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Improving the histopathologic diagnosis of pediatric malignancies in a low-resource setting by combining focused training and telepathology strategies
Abstract
Full text available at http://onlinelibrary.wiley.com/doi/10.1002/pbc.24071/epdf
Accurate diagnosis is critical for optimal management of pediatric cancer. Pathologists with experience in pediatric oncology are in short supply in the developing world. Telepathology is increasingly used for consultations but its overall contribution to diagnostic accuracy is unknown.
We developed a strategy to provide a focused training in pediatric cancer and telepathology support to pathologists in the developing world. After the training period, we compared trainee's diagnoses with those of an experienced pathologist. We next compared the effectiveness of static versus dynamic telepathology review in 127 cases. Results were compared by Fisher's exact test.
The diagnoses of the trainee and the expert pathologist differed in only 6.5% of cases (95% CI, 1.2–20.0%). The overall concordance between the telepathology and original diagnoses was 90.6% (115/127; 95% CI, 84.1–94.6%).
Brief, focused training in pediatric cancer histopathology can improve diagnostic accuracy. Dynamic and static telepathology analyses are equally effective for diagnostic review. Pediatr Blood Cancer 2012;59:221–225.
... Twenty-five full-text articles were included in this scoping review ( Figure 1). Of the 25 articles included, nine were quantitative studies [17][18][19][20][21][22][23][24][25], eleven were qualitative studies [27][28][29][30][31][32][33][34][35][36] and five were mixed method studies [37][38][39][40][41]. An overview of the selected articles is available in Table 1. ...
... Thirteen initiatives were conducted in the Middle East/Africa [17,19,20,25,26,29,32,34,35,[38][39][40][41], six in the Americas [18,23,24,27,28,31] and five in Asia/Pacific [21,30,33,36,37]. Project ECHO, a tele-mentoring programme for cervical cancer prevention was conducted in all three of these regions ( Figure 2) [22]. ...
... The initiatives focused on a range of oncology disciplines and topics. There were four initiatives in gynaecologic oncology (all in cervical cancer) [19,22,34,39], four in medical/haematologic oncology [21,29,30,41], four in paediatric oncology [18,28,31,35], two in radiation oncology [17,37], one in pathology [24] and one in surgical oncology [36]. There was one initiative that focused on both surgical oncology and pathology [20]. ...
Background:
The global cancer burden falls disproportionately on low and middle-income countries (LMICs). One significant barrier to adequate cancer control in these countries is the lack of an adequately trained oncology workforce. Oncology education and training initiatives are a critical component of building the workforce. We performed a scoping review of published training and education initiatives for health professionals in LMICs to understand the strategies used to train the global oncology workforce.
Methods:
We searched Ovid MEDLINE and Embase from database inception (1947) to 4 March 2020. Articles were eligible if they described an oncology medical education initiative (with a clear intervention and outcome) within an LMIC. Articles were classified based on the target population, the level of medical education, degree of collaboration with another institution and if there was an e-learning component to the intervention.
Findings:
Of the 806 articles screened, 25 met criteria and were eligible for analysis. The majority of initiatives were targeted towards physicians and focused on continuing medical education. Almost all the initiatives were done in partnership with a collaborating organisation from a high-income country. Only one article described the impact of the initiative on patient outcomes. Less than half of the initiatives involved e-learning.
Conclusions:
There is a paucity of oncology training and education initiatives in LMICs published in English. Initiatives for non-physicians, efforts to foster collaboration within and between LMICs, knowledge sharing initiatives and studies that measure the impact of these initiatives on developing an effective workforce are highly recommended.
... Among included studies, nine items [17,18,21,[23][24][25][26][27]31] were categorized as quantitative descriptive studies, and eight items [5,19,20,28,29,32,34,35] were categorized as non-randomized studies. Only one study [33] was implemented through a randomized controlled trial. ...
... The majority of studies have been conducted in Australia (n = 4, 20 %) [22,25,28,33] followed by Brazil [5,18] and Iceland [19,20]. Ten studies were conducted in more than one country [5,17,21,23,24,26,27,29,31,35] (Appendix Tables A6). ...
... The majority of studies have been conducted in Australia (n = 4, 20 %) [22,25,28,33] followed by Brazil [5,18] and Iceland [19,20]. Ten studies were conducted in more than one country [5,17,21,23,24,26,27,29,31,35] (Appendix Tables A6). In six out of these ten cases, one of the participating countries was USA [5,17,23,24,26,35], and seven cases inside in a city [19,20,22,25,28,30,33] and two of them were implemented between cities in a country [18,34]. ...
Background and objectives
Teleoncology can be used to reduce the limitations due to the lack of access to specialists, inadequate resources and training, and reducing unnecessary travels and arising of the costs. The purpose of this study was to review the literatures to identify and classify the areas of application and outcomes of using teleoncology in diagnosis, management, and treatment of children with cancer.
Methods
This scoping review of the published literatures was conducted by searching the Web of Science, PubMed/Medline, Scopus, and Cochrane Library databases in October 2019. Studies investigated telemedicine in diagnosis, management, and treatment of cancer in children were also included. We identified and classified different applications and the reported outcomes of this technology.
Results
In this study, 1834 articles were retrieved, and after removing the unrelated and duplicated articles, 20 articles were reviewed ultimately. We found that, teleoncology services were provided to the patients with cancer, their parents, and nurses in various clinical fields such as telepathology, telemental care (telepsychology), teleneurology, teledermatology, telehematology, and teleophthalmology. The findings also showed that, the outcomes of using telemedicine in children with cancer can be classified into six general categories (five primary and 14 secondary outcomes). Primary outcomes including diagnosis accuracy, reduced costs as well as mortality and secondary outcomes consist of improved relationship and training, better care management, satisfaction, and workload.
Conclusion
The use of telemedicine for children with cancer is growing, and there is a tendency for using this technology for families and clinical staff. Providing teleoncology services to children with cancer may improve diagnosis accuracy and reduce the cost and mortality rate. Also, better care management, appropriate relationships and training, increased satisfaction, and decreased workload may be achieved.
... The existing facilities and infrastructure can be augmented with provision of material and professional assistance from pathology associations in more developed countries and should, among other things, focus on supplementing residency education (7,8). Telemedicine is now widely used in industrialized countries for educational purposes (3,35). "Twinning" experiences (ie pairing a pathologist from a resource-limited setting to one from a more developed setting) using telemedicine between institutions have been limited but may be an effective training tool in pediatric neuro-oncology because of the major potential impact on patient care (3,35). ...
... Telemedicine is now widely used in industrialized countries for educational purposes (3,35). "Twinning" experiences (ie pairing a pathologist from a resource-limited setting to one from a more developed setting) using telemedicine between institutions have been limited but may be an effective training tool in pediatric neuro-oncology because of the major potential impact on patient care (3,35). Training goals and objectives should be tailored to the international pathologists' individual needs and level of expertise (5,35). ...
... "Twinning" experiences (ie pairing a pathologist from a resource-limited setting to one from a more developed setting) using telemedicine between institutions have been limited but may be an effective training tool in pediatric neuro-oncology because of the major potential impact on patient care (3,35). Training goals and objectives should be tailored to the international pathologists' individual needs and level of expertise (5,35). ...
The present state of pediatric neuropathology practice is in rudimentary developmental stages in most parts of sub-Saharan Africa. We sought to determine the pattern of neurosurgical lesions in children diagnosed in southwestern Nigeria and briefly address issues surrounding the practice of this aspect of pathology in Africa. We performed a retrospective review of histopathologic results of biopsies obtained from pediatric patients with neurosurgical lesions at the Department of Pathology, Obafemi Awolowo University Teaching Hospitals Complex, Ile–Ife, Nigeria, between January 2001 and December 2011. Demographic and clinical data were extracted from the Ife-Ijesha cancer registry and histopathological diagnoses were confirmed. A total of 111 biopsies were reviewed with a maximum of 17 in 2001 and minimum of 3 in 2005. Patient ages ranged between 1 day and 16 years with a male:female ratio of 1.02:1. There were 53 spinal lesions, 15 intracranial lesions, 36 scalp masses, 6 skull lesions and 1 muscle biopsy. Most of the specimens were from myelomeningoceles. This documentation of the major types of pediatric neurological conditions encountered in clinical practice in this relatively resource-limited setting indicate the need for collaboration with better developed centers to improve training in neurosurgery and neuropathology to enhance the quality of clinical care for young patients in Africa.
