Evidence-based medicine, medical decision analysis, and pathology

Marchevsky, Alberto M.; Wick, Mark R.

doi:10.1016/j.humpath.2004.06.004

Cited by 67 publications

(33 citation statements)

References 77 publications

(34 reference statements)

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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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Evidence‐based pathology and the pathologic evaluation of thymomas

Marchevsky

Gupta

McKenna

et al. 2008

Cancer

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“…29 Marchevsky and Wick 30 are the first to examine the broader role of EBM and 'medical decision analysis' (whereby mathematical tools are used to 'reason with uncertainty') in the practice of pathology. They noted that pathologists will be well served by becoming more familiar with the basic concepts of EBM and how pathology data can be better integrated into formal medical decision analysis.…”

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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“…[1][2][3][4][5] With our nation's health care costs rapidly rising, the use of efficient, evidence-based, and cost-effective diagnostic approaches is of utmost importance. Evidence-based guidelines can help direct physicians toward tests that have substantial impact on patient diagnosis and treatment and steer physicians away from those that do not.…”

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confidence: 99%

Patterns in Immunohistochemical Usage in Extended Core Prostate Biopsies: Comparisons Among Genitourinary Pathologists and Nongenitourinary Pathologists

Plourde

Gross

Jiang

et al. 2013

Archives of Pathology &Amp; Laboratory Medicine

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Context.-Immunohistochemical (IHC) stains have known utility in prostate biopsies and are widely used to augment routine staining in difficult cases. Patterns in IHC utilization and differences based on pathologist training and experience is understudied in the peer-reviewed literature.Objectives.-To compare the rates of IHC usage between specialized (genitourinary; [GU]) and nonspecialized (non-GU) pathologists in extended core prostate biopsies (ECPBs) and the effects of diagnosis; and in cancer cases Gleason grade, disease extent, and perineural invasion on the rate.Design.-Consecutive ECPBs from 2009-2011 were identified and billing data were used to determine the number of biopsies and IHC stains per case. Diagnoses were mapped and in cancer cases, Gleason grade, extent of disease, and perineural invasion were recorded. Pathologists were classified as GU or non-GU on the basis of training and experience.Results.-A total of 618 ECPBs were included in the study. Genitourinary pathologists ordered significantly fewer IHC tests per case and per biopsy than non-GU pathologists. The rate of ordering was most disparate for biopsies of cancerous and benign lesions. For biopsies of cancerous lesions, high-grade cancer, bilateral disease, and perineural invasion decreased the rate of ordering in both groups. In cancer cases, GU pathologists ordered significantly fewer stain tests for highest Gleason grade of 3 þ 3 ¼ 6, for patients with focal disease and for patients with multiple positive bilateral cores. The effect of the various predictors on IHC ordering rates was similar in both groups.Conclusions.-Genitourinary pathologists ordered significantly fewer IHC stain tests than non-GU pathologists in ECPBs. Guidelines to define when IHC workup is necessary and not necessary may be helpful to guide workups.

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Evidence-based medicine, medical decision analysis, and pathology

Cited by 67 publications

References 77 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?

Patterns in Immunohistochemical Usage in Extended Core Prostate Biopsies: Comparisons Among Genitourinary Pathologists and Nongenitourinary Pathologists

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