Evidence-based medicine in pathology: an introduction

Marchevsky, Alberto M.

doi:10.1053/j.semdp.2006.01.002

Cited by 22 publications

(18 citation statements)

References 136 publications

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“…Level 3 or 4 evidence, reported in retrospective case series, is subject to a variety of biases, including data accrued from patient population groups that are heterogeneous as a result of various referral practices, variability in the interpretation of diagnostic features by different pathologists, the use of different therapeutic modalities, and other technical issues that affect data analysis with statistical methods. 19,20,41,42 The publications that provide 'best current evidence' include a relatively small number of patients, multiple stages of thymoma, and somewhat heterogeneous treatment. For example, the number of patients with thymoma type B3 ranged from 5 to 51 in the studies reviewed, the number of patients in various tumor stages varied consider- It is difficult to derive evidence-based guidelines regarding the use of the WHO classification of thymomas based on current information.…”

Section: Discussionmentioning

confidence: 99%

“…The information provided by each publication was classified into levels of evidence, using previously published criteria. 19,20 Evidence-based pathology advocates the use of the so-called FRAP paradigm (frame questions, research, analyze best evidence, derive patient-based rules). 19,20 The information available in each publication was organized in tables designed to answer specific questions (Table 1).…”

Section: Methodsmentioning

confidence: 99%

“…19,20 It relies on systematic review of the literature; classification of information into levels of potential accuracy in an attempt at identifying 'best' current evidence; and the use of meta-analysis and other quantitative tools for the integration of best evidence into diagnostic rules, guidelines, or other algorithms that can help guide the treatment of individual patients. [21][22][23][24][25][26][27][28] We performed a systematic review of the literature to identify current 'best evidence' regarding the clinical value of the WHO classification of thymomas and evaluated the data using meta-analysis.…”

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confidence: 99%

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Evidence‐based pathology and the pathologic evaluation of thymomas

Marchevsky

Gupta

McKenna

et al. 2008

Cancer

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BACKGROUND.The clinical validity and applicability of the World Health Organization (WHO) histopathologic classification of thymomas (‘classification’) has been questioned. Evidence‐based pathology promotes the use of systematic reviews and analysis of data with meta‐analysis rather than subjective reviews of the literature.METHODS.The authors performed a review of the English literature from 1999 to the present to identify ‘best evidence’ regarding the use of the ‘classification.’ The data were analyzed with meta‐analysis software.RESULTS.To the authors' knowledge, only Level‐3 or ‐4 evidence published in retrospective cases series is currently available regarding the use of the ‘classification.’ Meta‐analysis demonstrated that only 3 WHO categories of thymomas are associated with significant survival differences: A/AB/B1, B2, and B3. It also indicated significant heterogeneity with regard to the results published in different studies. To the authors' knowledge there is no current evidence to determine whether thymoma types are significant prognostic features for patients previously stratified by stage.CONCLUSIONS.There is a lack of randomized clinical trials evaluating the prognosis of patients with thymomas and the effects of various treatment modalities. The WHO classification of thymomas needs revision and could most likely be simplified into fewer classes with significant prognostic value. Future studies are needed to evaluate the prognostic and/or predictive value for thymoma patients previously stratified by stage. The latter information is important to help select those patients who may benefit from neoadjuvant chemotherapy or postoperative radiotherapy and other modalities. Cancer 2008. © 2008 American Cancer Society.

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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confidence: 99%

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Evidence‐based pathology and the pathologic evaluation of thymomas

Marchevsky

Gupta

McKenna

et al. 2008

Cancer

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“…23,24 Indeed, the failure to demonstrate the effective utilization of laboratory tests generated either in the clinical laboratory or in anatomic pathology puts the profession of pathology at risk of being deemed outside 'best practices', and hence ineligible for reimbursement. 25 It is hoped that there will be continued effort to advance 'evidence-based laboratory medicine'. 26 In…”

Section: Ebm In Anatomic Pathologymentioning

confidence: 99%

“…The entire May 2005 issue of Seminars in Diagnostic Pathology was devoted to the role of EBM in pathology. 3,4,25,[35][36][37][38][39] A key point of these articles is that the practice guidelines of surgical pathologists, including our most revered classification schemes, are generally based on 'expert opinion', representing the weakest form of evidence. 39 …”

Section: Ebm In Anatomic Pathologymentioning

confidence: 99%

Original research in pathology: judgment, or evidence-based medicine?