... • A need for new systems and technologies to speed up wait time and diagnosis, and to obtain second opinions (eg, easily accessible virtual second opinion systems) [7]. ...
... • A need for information about, and access to, life-saving treatment methods that may not be available in a patient's local area [7]. ...
The internet holds the potential promise of improved patient outcomes, especially when one is faced with a critical or life-threatening disease or condition. Appropriate and timely access to health information can support informed negotiation of optimal treatments, optimal management, and expedited recovery, and to an improved outcome for a patient. However, there are many human and technical barriers that may prevent the application of the best possible information for both patient and provider alike, making the patient journey complex and potentially dangerous. In this viewpoint paper, the author (who is also a JMIR editor) reflects on a personal patient journey, where use of the internet facilitated a means of reaching a good patient outcome in the face of a variety of informational and organizational limitations and gaps. This journey illustrates the importance of human-related factors affecting access to health information. The application of a range of internet information resources at critical points can result in a positive patient outcome, as this case illustrates. This paper reflects on how the experience highlights several information needs and concerns. It also highlights the need for improved access to appropriate health information along the patient journey that can support patient and provider joint decision-making. This access to information can make the difference between positive clinical outcomes and death, illustrating how health information on the internet can be both critical and life saving.
... Poor availability of immunohistochemistry services and insufficient training of pathologists in the diagnosis of paediatric neoplasms were cited as contributors to the discrepancies in diagnosis. 53,54 Because few children who have had an incorrect diagnosis become event-free survivors, the overestimation of the rate of correct diagnosis would not lead to an overestimation of the final survival rate, but would misclassify the cause of treatment failure as relapse without necessarily recognising that the relapse was caused by the selection of an inappropriate treatment regimen due to misdiagnosis. Estimates of treatment abandonment, death due to treatment toxicity, and relapse rates were confined to regions or countries where patient-level data were available (figure 3). ...
... Similarly, if both access to diagnosis and treatment increased to 100%, the influx of new patients could overwhelm the already constrained human and financial resources of an oncology programme and decrease the event-free survival for all ( figure 3). We propose that priority should be given to interventions 54 Similarly, Mali retinoblastoma physicians use the ORBIS Cybersight system (London, UK) for case discussions with experts at the Curie Institute, Paris. Cancer registration at the hospital, regional, and national level has become increasingly common, even in low-income and middle-income countries, and has allowed the assessment of trends to inform health-care policy and support epidemiology studies. ...
In low-income and middle-income countries, an excess in treatment failure for children with cancer usually results from misdiagnosis, inadequate access to treatment, death from toxicity, treatment abandonment, and relapse. The My Child Matters programme of the Sanofi Espoir Foundation has funded 55 paediatric cancer projects in low-income and middle-income countries over 10 years. We assessed the impact of the projects in these regions by using baseline assessments that were done in 2006. Based on these data, estimated 5-year survival in 2016 increased by a median of 5·1%, ranging from-1·5% in Venezuela to 17·5% in Ukraine. Of the 26 861 children per year who develop cancer in the ten index countries with My Child Matters projects that were evaluated in 2006, an estimated additional 1343 children can now expect an increase in survival outcome. For example, in Paraguay, a network of paediatric oncology satellite clinics was established and scaled up to a national level and has managed 884 patients since initiation in 2006. Additionally, the African Retinoblastoma Network was scaled up from a demonstration project in Mali to a network of retinoblastoma referral centres in five sub-Saharan African countries, and the African School of Paediatric Oncology has trained 42 physicians and 100 nurses from 16 countries. The My Child Matters programme has catalysed improvements in cancer care and has complemented the efforts of government, civil society, and the private sector to sustain and scale improvements in health care to a national level. Key elements of successful interventions include strong and sustained local leadership, community engagement, international engagement, and capacity building and support from government.
... Poor availability of immunohistochemistry services and insufficient training of pathologists in the diagnosis of paediatric neoplasms were cited as contributors to the discrepancies in diagnosis. 53,54 Because few children who have had an incorrect diagnosis become event-free survivors, the overestimation of the rate of correct diagnosis would not lead to an overestimation of the final survival rate, but would misclassify the cause of treatment failure as relapse without necessarily recognising that the relapse was caused by the selection of an inappropriate treatment regimen due to misdiagnosis. Estimates of treatment abandonment, death due to treatment toxicity, and relapse rates were confined to regions or countries where patient-level data were available (figure 3). ...
... Similarly, if both access to diagnosis and treatment increased to 100%, the influx of new patients could overwhelm the already constrained human and financial resources of an oncology programme and decrease the event-free survival for all ( figure 3). We propose that priority should be given to interventions 54 Similarly, Mali retinoblastoma physicians use the ORBIS Cybersight system (London, UK) for case discussions with experts at the Curie Institute, Paris. Cancer registration at the hospital, regional, and national level has become increasingly common, even in low-income and middle-income countries, and has allowed the assessment of trends to inform health-care policy and support epidemiology studies. ...
In low-income and middle-income countries, an excess in treatment failure for children with cancer usually results from misdiagnosis, inadequate access to treatment, death from toxicity, treatment abandonment, and relapse. The My Child Matters programme of the Sanofi Espoir Foundation has funded 55 paediatric cancer projects in low-income and middle-income countries over 10 years. We assessed the impact of the projects in these regions by using baseline assessments that were done in 2006. Based on these data, estimated 5-year survival in 2016 increased by a median of 5·1%, ranging from −1·5% in Venezuela to 17·5% in Ukraine. Of the 26 861 children per year who develop cancer in the ten index countries with My Child Matters projects that were evaluated in 2006, an estimated additional 1343 children can now expect an increase in survival outcome. For example, in Paraguay, a network of paediatric oncology satellite clinics was established and scaled up to a national level and has managed 884 patients since initiation in 2006. Additionally, the African Retinoblastoma Network was scaled up from a demonstration project in Mali to a network of retinoblastoma referral centres in five sub-Saharan African countries, and the African School of Paediatric Oncology has trained 42 physicians and 100 nurses from 16 countries. The My Child Matters programme has catalysed improvements in cancer care and has complemented the efforts of government, civil society, and the private sector to sustain and scale improvements in health care to a national level. Key elements of successful interventions include strong and sustained local leadership, community engagement, international engagement, and capacity building and support from government.
... Telemedicine improves the care of patients with pediatric cancer, [8][9][10] including complex cases such as brain tumors 5,6 and retinoblastoma. 7 The Iraqi-Italian experience is unique among previous telemedicine initiatives because of the large number of patients discussed, the diverse types of pediatric neoplasms covered, and its emphasis on building local capacity and education. ...
Background:
Iraq's health care system has gradually declined after several decades of wars, terrorism, and UN economic sanctions. The Oncology Unit at Children's Welfare Teaching Hospital (CWTH) in Baghdad was lacking basic facilities and support. To address this shortcoming, a humanitarian and educational partnership was established between CWTH and Sapienza University of Rome (SUR).
Methods:
We investigated the outcomes of 80 online and 16 onsite educational sessions and 142 teleconsultation sessions from 2006 to 2014. We also determined the outcomes of pathology reviews by SUR of 1216 tissue specimens submitted by CWTH from 2007 until 2019 for second opinions. The primary outcomes were discordance, concordance, and changes among clinical diagnoses and pathology review findings. The measures included the frequency of teleconsultation and tele-education sessions, the topics discussed in these sessions, and the number of pathology samples requiring second opinions.
