the diagnosis was not confirmed.

According to the assessment of the chief oncologist of Russia, Academician Mikhail Davydov, today only 40% of cancer patients have a morphologically confirmed diagnosis. According to the Ministry of Health for 2014, this figure is twice as high. But even official statistics admit that, in 20% of cases when the diagnosis was not confirmed morphologically, the patient could have anything – a benign tumor, a parasite, etc.

According to the medical technology company Unim, which verifies (rechecks histological diagnoses), about 40% of diagnoses contain errors - both in determining nosology and in establishing malignancy in general. In some types of nosologies, this percentage is higher. For example, about 50% of lymphomas are incorrectly diagnosed, and in the case of CNS tumors, this figure reaches about 80%. The most problematic regions in Russia are the south of the country and the Far East.

"We also conducted a small study on the diagnosis of breast cancer," said Alexey Remez, the founder of UNIM. – On average, five breast removal operations are performed in the regional oncological dispensary per day. At the same time, according to some estimates, one operation per week is statistically performed on the basis of an incorrectly diagnosed diagnosis. That is, about 4% of women mistakenly remove their breasts."

pathomorphological department of FGBURDKB, Candidate of Medical Sciences Dmitry Rogozhin.

– The process of histological diagnostics should work like a well-oiled conveyor. Each stage of it must be very well thought out and performed according to certain standards in order to eventually get a high-quality drug that can be diagnosed. If at least one of these stages is violated, then there will be no qualitative result. When material is sent to our or another central clinic for analysis, we often have questions about the adequacy of this material itself.

– Please tell us more about the stages?

– First of all, we need a normal amount of material. Before performing a biopsy (obtaining histological material in the operating room), the surgeon must clearly imagine how he will do it. If it falls not into the tumor itself, but into the zone of reactive changes, then the result, of course, will not work, and you will have to repeat the operation. 

The surgeon should discuss and plan this work together with the morphologist and radiologist (if it is a bone tumor). Sometimes the biopsy itself is performed under the supervision of a radiologist and in the presence of a pathologist.

The resulting histological material must be fixed in a certain way in formalin and delivered as soon as possible to the pathology department or histological laboratory, where it is described by a pathologist. The next stage is histological wiring (special chemical treatment of tissues). Then the material is poured into a special medium, which is simply called paraffin, after which the laboratory technician makes thin slices and places them on a special glass. The sections are properly stained and submitted to specialists (pathologists) for evaluation.

And there are two possible options. Or we have enough data to make a final diagnosis, which is the basis for the appointment of appropriate treatment. Or, we cannot formulate a diagnosis and must make a differential diagnosis between other tumors having a similar structure. In such cases, an additional study is used – immunohistochemistry (IHC). Depending on the specific set of antigens on the cells of the tumor itself, which this study shows, we evaluate everything again and formulate a final conclusion, which is also a guide to action. This is a fairly routine method. But, unfortunately, it is not used everywhere in the regions.

– And this is the main reason for the incorrect diagnosis? Or are there other problems?

– There are others. Each region, of course, has its own peculiarities, but there are several common main problems. Firstly, there is insufficient funding. And, as a consequence, the lack of normal equipment – certain equipment and consumables.

The second reason is the lack of experience among specialists and the problem with their coordination. I have already talked about the interaction of a surgeon, a pathologist and a radiologist, which already at the stage of planning a biopsy can narrow down the range of diagnoses and pre-decide which pathology we are dealing with. There is often no such interdisciplinary interaction in the regions.

Another serious problem that both large central institutions and regional clinics face is rare diagnoses. You can work all your life and not meet with some kind of tumor. And here it is no longer a matter of low qualification of the doctor, but of specialization. Every pathologist has a certificate. And he has to look at all the material, any biopsy. And this is not quite right. It is not for nothing that there are various specialties within medicine and divisions within the specialties themselves, when a person deals with a narrow range of problems.

Also, a pathologist should specialize in something specific. If he comes across a tumor that he has never dealt with, he may make an erroneous conclusion. A correctly diagnosed tumor is also a specific treatment program for this particular tumor, and, consequently, a prognosis. If, due to a pathologist's error, the wrong treatment protocol was applied, then the price of such an error can be very high.

– And what to do?

– It is very important to get a second opinion, which is why there are reference centers in large clinics, depending on their specialization. If a pathologist sees a tumor in the region for the first time, then he should act as a switchman: if, for example, it is a bone tumor, offer to send it to the RDKB, if a tumor of the lymph nodes – to the DGOI im. Rogachev, where there are specialists who deal only with lymphomas and leukemias. They see dozens of such tumors a day, they have tremendous experience.

A system in which an independent second opinion is required exists throughout the civilized world. And if the diagnoses match, the probability of error is minimized, and there is more confidence that the treatment will be prescribed correctly. There is also such a practice in central Russian clinics. In RDKB we have an oncological department, where children with rare diseases, tumors of bones and soft tissues are admitted. We make our diagnosis and, as a rule, the material is sent to another central medical institution to get a second opinion. It can be a RONC named after Blokhin, or a DGOI named after him. Rogachev, or some other medical institution. It happens that the diagnoses do not match, and then it is desirable to get a third conclusion, say from foreign colleagues.

Now there is an opportunity to consult with foreign experts without sending them the material itself – the Russian company UNIM has developed a Digital Pathology program for remote diagnostics. We upload histological preparations digitized using a special scanning microscope into this system, and a foreign expert can view them on a computer screen in the same way as he would look under a microscope. He can increase them, decrease them, consider any field of view, put labels, measure something.

In addition, properly sorted drugs make up an electronic archive, to which, if necessary, you can return at any time. Such a need arises, for example, when a few years after treatment, the patient has a relapse of the disease. We have to go back to the old material, compare and establish a causal relationship. Theoretically, paraffin blocks, from which histological preparations can be made anew, can be stored almost forever (under certain conditions). But their quality still decreases over the years, and if additional studies are required to clarify the diagnosis – immunochemical or cytogenetic – it is much more difficult to work with this material. There are no such problems with the electronic archive.

– Are such technologies used in the country?

– Yes, such a system works well within the country. Contracts are concluded with medical institutions in the regions. And where the quality and equipment allow it, histological preparations are scanned and sent to us for reference. This is an absolutely logical and progressive solution to the problem.

Our clinic treats children from all regions of Russia. We have a telemedicine center that allows remote consultations. Our and regional specialists can get together and determine some points in the treatment of the child. And now we can also consult histological preparations. This is very cool!

But even here the main problem is the lack of funding in the regions. And often, there is also a lack of understanding of this problem – this immediately excludes the possibility of using new technologies. Of course, not all regions are in an equal position. For example, in Rostov and the Rostov region, which attract the entire southern territory of the country, the work is very well done. They understand and comply with all stages of obtaining histological preparations and provide us with high-quality materials. But there are regions that do not appeal to us at all. And patients who want to get a second opinion have to solve this problem privately and in the old–fashioned way - to take their material to Moscow themselves or transfer it by courier.

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16.10.2015