Crawford

2007

Laboratory Investigation

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Pathology is both a medical specialty and an investigative scientific discipline, concerned with understanding the essential nature of human disease. Ultimately, pathology is accountable as well, as measured by the accuracy of our diagnoses and the resultant patient care outcomes. As such, we must consider the evidence base underlying our practices. Within the realm of Laboratory Medicine, extensive attention has been given to testing accuracy and precision. Critical examination of the evidence base supporting the clinical use of specific laboratory tests or technologies is a separate endeavor, to which specific attention must be given. In the case of anatomic pathology and more specifically surgical pathology, the expertise required to render a diagnosis is derived foremost from experience, both personal and literature-based. In the first instance, knowledge of the linkage between one's own diagnoses and individual patient outcomes is required, to validate the role of one's own interpretations in the clinical course of patients. Experience comes from seeing this linkage first hand, from which hopefully comes wisdom and, ultimately, good clinical judgment. In the second instance, reading the literature and learning from experts is required. Only a minority of the relevant literature is published in pathology journals to which one may subscribe. A substantial portion of major papers relevant to the practice of anatomic pathology are published in collateral clinical specialty journals devoted to specific disease areas or organs. Active effort is therefore required to seek out the literature beyond the domain of pathology journals. In examining the published literature, the essential question then becomes: Does the practice of anatomic pathology fulfill the tenets of 'evidence-based medicine' (EBM)? If the pinnacle of EBM is 'systematic review of randomized clinical trials, with or without meta-analysis', then anatomic pathology falls far short. Our published literature is largely observational in nature, with reports of case series (with or without statistical analysis) constituting the majority of our 'evidence base'. Moreover, anatomic pathology is subject to 'interobserver variation', and potentially to 'error'. Taken further, individual interpretation of tissue samples is not an objective endeavor, and it is not easy to fulfill the role of a 'gold standard'. Both for rendering of an overall interpretation, and for providing the semi-quantitative and quantitative numerical 'scores' which support evidence-based clinical treatment algorithms, the Pathologist has to exercise a high level of interpretive judgment. Nevertheless, the contribution of anatomic pathology to 'EBM' is remarkably strong. To the extent that our judgmental interpretations become data, our tissue interpretations become the arbiters of patient care management decisions. In a more global sense, we support highly successful cancer screening programs, and play critical roles in the multidisciplinary management of complex patients. The true error ...

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Evidence‐based guidelines to optimize the selection of antibody panels in cytopathology: Pleural effusions with malignant epithelioid cells

Westfall¹,

Fan²,

Marchevsky³

2009

Diagnostic Cytopathology

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There is no established methodology to help select cost effective antibody panels. We used Bayesian statistics and an evidence-based pathology (EBP) approach to retrospectively review the use of immunohistochemistry (IHC) in 153 consecutive pleural effusions evaluated in our laboratory from 2005-2007 for the differential diagnosis of malignant mesothelial cells versus carcinoma cells and to estimate the likely site of origin of a carcinoma. The results in this "training" set were used to design antibody panels and test their clinical applicability on a "test set" of 44 pleural effusions collected in early 2008. Cytopathologists had used 6 +/- 4.5 IHC tests per case for the diagnosis of malignant mesothelioma (n = 9) and carcinomas of lung (n = 60), breast (n = 47), Müllerian (n = 25), and other origins in the "training set". The sensitivity and specificity of pleural cytology using all these IHC tests were 32% and 95%, respectively. Sensitivity, specificity and post-test odds (PTO) of a positive IHC result were calculated for each antibody and by the following classes: malignant mesothelial cells and carcinoma cells by primary site of origin. The antibodies that provided the best PTO to diagnose the most prevalent tumors in our population were included in diagnostic panels for male (calretinin, TTF-1, PSA and CDX-2) and female (calretinin, TTF-1, ER and CA125) patients. These panels provided 100% specificity and 77% and 50% sensitivity, respectively, for the pleural effusions from female and male patients in the "test set." The use of an EBP approach for test selection in cytopathology is discussed.

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Evidence-based medicine in pathology: an introduction

Cited by 22 publications

References 136 publications

Evidence‐based pathology and the pathologic evaluation of thymomas

Evidence‐based pathology and the pathologic evaluation of thymomas

Original research in pathology: judgment, or evidence-based medicine?

Evidence‐based guidelines to optimize the selection of antibody panels in cytopathology: Pleural effusions with malignant epithelioid cells

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