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Characteristics associated with requests by pathologists for second opinions on breast biopsies
  1. Berta M Geller1,
  2. Heidi D Nelson2,
  3. Donald L Weaver3,
  4. Paul D Frederick4,
  5. Kimberly H Allison5,
  6. Tracy Onega6,
  7. Patricia A Carney7,
  8. Anna N A Tosteson8,
  9. Joann G Elmore4
  1. 1Department of Family Medicine, University of Vermont, Burlington, Vermont, USA
  2. 2Departments of Medical Informatics and Clinical Epidemiology and Medicine, Oregon Health & Science University; and Providence Cancer Center, Portland, Oregon, USA
  3. 3Department of Pathology, University of Vermont and UVM Cancer Center, Burlington, Vermont, USA
  4. 4Department of Medicine, University of Washington, Seattle, Washington, USA
  5. 5Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
  6. 6Departments of Biomedical Data Science and Epidemiology, Norris Cotton Cancer Center and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, One Medical Center Drive, Lebanon, New Hampshire, USA
  7. 7Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
  8. 8Norris Cotton Cancer Center and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, One Medical Center Drive, Lebanon, New Hampshire, USA
  1. Correspondence to Joann G Elmore, MD, MPH Department of Medicine, University of Washington School of Medicine, 325 Ninth Ave., Box 359780 Seattle, WA 98104, USA; jelmore{at}


Aims Second opinions in pathology improve patient safety by reducing diagnostic errors, leading to more appropriate clinical treatment decisions. Little objective data are available regarding the factors triggering a request for second opinion despite second opinion consultations being part of the diagnostic system of pathology. Therefore we sought to assess breast biopsy cases and interpreting pathologists characteristics associated with second opinion requests.

Methods Collected pathologist surveys and their interpretations of 60 test set cases were used to explore the relationships between case characteristics, pathologist characteristics and case perceptions, and requests for second opinions. Data were evaluated by logistic regression and generalised estimating equations.

Results 115 pathologists provided 6900 assessments; pathologists requested second opinions on 70% (4827/6900) of their assessments 36% (1731/4827) of these would not have been required by policy. All associations between case characteristics and requesting second opinions were statistically significant, including diagnostic category, breast density, biopsy type, and number of diagnoses noted per case. Exclusive of institutional policies, pathologists wanted second opinions most frequently for atypia (66%) and least frequently for invasive cancer (20%). Second opinion rates were higher when the pathologist had lower assessment confidence, in cases with higher perceived difficulty, and cases with borderline diagnoses.

Conclusions Pathologists request second opinions for challenging cases, particularly those with atypia, high breast density, core needle biopsies, or many co-existing diagnoses. Further studies should evaluate whether the case characteristics identified in this study could be used as clinical criteria to prompt system-level strategies for mandating second opinions.


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  • Handling editor Cheok Soon Lee.

  • Contributors BMG, HDN, PDF, JGE conceived and designed the study. DLW, KHA, HDN, BMG, JGE, PAC, TLO, AT contributed to the development of the survey and the acquisition of data. BMG, HDN, DLW, JGE, PDF contributed to the analysis. DLW, KHA, HDN, BMG, JGE, PAC, TLO, ANAT contributed to the interpretation of data. BMG, HDN, JGE, TLO, PDF contributed to drafting the manuscript. DLW, KHA, HDN, BMG, JGE, PAC, TLO, ANAT, PDF contributed to revising it critically for important intellectual content as well as approving the final version.

  • Funding This work was supported by the National Cancer Institute of the National Institutes of Health (R01 CA140560, R01 CA172343, U01CA86082, U01CA70013); and by the National Cancer Institute-funded Breast Cancer Surveillance Consortium (HHSN261201100031C). The content is solely the responsibility of the authors and does not necessarily represent the views of the National Cancer Institute or the National Institutes of Health.

  • Competing interests None declared.

  • Ethics approval The Institutional Review Boards of Dartmouth College, the Fred Hutchinson Cancer Research Center, Providence Health & Services of Oregon, the University of Vermont, and the University of Washington approved all study procedures. All participating pathologists signed an informed consent form.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The collection of cancer and vital status data used in this study was supported in part by several state public health departments and cancer registries throughout the US. For a full description of these sources, please see: Please contact the authors directly if you would like to discuss data.