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Physicians: .25 AMA PRA Category I CreditsTM
Family Physicians: .25 Prescribed credits
Nurse Practitioners: .25 Contact hours

Release Date: March 25, 2015
Expiration Date: March 25, 2016

Estimated Completion Time: 15 minutes

There is no fee for this activity.

To Receive Credit

In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon above.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:

1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.

Faculty Information

Alan Ehrlich, MD
Assistant Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Executive Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP
Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company


Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

No commercial support has been received for this activity.

Accreditation Statements

ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint providership of Antidote Education Company and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: This enduring material activity, DynaMed EBM Focus Volume 9, has been reviewed and is acceptable for up to 15.25 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 5, 2014. Term of approval is for one year from this date. Each EBM Focus is approved for .25 Prescribed credits. Credit may be claimed for one year from the date of each update. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AANP: This program is approved for 0.25 contact hour(s) of continuing education by the American Association of Nurse Practitioners. This program was planned in accordance with AANP CE Standards and Policies and AANP Commercial Support Standards. Program ID: 1405237T2

Last week 716 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 221 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to inform clinical practice," one article was selected by the DynaMed Editorial Team.

Atypical Hyperplasia on Breast Biopsy may be Misinterpreted by Experienced Pathologists

Reference: JAMA 2015 Mar 17;313(11):1122

Breast cancer is the most common form of cancer and second leading cause of cancer deaths in women in the United States (J Natl Cancer Inst 2011 May 4;103(9):714).  Increased mammography screening has increased the diagnosis of early stage breast cancer over the last 30 years, but overdiagnosis is common (N Engl J Med 2012 Nov 22;367(21):1998).  While approximately 25% of breast biopsies have been reported to diagnose invasive carcinoma, most biopsy specimens result in a diagnosis of benign or precancerous lesions (Cancer 2006 Feb 15;106(4):732). A recent study evaluated the rate of diagnostic inaccuracies of 240 breast biopsy samples evaluated by 126 pathologists from across the United States.

Excisional or core needle biopsy samples were randomly selected from a registry of 19,498 cases based on the original diagnosis, patient age, breast density, and biopsy type. The consensus diagnosis from a panel of 3 expert pathologists served as the reference standard, with a consensus diagnosis of invasive breast cancer in 10%, ductal carcinoma in situ (DCIS) in 30%, atypical hyperplasia in 30%, and benign without atypia in 30%. All 126 individual pathologists participating in the study had ≥ 1 year of experience interpreting breast biopsy specimens and planned to continue for ≥ 1 additional year. Each participating pathologist was randomized to 1 of 4 test sets containing 60 samples each, with a single slide for each case. Of the 126 pathologists randomized, 115 (91%) completed the assessment of all 60 slides in their assigned test set and these 6,900 interpretations were compared to the expert consensus for each specimen.

Overall concordance between the expert panel diagnosis and the individual pathologist interpretation was 75.3%. The rate of concordance as well as the rate of overinterpretation and underinterpretation can be found in the table below.
Reference Diagnosis Rate of Concordance Rate of Underinterpretation Rate of Overinterpretation
Invasive Carcinoma 96% 4% ---
DCIS 84% 13% 3%
Atypical hyperplasia 48% 35% 17%
Benign without atypia 87% --- 13%

While the rate of concordance was very high for invasive carcinoma, with only 4% of cases misinterpreted as DCIS, the concordance rate drops considerably for atypical hyperplasia, with most misinterpretations resulting in an underinterpretation of the disease as a benign biopsy. Misinterpretation was not limited to a few specific pathologists or specific cases, but was found to be more widely distributed. Higher rates of disagreement were significantly associated with increased breast density and pathologist characteristics including lower weekly case volume, smaller practices, and nonacademic settings.

The results of this study suggest that while pathologists generally agree upon interpretation of invasive carcinoma samples, their interpretations of precancerous lesions may be more variable. Pathologists based their diagnosis on a single specimen, however, and in practice pathologists usually review multiple specimens before establishing a diagnosis. This limitation may have contributed to the variability observed, especially for diagnoses with less standardized criteria. Decreasing variability in biopsy diagnosis is important as overinterpretation may lead to unnecessary treatment and underinterpretation may withhold necessary treatments or decrease surveillance in patients with precancerous lesions. While further studies may be necessary to determine ways to better identify atypical histological features, a second opinion may increase the reliability of diagnosis and help prevent incorrect treatment.

For more information, see the Breast cancer in women topic in DynaMed.

DynaMed Introduces New and Improved Mobile App

DynaMed users can now access valuable, evidence-based content anywhere with the new DynaMed mobile app. The new app has been redesigned to make it easier and faster for physicians to find answers to clinical questions. The app features an improved user experience, seamless authentication and easy access to the latest clinical content. It provides offline access, and the ability to denote favorites, email topics and write and save notes about particular topics. Users download the complete DynaMed content set and periodically receive notifications to update the content.

The DynaMed app is a complimentary part of personal and institutional DynaMed subscriptions. The app has also been designed for easy, one-time authentication via email, making the process as convenient as possible.

The app can be downloaded from the iTunes Store or Google Play. For more information, please visit the DynaMed Mobile Access page.

DynaMed Careers

The DynaMed editorial team is seeking specialist editors in the following fields: Gastroenterology, Nephrology, Oncology (especially Breast cancer and Pancreatic cancer), Ophthalmology, and Pediatric Neurology.

If interested, please send a recent copy of your CV to Rachel Brady at rbrady@ebsco.com.

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