Findings:
A total of 500 cases were discussed via teleconsultations during the study period. The median patient age was 7 years (range, 24 days to 16·4 years), and the cases comprised 79 benign tumors, 299 leukemias, 120 lymphomas, and 97 solid tumors. The teleconsultation sessions yielded 27 diagnostic changes, 123 confirmed diagnoses, and 13 equivocal impacts. The pathology reviews by SUR were concordant for 996 (81·9%) cases, discordant for 186 (15·3%), and inconclusive for 34 (2·8%). The major cause of discordance was inadequate immunohistochemical staining. The percentage of discordance markedly decreased over time (from 40% to 10%). The cause of the improvement is multifactorial: training of two CWTH pathologists at SUR, better immunohistochemical staining, and the ongoing clinical and pathologic telemedicine activities. The partnership yielded 12 publications, six posters, and three oral presentations by CWTH investigators.
Interpretation:
The exchange of knowledge and expertise across continental boundaries meaningfully improved the diagnoses and management of pediatric cancer at CWTH.
... This impact is consistent with what has been published in other countries where telepathology consultation has been used. 15,16 The telepathology platform also gives us access to specialist pathologists both inside and outside Uganda, and this access has greatly improved the quality of our diagnoses. The telepathology platform has also served as a training tool for students pursuing their pathology and hematology training. ...
Objectives
An accurate cancer diagnosis is critical to providing quality care to patients with cancer. We describe the results of a laboratory improvement process that started in 2017 to improve access to cancer diagnostics at the Uganda Cancer Institute (UCI). The overall objective of the project was to build capacity for the provision of quality and timely laboratory diagnostics to support cancer care in Uganda.
Methods
A phased multistep approach was used to improve laboratory capacity, including staff training, additional staff recruitment, equipment overhaul, and optimization of the supply chain.
Results
The program led to the establishment of a pathology laboratory that handled 5,700 tissue diagnoses in 2019. Immunohistochemistry services are now offered routinely. Turnaround time for histopathology has also reduced from an average of 7 to 14 days to 5.4 days. The main clinical laboratory has also increased both the test volume and the test capacity, with the additional establishment of a molecular diagnostics laboratory.
Conclusions
Our project shows a pathway to the improvement of laboratory diagnostic capacity in cancer care centers in sub-Saharan Africa (SSA). Improved laboratory diagnostic capacity is critical to improving cancer care in SSA and more rational use of targeted therapies.
... Similarly, the World Health Organization has developed methods for earlier recognition of symptoms and faster diagnosis [5,25]. Effectively implemented strategies to facilitate earlier and more accurate cancer diagnosis in LMICs in remote areas include the use of telemedicine to complement on-site continuing education and networks for input from experts [30][31][32][33][34]. ...
Background
Treatment options for childhood cancer have improved substantially, although in many low- and middle-income countries survival is lagging behind. Integral childhood cancer care involves the whole spectrum from detection and diagnosis to palliative and survivorship care.
Methods
Based on a literature review and expert opinions, we summarized current practice and recommendations on the following aspects of childhood cancer in Latin America: diagnostic processes and time to diagnosis, stage at diagnosis, treatments and complications, survivorship programs and palliative care and end-of-life services.
Results
Latin America is a huge and heterogeneous continent. Identified barriers show similar problems between countries, both logistically (time and distance to centers, treatment interruptions) and financially (cost of care, cost of absence from work). Governmental actions in several countries improved the survival of children with cancer, but difficulties persist in timely diagnosis and providing adequate treatment to all childhood cancer patients in institutions with complete infrastructure. Treatment abandonment is still common, although the situation is improving. Cancer care in the region has mostly focused on acute treatment of the disease and has not adequately considered palliative and end-of-life care and monitoring of survivors.
Conclusions
Decentralizing diagnostic activities and centralizing specialized treatment will remain necessary; measures to facilitate logistics and costs of transportation of the child and caretakers should be implemented. Twinning actions with specialized centers in high income countries for help in diagnosis, treatment and education of professionals and family members have been shown to work. Palliative and end-of-life care as well as childhood cancer survivorship plans are needed.
... Barriers to access can be due to the unavailability of services or the inability of patients to pay for these services in health care systems that primarily depend on families' outof-pocket contributions (29). Strategies to facilitate earlier and more accurate cancer diagnosis in LMIC include the use of telemedicine with local, cross-regional or international expert groups to complement on-site continuing education; both clinical referral networks and professional networks for local input or virtual input from international experts have been successfully implemented in LMIC (3,9,(30)(31)(32)(33)(34)(35). An example of such long-term collaboration is outlined later in this Review. ...
Each year ~429,000 children and adolescents aged 0 to 19 years are expected to develop cancer. Five-year survival rates exceed 80% for the 45,000 children with cancer in high-income countries (HICs) but are less than 30% for the 384,000 children in lower-middle-income countries (LMICs). Improved survival rates in HICs have been achieved through multidisciplinary care and research, with treatment regimens using mostly generic medicines and optimized risk stratification. Children’s outcomes in LMICs can be improved through global collaborative partnerships that help local leaders adapt effective treatments to local resources and clinical needs, as well as address common problems such as delayed diagnosis and treatment abandonment. Together, these approaches may bring within reach the global survival target recently set by the World Health Organization: 60% survival for all children with cancer by 2030.
... Применение медицинских телекоммуникационных систем для развития онкологических программ и всех связанных с ними дисциплин потенциально может расширить доступ к лечению и улучшить его качество, а также повысить качество образования и обучения (см. табл. 1) [73,79,80]. Развитие успешных программ по детской онкологии в странах с низким и средним уровнем доходов должно постепенно включать клинические исследования в свою практику. ...
... 20 For special questions (for instance paediatric cancer) and in the setting of a high level of training concordance, values of 90.6% between the diagnoses of trainees and experienced pathologists are possible. 21 However, with all of these studies a complete comparability between the individual projects can probably not be achieved. The reason for this can be found, amongst other things, in the diverse reasons for diagnostic error, e.g. the quality of clinical information and questions, the quality of the specimen, the quality of technical processing and stains, the availability of different stains or further methods like immunohistochemistry, the quality of photographic documentation, the quality of the reproduced pictures on the computer monitors of the remote pathologists, the degree of training and specialisation of primary and secondary pathologists, and last but not least, the quality and intensity of communication between clinical colleagues, technicians and pathologists aiming to solve the problems, which could lead to diagnostic errors. ...
Introduction:
Static telepathology (TP) was used to support a hospital in Tanzania that cannot employ a resident pathologist but has a basic laboratory. Histological slides were prepared by the local technical staff and digital images were uploaded into an Internet-based system; consultant pathologists in Germany could give their opinion. The aim of the study was to examine the diagnostic validity of this project without local pathologists.
Methods:
The set-up period for special training of local technical assistants was 10 weeks. Diagnoses of the first 545 cases that were processed via TP were compared with the results of a second opinion on the basis of routine slides created from the corresponding paraffin blocks, which were sent to Germany.
Results:
Of all cases, 384 (70%) TP diagnoses were completely confirmed by the second opinion. Minor deviations (e.g. divergent subtypes of tumours or other aetiology of non-specific reactive processes) were documented in 76 cases (14%), so that overall, 84% of diagnoses were useful in the setting of the available therapeutic possibilities. The results were better in some subgroups of diseases (90-100% useful diagnoses) and suboptimal (minimum 63%) in a few subgroups with rare diseases. Thirty (5%) malignant diseases were primarily misinterpreted as being benign and 12 (2%) benign diseases as malignant. Forty-three (8%) cases were insufficient for diagnosis using TP and could not be provided with a primary assessment.
