The Institutional Review Board at the Medical University of South Carolina (MUSC) approved this study. We performed a retrospective observational analysis of patients who presented to the MUSC Hollings Cancer Center for evaluation from August 2015 to March 2016 with a diagnosis of stages 0–3 breast cancer. This review included only patients with a diagnosis determined outside MUSC who were referred or self-referred for a second opinion.
All second-opinion patients had pathology slides and radiologic imaging reviewed by fellowship-trained breast radiologists and pathologists and were presented at an MTB. The breast cancer MTB at MUSC is a weekly collaborative meeting of surgical oncologists, medical oncologists, radiation oncologists, radiologists, pathologists, genetic counselor, and nurse navigators. The physician to whom the patient was referred, typically the surgical oncologist, presents the patient.
Zip codes were obtained, and using the Health Resources & Services Administration database,11 we were able to stratify our patient population into the lowest and highest health care-funded counties in South Carolina. The radiology reports were reviewed to ascertain whether the first opinion was obtained at an academic medical center (a hospital affiliated with a medical school).
We compared the outside radiology reports with the reports generated by MUSC radiologists. Changes in diagnosis as a result of additional assessment or imaging were noted. This included additional imaging recommended, additional biopsies recommended, and additional new cancer diagnosed in the ipsilateral or contralateral breast or axillary lymph node. Change in pathologic diagnosis was assessed by comparing the outside pathology report with the MUSC pathology report. The recommendation for genetic counseling was obtained from the outside physicians’ notes and compared with the review at our MTB to determine whether the patient met the NCCN guidelines for genetic testing or not.
Outside films were reviewed in a radiology consensus conference at MUSC that consisted of board-certified radiologists, all of whom had completed fellowship training in breast radiology. When necessary, additional views were recommended and ordered, including mammograms, breast or axillary ultrasound, or breast magnetic resonance imaging (MRI). Based on this review, some patients were scheduled to undergo stereotactic core biopsy, ultrasound-guided core biopsy of the breast or axilla, or MRI-guided biopsy (of either the ipsilateral or contralateral breast). The parameters analyzed for radiology were change in tumor size, new lesion, new calcifications, additional views recommended (mammogram, breast ultrasound, axillary ultrasound, breast MRI), additional biopsy performed (stereotactic, breast ultrasound, axillary ultrasound, or MRI-guided biopsy), additional cancer diagnosed in the ipsilateral breast, additional contralateral breast cancer diagnoses, and new axillary metastases identified.
Pathology was reviewed by board-certified pathologists with specialization in breast cancer. Hormone receptors for estrogen, progesterone, and human epidermal growth factor 2 (HER2)neu were evaluated but not routinely repeated unless the internal control was negative or unless HER2neu was equivocal. The data for pathology were assessed for change in histology, change in tumor grade, change in tumor size, and change in ER, PR or HER2/neu status.
Genetic Testing Review
All the patients were reviewed by the tumor board to determine whether a referral for genetic counseling was indicated. We identified the number of patients who met the NCCN guidelines for genetic testing but did not have this offered at the initial institution. Patients who saw the genetic counselor at MUSC and met the NCCN guidelines for genetic testing were offered genetic testing.