Discussion:
Static TP can help support medical services in low-income countries in the absence of local pathologists with a potentially high diagnostic validity, especially for selected groups of diseases. The procedure can significantly improve the diagnostic procedures before commencement of therapy - a substantial contribution within a globalised world.
... Neuroradiology, neuropathology, and neurosurgery were the most requested subspecialties. Previous experiences showed that telemedicine is feasible and effective in the fields of radiology and pathology [21][22][23][24][25]. Additionally, virtual interactive technologies for real-time long-distance surgical collaboration may improve telemedicine and global neurosurgical education opportunities [26,27]. ...
Purpose
The Latin American Brain Tumor Board (LATB) is a weekly teleconference connecting pediatric neuro-oncologists from referral centers in high-income countries with pediatric subspecialists from 20 Latin American countries since 2013. This survey explored the participants’ experience utilizing this resource.
Methods
A cross-sectional electronic questionnaire was distributed to 159 participants through email and Cure4Kids.
Results
Ninety-five respondents (60%) from all the participating countries completed the survey. Sixty-one reported frequent-attendance (≥ 1 per month), 23 reported infrequent-attendance (< 1 per month), and 11 never participated. The most frequently reported attendance-barriers were the subspecialist’s workload (64%), the timing of the teleconference (38%), and Internet connectivity problems (29%). Subspecialist’s workload was more frequently reported as a barrier compared with other barriers, in both the frequent- and infrequent-attendance groups (p < 0.05), with the exception of the timing of the meeting in the infrequent-attendance group. More than 80% of attendees found the frequency and duration of the teleconference were sufficient. Utilizing Spanish as the primary language was reported to enhance the recommendations by 93% of the attendees. Moreover, 84% reported that the recommendations (almost) always fit the local circumstances. Furthermore, 99% of attendees found the teleconference provided a continuing medical education opportunity. Finally, 96% of attendees (almost) always found that the provided recommendations helped to improve the outcomes/quality of life of the patients.
Conclusions
The LATB teleconference provided a valuable tool for the management of pediatric brain tumors in Latin America as it provided a feasible and easy to access continued medical education opportunity for the participants.
... In low and middle-income countries the reasons for poor diagnostics are numerous. Advanced diagnostic immune techniques may not be available, poor surgery may result in low quality biopsies, conservation of biopsies may be improper, and pathologists may lack adequate training [27,28]. Our study therefore underlines the importance for an in-depth investigation of the diagnostic problems faced at the Dr Sardjito Hospital. ...
Background: Improving the quality of care in resource limited settings through an outreach program is challenging. Teleconferencing is increasingly being used and considered a breakthrough in medical education. We evaluated adherence with childhood oncology-hematology teleconferences between two academic hospitals in Indonesia and Netherlands. Methods: Teleconferences held during 12 months between an Indonesian and a Dutch academic hospital were evaluated using a standardized form. Both adherence with diagnostic and treatment advices for individual patients were explored in medical records. Results: During 38 teleconferences, difficult cases of 53 children were discussed by Dutch pediatric oncologists and Indonesian residents. Dutch oncologists advised diagnostic adjustments in 41 cases (77%). Most common diagnostic advices were: laboratory tests (68%), imaging (54%), physical examination (41%). Diagnostic advices were not adhered to in 12 children (30%). Common reasons for non-adherence were: not applicable in middle-income setting (25%), disagreement with Dutch advice (17%), CT scan is out of order (17%), patient died (17%). Dutch oncologists advised treatment adjustments in 40 cases (75%). Most common treatment advices were: change of protocol (38%), nutritional support (30%), prevention of tumor lysis syndrome (20%). Treatment advices were not adhered to in 9 children (22%). Common reasons for non-adherence were: poor condition of child (44%), not applicable in middle-income setting (22%), patient died (22%), disagreement with Dutch advice (11%). Twenty-four children (45%) died after teleconference was held. Twenty-nine children (55%) were alive. These children abandoned (38%), completed (31%) or were still under treatment (31%). Conclusion: Through teleconferencing, knowledge between high and low or middle-income countries can be shared to improve patient care. Locally applicable advices are required. Active participation by pediatric oncologists at both partner sites is recommended. Keywords: Outreach program, Childhood oncology-hematology, Teleconference, Adherence
... Tele-support services after discharge has brought families' high satisfaction [50]. Furthermore, the agreement between diagnosis via telemedicine and the routine method was 90.6% [51]. Implementation of home care after discharge with telephone consultation had a major effect on meeting the needs of children with cancer and reduced unplanned hospitalizations [52]. ...
The purpose of this study was to review different telemedicine services in diagnosis, treatment and management of various children diseases and providing an overview of systematic reviews conducted in this regard. We searched English articles published in peer-reviewed journals between 2000 to 2016. We found that tele-pediatric services have been reported in various areas such as cardiology, burn, diabetes, obesity, emergency medicine, speech and hearing loss, Ear, Nose and Throat, psychology and psychiatry, radiology, oncology, home healthcare, asthma, genetics and dentistry. These studies mainly reported positive results. However, systematic reviews in tele-pediatric showed that these studies have not proven the clinical effectiveness or suggested further studies to assess the clinical outcomes of services provided through telemedicine technologies.
... Innovative programmes such as medical telecommunication could improve access to quality cancer care for children in LMICs and have application to underserved populations in high-income countries. 176,177 A goal should be to establish international research networks for biological, epidemiological, clinical, and health-services research in partnership with paediatric cancer centres in LMICs to identify insights into cancer aetiology and treatment innovations with maximum benefit to children with cancer who live in LMICs. ...
We are in the midst of a technological revolution that is providing new insights into human biology and cancer. In this era of big data, we are amassing large amounts of information that is transforming how we approach cancer treatment and prevention. Enactment of the Cancer Moonshot within the 21st Century Cures Act in the USA arrived at a propitious moment in the advancement of knowledge, providing nearly US$2 billion of funding for cancer research and precision medicine. In 2016, the Blue Ribbon Panel (BRP) set out a roadmap of recommendations designed to exploit new advances in cancer diagnosis, prevention, and treatment. Those recommendations provided a high-level view of how to accelerate the conversion of new scientific discoveries into effective treatments and prevention for cancer. The US National Cancer Institute is already implementing some of those recommendations. As experts in the priority areas identified by the BRP, we bolster those recommendations to implement this important scientific roadmap. In this Commission, we examine the BRP recommendations in greater detail and expand the discussion to include additional priority areas, including surgical oncology, radiation oncology, imaging, health systems and health disparities, regulation and financing, population science, and oncopolicy. We prioritise areas of research in the USA that we believe would accelerate efforts to benefit patients with cancer. Finally, we hope the recommendations in this report will facilitate new international collaborations to further enhance global efforts in cancer control.
... One such collaboration between the Instituto Materno Infantil de Pernambuco (Recife, Brazil) and St. Jude Children's Research Hospital (Memphis, TN) showed that static (transmission of single, static images) and dynamic (real-time, continually transmitted images) telepathology are equally effective in establishing proper histologic diagnosis. This is particularly beneficial, as the static method is less expensive and requires no real-time collaboration between professionals [55]. ...
As the morbidity and mortality associated with communicable diseases continue to decrease in the developing world, the medical burden of childhood cancer continues to expand. Although international aid and relief groups such as the World Health Organization recognize the importance of childhood cancer, their main emphasis is on the more easily treated malignancies, such as leukemias and lymphomas, and not pediatric brain tumors, which are the second most common malignancy in children and the leading cause of cancer-related deaths in the pediatric population. Addressing the needs of these children is a growing concern of several professional neuro-oncology-related societies. Thus, the goal of this review is to describe the current state of pediatric neuro-oncology care in the developing world, address the current and future needs of the field, and help guide professional societies' efforts to contribute in a more holistic and multidisciplinary manner.
We reviewed the literature to compare the availability of neuro-oncology care in various regions of the developing world with that in higher income nations, to describe examples of successful initiatives, and to present opportunities to improve care.
The current challenges, previous successes, and future opportunities to improve neuro-oncology care are presented. The multidisciplinary nature of neuro-oncology depends on large teams of highly specialized individuals, including neuro-oncologists, neurosurgeons, neurologists, radiologists, radiation oncologists, pathologists, palliative care specialists, oncology nurses, physical therapists, occupational therapists, speech therapists, pediatric intensivists, and social workers, among others.
Pediatric neuro-oncology is one of the most complex types of medical care to deliver, as it relies on numerous specialists, subspecialists, support staff, and physical resources and infrastructure. However, with increasing collaboration and advancing technologies, developed nations can help substantially improve neuro-oncology care for children in developing nations.
... Focused training of a general pathologist in the diagnosis of pediatric neoplasms, implementation of a basic IHC panel in a pathology laboratory in a developing country, and inclusion of the pathologist in a multidisciplinary team can dramatically improve the diagnostic accuracy of pediatric neoplasms. 16 Immunohistochemistry is an important and sometimes essential tool for the definitive diagnosis of pediatric neoplasms. In a limited resource area, use of a comprehensive panel of available antibodies is probably unrealistic. ...
Context:
Correct histopathologic diagnosis is fundamental to defining proper treatment and improving outcomes in children with malignancies. The Department of Pathology at St. Jude Children's Research Hospital (SJCRH) has collaborated with SJCRH International Outreach Program partner sites to improve the accuracy of histopathologic diagnoses in countries with limited resources. Pathologists at SJCRH provide review and evaluation of cases that are considered difficult or complex.
Objectives:
To determine the quality of pathology diagnosis and to identify areas for improvement in our international partner sites, we retrospectively analyzed all the international cases that were submitted for review. A comparison of our data with selected reports of surgical pathology error rates published in the medical literature was performed.
Design:
From January 2009 through December 2011, SJCRH received 763 cases submitted by international pathologists from 37 countries for histopathologic review and evaluation. Of 763 cases reviewed, 705 (92.4%) met the criteria for inclusion in this study. Rates of concordance between the submitted diagnoses and SJCRH reviewed diagnoses were analyzed.
Results:
Overall concordance, minor disagreement, and major disagreement rates between submitted diagnoses and SJCRH reviewed diagnoses were 430 (61.0%), 98 (13.9%), and 177 (25.1%) of the cases, respectively. Major disagreement rates ranged from 13.7% to 37.1% among studied countries.
Conclusions:
The major disagreement rate between referring international sites and SJCRH was substantially higher than the major disagreement rate among US institutions. Lack of the availability of immunohistochemistry and the training of pathologists in the diagnosis of pediatric neoplasms may have contributed to the discrepancies.
... 242 More recently, an eff ort in Pernambuco raised the accuracy of diagnosing childhood cancer after the introduction of a focused training programme and the establishment of telepathology in the region. 257 ...
Non-communicable diseases, including cancer, are overtaking infectious disease as the leading health-care threat in middle-income and low-income countries. Latin American and Caribbean countries are struggling to respond to increasing morbidity and death from advanced disease. Health ministries and health-care systems in these countries face many challenges caring for patients with advanced cancer: inadequate funding; inequitable distribution of resources and services; inadequate numbers, training, and distribution of health-care personnel and equipment; lack of adequate care for many populations based on socioeconomic, geographic, ethnic, and other factors; and current systems geared toward the needs of wealthy, urban minorities at a cost to the entire population. This burgeoning cancer problem threatens to cause widespread suffering and economic peril to the countries of Latin America. Prompt and deliberate actions must be taken to avoid this scenario. Increasing efforts towards prevention of cancer and avoidance of advanced, stage IV disease will reduce suffering and mortality and will make overall cancer care more affordable. We hope the findings of our Commission and our recommendations will inspire Latin American stakeholders to redouble their efforts to address this increasing cancer burden and to prevent it from worsening and threatening their societies.
... Similarly to adult cancer, pediatric cancer diagnosis, treatment, and support require a sophisticated integration of multiple specialties, including (but not limited to) nursing, pediatric and radiation oncology, surgery, pathology, infection control, laboratory and imaging medicine, psychosocial, and palliative care. Adequate training for 79,80]. The development of successful pediatric oncology programs in LMICs should progressively incorporate clinical research into their practices. ...
Reduction of child mortality is one of the Millennium Development Goals; as low-income and middle-income countries (LMICs) advance toward the achievement of this goal, initiatives aimed at reducing the burden of noncommunicable diseases, including childhood cancer, need to be developed.
Approximately 200 000 children and adolescents are diagnosed with cancer every year worldwide; of those, 80% live in LMICs, which account for 90% of the deaths. Lack of quality population-based cancer registries in LMICs limits our knowledge of the epidemiology of pediatric cancer; however, available information showing variations in incidence may indicate unique interactions between environmental and genetic factors that could provide clues to cause. Outcome of children with cancer in LMICs is dictated by late presentation and underdiagnosis, high abandonment rates, high prevalence of malnutrition and other comorbidities, suboptimal supportive and palliative care, and limited access to curative therapies. Initiatives integrating program building with education of healthcare providers and research have proven to be successful in the development of regional capacity. Intensity-graduated treatments adjusted to the local capacity have been developed.
Childhood cancer burden is shifted toward LMICs; global initiatives directed at pediatric cancer care and control are urgently needed. International partnerships facilitating stepwise processes that build capacity while incorporating epidemiology and health services research and implementing intensity-graduated treatments have been shown to be effective.
Abstract
Background: Iraq's health care system has gradually declined after several
decades of wars, terrorism, and UN economic sanctions. The Oncology Unit at
Children's Welfare Teaching Hospital (CWTH) in Baghdad was lacking basic
facilities and support. To address this shortcoming, a humanitarian and educa�tional partnership was established between CWTH and Sapienza University of
Rome (SUR).
Methods: We investigated the outcomes of 80 online and 16 onsite educational
sessions and 142 teleconsultation sessions from 2006 to 2014. We also determined
the outcomes of pathology reviews by SUR of 1216 tissue specimens submitted by CWTH from 2007 until 2019 for second opinions. The primary outcomes were
discordance, concordance, and changes among clinical diagnoses and pathology
review findings. The measures included the frequency of teleconsultation and
tele-education sessions, the topics discussed in these sessions, and the number of
pathology samples requiring second opinions.
Findings: A total of 500 cases were discussed via teleconsultations during the
study period. The median patient age was 7 years (range, 24days to 16·4 years),
and the cases comprised 79 benign tumors, 299 leukemias, 120 lymphomas, and
97 solid tumors. The teleconsultation sessions yielded 27 diagnostic changes, 123
confirmed diagnoses, and 13 equivocal impacts. The pathology reviews by SUR
were concordant for 996 (81·9%) cases, discordant for 186 (15·3%), and inconclu�sive for 34 (2·8%). The major cause of discordance was inadequate immunohisto�chemical staining. The percentage of discordance markedly decreased over time
(from 40% to 10%). The cause of the improvement is multifactorial: training of
two CWTH pathologists at SUR, better immunohistochemical staining, and the
ongoing clinical and pathologic telemedicine activities. The partnership yielded
12 publications, six posters, and three oral presentations by CWTH investigators.
Interpretation: The exchange of knowledge and expertise across continental
boundaries meaningfully improved the diagnoses and management of pediatric
cancer at CWTH.
KEYWORDS
cancer, children, developing countries, pathology review, pediatric oncology, pediatric
pathology, teleconsultation, telemedicine
Background/objective:
In a project of telepathology (TP) between German pathologists and a hospital in Tanzania, trained technical assistants have uploaded digital histological images onto the internet-based platform ipath. The diagnoses from 486 paediatric specimens were analysed.
Methods:
The investigation included diagnoses, either primarily done via TP or secondarily after a further workup of the paraffin-embedded tissue, which was sent to Germany for cases which could not be solved via TP. In the latter, the initial TP-diagnoses were compared with the results after re-evaluation.
Results:
The median age was 11 years. The cohort comprised 390 benign diseases (80.2%) and 96 malignant diseases (19.8%). For benign diseases, the most frequent anatomic sites were lymph nodes, skin, and soft tissue, breast, and head&-neck. Frequent diagnoses were non-specific inflammations and benign tumors. In malignant diseases, the most sites were lymph nodes, skin, soft tissue, head&neck, and ovary and the most frequent diseases sarcomas and lymphomas. The paraffin embedded tissue of 179 cases (36.3%) was shipped to Germany. With the concordance analysis, we could discover the mandatory necessity for the possibility of second opinion in difficult cases.
Conclusion:
An exclusively TP-support cannot meet all requirements of modern medical diagnostics. The education of local pathologists is imperative.
Since 2007, a hospital in Tanzania has been supported with histopathological reports via telepathology (TP) by German pathologists. For this, the Internet-based platform iPath is used. The aim of this study was to analyse the rate of discrepancies in defined diagnostic groups. After shipment of paraffin-embedded tissue to Germany, specimens were processed according to recent diagnostic standards. All diagnoses were grouped into eight benign and 11 malignant main categories. The comparison comprised the following categories: 1, identical diagnosis; 2, mild discordance; 3, correct distinction between benign and malignant process, 4, false malignant; 5, false benign; and 6, no primary diagnosis possible. The cohort comprised 396 benign and 336 malignant diseases. Of the benign diseases, 62% were category 1, 23% category 2, 2% category 3, 6% category 4 and 7% category 6. Of the malignant diseases, 42% were category 1, 16% category 2, 12% category 3, 14% category 5 and 15% category 6. Exclusive support with static TP cannot meet all requirements of modern medical diagnostics. However, the project shows a approach for how pathologists in industrial countries can help low-income countries. In difficult cases, the opportunity for a final work-up using additional methods must be given for useful diagnostic purposes.
Across much of Africa, there is a critical shortage of pathology services necessary for clinical care. Even in settings where specialty-level clinical care, such as medical oncology, is available, access to anatomic pathology services has often lagged behind. Pathology laboratories in the region are challenging to establish and maintain. This article describes the successful implementation of telepathology services in Malawi and reviews other successful programs developed to support diagnostic pathology in resource-limited settings.
Background:
A gap in childhood cancer outcomes remains between developed and developing countries. Persistence of this gap may be caused by financial, social, or educational disparities. Twinning and distance learning initiatives may improve such disparities. Integrating telemedicine into pediatric oncology twinning programs enhances education and facilitates patient-centered capacity building.
Materials and methods:
We performed an analysis of Web-based meetings held from August 2005 through July 2009 between the International Outreach Program at St. Jude Children's Research Hospital and the Instituto Materno Infantil de Pernambuco (IMIP) in Recife, Brazil. We determined the effect of these online conferences on the development and implementation of an innovative protocol for children with acute lymphoblastic leukemia (ALL) at IMIP.
Results:
Meetings occurred in 45 months of the 48-month study period with an average of two meetings per month. A total of 163 new patients were discussed during the study period; we retrieved documentation of patient-related discussions for 147 of them, constituting 286 discussions. On average, each patient was discussed 1.9 times (range, 1-15 discussions/patient). Compared with that of the era predating the online meetings (1993-2005), overall mortality, early death, and relapse of patients with ALL decreased after the telemedicine program was instituted at IMIP.
Discussion:
Personal dedication and institutional support are essential for successful telemedicine initiatives. Documentation and archival of meetings are important for accurately measuring outcomes and developing methods for improved care.
Conclusions:
Integration of telemedicine into twinning programs facilitates communication about interventions, leading to improved outcomes of pediatric patients with cancer.
Introduction:
Telepathology evolved from video microscopy (i.e., "television microscopy") research in the early 1950s to video microscopy used in basic research in the biological sciences to a basic diagnostic tool in telemedicine clinical applications. Its genesis can be traced to pioneering feasibility studies regarding the importance of color and other image-based parameters for rendering diagnoses and a series of studies assessing concordance of virtual slide and light microscopy diagnoses. This article documents the empirical foundations of telepathology.
Methods:
A selective review of the research literature during the past decade (2005-2016) was conducted using robust research design and adequate sample size as criteria for inclusion.
Conclusions:
The evidence regarding feasibility/acceptance of telepathology and related information technology applications has been well documented for several decades. The majority of evidentiary studies focused on intermediate outcomes, as indicated by comparability between telepathology and conventional light microscopy. A consistent trend of concordance between the two modalities was observed in terms of diagnostic accuracy and reliability. Additional benefits include use of telepathology and whole slide imaging for teaching, research, and outreach to resource-limited countries. Challenges still exist, however, in terms of use of telepathology as an effective diagnostic modality in clinical practice.
The diagnosis of bone and soft tissue tumors in children is challenging. These lesions are especially difficult for general pathologists. We reviewed our experience with pediatric mesenchymal tumors sent in consultation to our service, with the goal of identifying issues that most often prompted second-opinion referral. Roughly 16 000 cases were seen in toto, of which 1601 occurred in children. These included 491 bone cases and 1110 soft tissue cases. The cases were referred by private practices/nonacademic medical centers (85%), academic medical centers (8%), and pediatric hospitals (7%). Reasons for referral were (a) self-perceived lack of experience with pediatric mesenchymal tumors (n = 930), (b) second opinion requested by the clinician or patient (n = 132), and (c) perceived or real need for ancillary studies not available at the referring institution (n = 116). The referring pathologists suggested a diagnosis for 670 cases; of these, 476 (71%) were in essential agreement with our final diagnosis. Of the remaining, 139 (21%) were considered “minor disagreements” and 55 (8%) “major disagreements.” The “major disagreement” cases could be divided into (a) malignant tumors submitted with benign diagnoses (58%), (b) benign tumors submitted with malignant diagnoses (25%), (c) nonneoplastic conditions submitted as representing neoplasms (11%), and (d) neoplasm submitted as representing nonneoplastic conditions (6%). Pediatric mesenchymal tumors comprised 10% of cases sent to our mesenchymal tumor consultation practice. The rates of diagnostic disagreement found in this study are roughly in accordance with prior studies of mandatory and voluntary second opinion in adult soft tissue tumors. Given the rarity of these tumors, expert second opinion may be of value.
Introduction: Although many studies have been conducted in the telepathology field in recent years, a systematic review that examines
studies in a comparative manner has not yet been undertaken. This paper aims to review the published papers on telepathology projects
and compare them in several aspects such as telepathology method,telecommunication method, clinical outcome, etc.
Method: This is a systematic review study. PubMed database was used to find the studies published in the past ten years (2004–2014).
The 71 final related papers were evaluated. Data were extracted from these studies based on the following items: country, national (in
country) or international (between countries), frozen section or slide, body part, type of camera used, telecommunication method,
telepathology method, clinical outcome, cost evaluation, satisfaction evaluation and the description of consultation providers and
receivers. Data were analyzed using descriptive analysis.
Results: Results showed that most of the studies were performed in developed countries on a national level, on slide and on a specific body
part. In most studies, a Nikon camera was used to take images. Online methods were the most used telecommunication method in the
studies, while store and forward was the most used telepathology method. Clinical outcome of many studies showed that telepathology
is a reliable and accurate method for consultation. More than half of the studies considered the cost, and most of them showed that a
telepathology system is cost effective. Few studies evaluated satisfaction of the participants. In most studies, the telepathology project
was undertaken between pathologists.
Conclusion: Although there is enough evidence to suggest that telepathology is an effective way of consultation between pathologists,
there are still some areas that should be addressed and for which there is a lack of convincing evidence. For example, pathologist
satisfaction, cost evaluation, legal issues and ethical issues still need to be addressed
Telemedicine is widely used in industrialized countries for educational purposes. Twinning experiences using telemedicine between institutions in industrialized and developing countries (DC) have been limited. Pediatric neuro-oncology is a complex multidisciplinary discipline that is underserved in most of DC and provides a model to test the feasibility of such tool for twinning purposes.
A computer, an EMLO visual presenter HV-7600SX document camera, and a TANDBERG 6000 model videoconference unit were used to present data. For connectivity, we used a six-channel ISDN telephone line. Each channel is 64 megabytes/sec.
Between December 2004 and May 2006, 20 sessions of videoconference were held between King Hussein Cancer Center and the Hospital for Sick Children to discuss 72 cases of 64 patients with various brain tumors (5 patients were discussed twice and 1 patient four times). In 23 patients (36%), major changes from original plan were recommended on different aspects of the care. In 21 patients (91%), those recommendations were followed, with potentially significant positive impact on patients' care.
Videoconferencing is a feasible and practical twinning tool in pediatric neuro-oncology with a potentially major impact on patient care.
To describe the clinical and demographic characteristics of non-Hodgkin's lymphoma patients diagnosed at the Pediatric Oncology Unit at the Instituto Materno-Infantil Professor Fernando Figueira (IMIP) over a 9-year period, and also to describe their survival rates and possible associations between the survival rates and the clinical and demographic characteristics analyzed in the study.
This was a cross-sectional study. Data were collected by a retrospective review of the charts of all 110 patients admitted to our unit during the period of May 1994 through May 2003. Probability of survival was calculated in accordance with the techniques of Kaplan-Meier, using log rank to evaluate differences between the groups.
The average age was 6.1 years. The male/female ratio was 2.4:1. The most frequent histological subtype was Burkitt's lymphoma. The majority of patients had been diagnosed with advanced disease (stage III or IV of Murphy's Classification) and was from rural areas. Family income per capita was lower than 1/2 minimum wage in 36.4% of cases; maternal illiteracy was observed in 12.7% of cases. The 5-year overall survival and disease-free survival rates were 70+/-4% and 68.4+/-4%, respectively. None of the clinical-demographic characteristics had a significant association with the probability of survival (p > 0.05).
Children admitted to the IMIP seemed to be affected by non-Hodgkin lymphoma at a younger age, with a higher incidence of Burkitt's lymphoma and with survival rates similar to those described in the literature of developed countries. No clinical demographic characteristics had a statistically significant association with prognosis
The paper reviews the development of the application of telepathology in a department of surgical pathology between 1991 and 2003. The goal of the efforts during this time was to give up the concept of programming a single application, available only between two fixed workstations with sophisticated devices and special software, and to find the virtual "largest common denominator" for implementing as many different applications as possible with the same basic system.
A new telepathology system was designed as a client-server system with a relational database at its centre. The clients interact together by transferring the questions (texts and images) to a record (case) in the database on the server and by transferring the answers to the same record on the database.
The new "open" telepathology system iPath (http://telepath.patho.unibas.ch) has been very well accepted by many groups around the world. The main application fields are: consultations between pathologists and medical institutions without a pathologist (e.g. for frozen section diagnoses or for surgical diagnoses in hospitals in South Asia or Africa), tumour boards, field studies and distance education (http://teleteach.patho.unibas.ch).
Having observed that with iPath we have succeeded in satisfying all our telepathology needs, we are inclined to put the emphasis on the nature of the tasks being performed, as opposed to the methods or technical means for performing a given task. The three organisation models proposed by Weinstein et al. (2001) can be reduced to only two models: the model of discussion groups and the model of expert groups (virtual institutes).
The morphologic diagnosis of tumor specimens with precise tumor typing, staging, and grading remains the basis of almost all cancer treatments. Thus, in each tumor case, a histologic diagnosis of the highest quality should be the physician's priority. In approximately 10–20% of tumor cases, diagnostic uncertainty remains to some degree, requiring a second opinion in determining the biologic behavior, the histogenesis, the grade of dedifferentiation, or any other parameter. Facilitating the communication between pathologists and the exchange of cases, telepathology gains more and more importance. To benefit from this technical development, the International Union Against Cancer (UICC) has decided to establish a Telepathology Consultation Center (UICC-TPCC) for interested pathologists around the world.
BACKGROUND
To the authors' knowledge, the frequency and clinical impact of errors in the anatomic pathology diagnosis of cancer have been poorly characterized to date.METHODS
The authors examined errors in patients who underwent anatomic pathology tests to determine the presence or absence of cancer or precancerous lesions in four hospitals. They analyzed 1 year of retrospective errors detected through a standardized cytologic–histologic correlation process (in which patient same-site cytologic and histologic specimens were compared). Medical record reviews were performed to determine patient outcomes. The authors also measured the institutional frequency, cause (i.e., pathologist interpretation or sampling), and clinical impact of diagnostic cancer errors.RESULTSThe frequency of errors in cancer diagnosis was found to be dependent on the institution (P < 0.001) and ranged from 1.79–9.42% and from 4.87–11.8% of all correlated gynecologic and nongynecologic cases, respectively. A statistically significant association was found between institution and error cause (P < 0.001); the cause of errors resulting from pathologic misinterpretation ranged from 5.0–50.7% (the remainder were due to clinical sampling). A statistically significant association was found between institution and assignment of the clinical impact of error (P < 0.001); the aggregated data demonstrated that for gynecologic and nongynecologic errors, 45% and 39%, respectively, were associated with harm. The pairwise kappa statistic for interobserver agreement on cause of error ranged from 0.118–0.737.CONCLUSIONS
Errors in cancer diagnosis are reported to occur in up to 11.8% of all reviewed cytologic-histologic specimen pairs. To the authors' knowledge, little agreement exists regarding whether pathology errors are secondary to misinterpretation or poor clinical sampling of tissues and whether pathology errors result in serious harm. Cancer 2005. © 2005 American Cancer Society.
Access to quality cancer care is often unavailable in low-income and middle-income countries, and also in rural or remote areas of high-income countries. Teleoncology-oncology applications of medical telecommunications, including pathology, radiology, and other related disciplines-has the potential to enhance access to and quality of clinical cancer care, and to improve education and training. Implementation of teleoncology in the developing world requires an approach tailored to priorities, resources, and needs. Teleoncology can best achieve its proposed goals through consistent and long-term application. We review teleoncology initiatives that have the potential to decrease cancer-care inequality between resource-poor and resource-rich institutions and offer guidelines for the development of teleoncology programmes in low-income and middle-income countries.
Issues involving brain tumor diagnosis are discussed in light of the frequently observed discrepancies between the diagnoses of general pathologists and neuropathologists. Accuracy of diagnoses could be improved if definitions or criteria for specific categories of tumors were simplified, clearly established, and consensually accepted.
The morphologic diagnosis of tumor specimens with precise tumor typing, staging, and grading remains the basis of almost all cancer treatments. Thus, in each tumor case, a histologic diagnosis of the highest quality should be the physician's priority. In approximately 10-20% of tumor cases, diagnostic uncertainty remains to some degree, requiring a second opinion in determining the biologic behavior, the histogenesis, the grade of dedifferentiation, or any other parameter. Facilitating the communication between pathologists and the exchange of cases, telepathology gains more and more importance. To benefit from this technical development, the International Union Against Cancer (UICC) has decided to establish a Telepathology Consultation Center (UICC-TPCC) for interested pathologists around the world.
The communication and exchange of histologic images works via the Internet. To ensure constant documentation, a case-based data base and image archive is used. Special TPCC software handles all requests to the TPCC and controls the interaction among requesting pathologists, TPCC, and UICC experts (transferring, reading, answering, logging, storing, etc.). All necessary data for controlling the telepathology service are stored in a customized SQL data base. The necessary equipment for the requesting pathologist is a personal computer; a digital or television camera/frame grabber, which is attached to a microscope; and access to the Internet. The requesting party contacts the TPCC's World Wide Web server and uploads the images and the clinical data of their case. To ensure uninterrupted functioning, the hardware will be part of a high-level communication center, which is connected via ATM (asynchronous transfer mode, 155 megabits per second) to the Internet.
The UICC has decided to establish the TPCC at the Institute of Pathology at the Charité, Humboldt-University, Berlin, Germany. The TPCC will not make the diagnoses itself but will involve an affiliated specialized expert pathologist. He or she will be on the panel of UICC experts who will constitute the "diagnostic backbone" of the TPCC. The center will function as follows: If a pathologist anywhere on the globe is confronted with the diagnosis of a difficult tumor case, he takes digitized histologic images (5-40 in number) and sends them along with sufficient clinical data to the server of the UICC-TPCC, asking for a second opinion. The center checks the case and transfers it to one of the UICC experts. This expert makes his or her diagnostic suggestion, which is then transferred back to the requesting pathologist via the UICC-TPCC.
The UICC-TPCC will be able to provide rapid and inexpensive diagnostic aid to pathologists all over the world, offering the possibility of a second opinion in accordance with the UICC-TNM and World Health Organization (WHO) standards. During the first and second year, the UICC-TPCC will be financed by sponsors. Telepathology makes the distribution of new developments of diagnostic standards, e.g., of the TNM system, WHO terminology, new tumor classifications, and updated information on actual technologies, globally accessible in a direct and rapid way. It also enables a high quality of education and teaching.
The chief relevance of telemedicine lies in its capability to link medical practitioners and remote hospitals to larger or specialized facilities in a very fast electronic manner. This may become even more important due to current increase in subspecialization and demand for more precise diagnosis and consultation in difficult cases. A network attaching small clinics or laboratories to larger and more specialized units, and to highly specialized referral centers may improve the professional standard of health care services and education. For a wider use, a technological standardization will be required, since the existence of several types of computer and numerous image manipulation programs, have resulted in a proliferation of file formats. However, every potential user or client of telemedicine should keep in mind, that standardization also includes legal and ethical issues such as patient confidentiality and malpractice avoidance. The adoption of workable guidelines and protocols is required. Telepathology in general and teleneuropathology in particular is the practice of pathology at a distance, viewing digitized images of histological slides on a video monitor rather than directly through a light microscope. For the transmission of the digitized images from a telemicroscope to the remote diagnostic video monitor, different technologies such as ordinary telephone lines, broadband telecommunications channels, and the Internet can be used. The transmitted images may serve for primary neuropathological diagnosis, teleconsultation, quality assurance, proficiency testing, and distance learning. Static-imaging and dynamic-imaging are the two major competing technologies of telemicroscopy. Static-imaging systems appear to have levels of diagnostic accuracy which are not satisfactory for diagnostic neuropathology. On the contrary, high levels of diagnostic accuracy can be achieved using dynamic-imaging systems with the transmission of live video images in real time and by using a robotized telemicroscope with the possibility to examine the entire histological specimen under control of the remote teleneuropathologist.
Small blue cell tumors are a group of tumors that share a common histologic characteristic with H&E staining. This makes differentiation from one another difficult as they all appear small, blue and round. Even though they all appear the same, they are vastly different from each other. Several different techniques have been developed to help further delineate and classify these tumors which include: small cell lung cancer (SCLC); non-Hodgkin's lymphoma (NHL); Ewing's sarcoma; rhabdomyosarcoma; Merkel carcinoma; neuroblastoma; carcinoid tumors; and intra-abdominal desmpolastic small round cell tumor. Using immunoperoxidase staining, reverse transcriptase polymerase chain reaction and fluorescence in situ hybridization techniques, these tumors have been successfully differentiated from one another. This separation makes staging and treatment of these tumors more effective, as not all of these tumors respond to the same modality of treatment. The following review summarizes some of the recent findings in the various small blue cell tumors and with the potential of novel therapies.
The objectives of the current study were to determine the outcome of children who were treated with chemotherapy and radiotherapy on the Children's Cancer Group (CCG) high-grade glioma protocol (CCG-945) who were diagnosed with low-grade gliomas on post hoc central pathologic review and to identify clinical and biologic features associated with prognosis.
Between 1985 and 1991, 250 children with institutionally classified high-grade gliomas were enrolled on CCG-945. Patients older than 24 months with intracranial lesions were assigned randomly to receive either lomustine, vincristine, and prednisone (control regimen) or the 8-drugs-in-1-day regimen (experimental regimen); younger patients and those with primary spinal cord tumors were assigned nonrandomly to the experimental regimen. Central independent review by 5 neuropathologists led to a reclassification of low-grade glioma in 70 patients, who were the focus of the current study.
The study involved 42 males and 28 females (median age, 7.7 years) with a median follow-up of 10.4 years. At 5 years, the progression-free survival (PFS) rate was 63% +/- 6%, and the overall survival (OS) rate was 79% +/- 5%, compared with a PFS rate of 19% +/- 3% (P < 0.0001) and an OS rate of 22% +/- 3% (P < 0.0001) in the remainder of the cohort. Significantly poorer 5-year PFS was seen in children younger than 24 months, those with fibrillary astrocytoma, and those with posterior fossa tumors. Patients demonstrated a modest improvement in PFS but no improvement in OS compared with children with low-grade gliomas who were treated with contemporary chemotherapy-alone approaches.
The current report calls attention to the importance of central pathologic review in large multiinstitutional trials of children with gliomas and suggests that aggressive front-line combined chemoradiotherapy does not confer a survival advantage in this highly selected population of patients.
The National Referral Hospital in Honiara, Solomon Islands, has used an Internet-based system in Switzerland for telepathology consultations since September 2001. Due to the limited bandwidth of Internet connections on the Solomon Islands, an email interface was developed that allows users in Honiara to submit cases and receive reports by email. At the other end, consultants can use a more sophisticated Web-based interface that allows discussion of cases among an expert panel. The result is a hybrid email- and Web-based telepathology system. Over two years, 333 consultations were performed, in which 94% of cases could be diagnosed by a remote pathologist. A computer-assisted 'virtual institute' of pathologists was established. This form of organization helped to reduce the median time from submission of the request to a report from 28 h to 8.5 h for a preliminary diagnosis and 13 h for a final report. A final report was possible in 77% of all submitted cases.
Soft tissue sarcomas represent a heterogeneous group of tumours with a wide range of clinical behaviour. Exact determination of diagnosis and prognosis is critical in order to guide surgical decisions and provide systemic therapy or radiation for patients. The value of consultative second opinions has been proven for general surgical pathology; some studies suggest an even higher value for the soft tissue tumour specimens in particular.
We reviewed 603 patients who were operated on at our institution with the diagnosis of soft tissue sarcoma and aggressive fibromatosis; we focused on mismatches in primary and definite tumour-entity and -grading with respect to the diagnosing institution and the primary surgical procedure.
We found concordant primary diagnosis in 28.3% for pathologists in private clinics, 29.6% for hospital pathologists, 36.8% for academic medical centres (university hospitals) and 70.5% for the Department of Pathology at our institution. An improvement in diagnosis or confirmation of the correct primary diagnosis by the second opinion was seen in 73.1% of the patients; in 2.5%, the second opinion was false.
For accurate determination of prognosis and to provide optimal therapeutic decisions we consider expert second opinion essential for optimal treatment of soft tissue sarcomas.
- Gf Walter
- Hk Matthies
- A Brandis
Walter GF, Matthies HK, Brandis A, et al. Telemedicine of the future: Teleneuropathology. Technol
Health Care 2000;8:25–34.
The UICC Telepathology Consultation Center. International Union Against Cancer. A global approach to improving consultation for pathologists in cancer diagnosis
- Dietel