The 2009 version of the cancer protocols of the college of american pathologists.

Abstract

In recent years, breathtaking advances in cancer have occurred at many levels such that the management of patients with cancer often emanates from complex therapeutic decisions that are made based on input from a multidisciplinary team of surgeons, oncologists, radiation oncologists, pathologists, and radiologists. The culmination of the professional assessment of a pathologic specimen resected for cancer is reflected in the form and content of the pathology report. Embodied within the report is a synopsis of the cornerstone of our evaluation—gross pathology, microscopic examination, and use of ancillary diagnostic modalities. The latter have evolved in recent years from being primarily diagnostic to having prognostic and predictive value such that they have become an integral component of the pathology report for some cancers. In the contemporary era of personalized molecular medicine, this list is only apt to grow exponentially. Given the increasing critical role of pathology reports in determining prognosis, adjuvant therapies, and overall management, there has been a greater emphasis on the accuracy, completeness, and timeliness of the pathology report. A little less than 25 years ago, the Cancer Committee of the College of American Pathologists (CAP) recognized the great heterogeneity in the reporting of resected cancer specimen findings such that often critical elements required for patient management were incomplete or missing from the report. To address this issue the Cancer Committee of the CAP, in 1986, published the first set of protocols on breast cancer, bladder cancer, and Hodgkin disease. In the ensuing years, protocols for several major cancer sites were published in the Archives of Pathology & Laboratory Medicine primarily with the aim of being guidelines and a resource tool for pathologists. A compendium of several major protocols was first published as a single offering by the CAP in September 1998 (Table 1). In this offering, a conscious effort was made to develop the protocols as a resource tool for pathologists and not as form of marching orders. Reporting in a checklist or synoptic format was encouraged for completeness and consistency. As more protocols were being developed during the last decade, and with the growing complexity of information included in a pathology report, there was increased recognition within our community of the need to present relevant pathologic information in a synoptic style of reporting. Many institutions began developing their own synoptic reports, or checklists, often using CAP’s protocols as a reference tool. The Association of Directors of Anatomic and Surgical Pathology also released its recommendations for common cancer pathology reporting and served as an additional valuable resource. Each published cancer protocol consisted of a background documentation section (a long comprehensive list of elements to be reported including demographics and clinical information, gross and microscopic findings, and ancillary studies), explanatory notes, references, and a short form or checklist. The response to the protocols from the community ranged from the view that they were an outstanding resource tool to the opinion that protocols promoted excessively long documents and that any form of protocol implementation was overly time consuming in a climate of increasing work and decreasing compensation. Other potential drawbacks that were discussed include inhibition of thoughtful and systematic evaluation of a case that would also be detrimental to resident education, the end of the consultative expression of the ‘‘art of pathology’’ and the personalized nature of a pathologist’s evaluation, making it more objective and uniform in appearance. There was fear that there would be increased need for sophisticated laboratory information systems, which would be expensive to implement, and potential increase in transcription errors. Despite the controversies and inconsistent use of protocols, the benefits of synoptic reporting became steadily recognized with increased acceptance. The American College of Surgeons (ACS) Commission on Cancer (COC) initially endorsed voluntary use of the cancer protocols but indicated a desire to implement mandatory use of the CAP protocols beginning in 2002 with expected compliance in 2003 for ACS COC accreditation. Because of the complexity of requiring a large Accepted for publication November 9, 2009. From the Department of Pathology and Laboratory Medicine, CedarsSinai Medical Center, Los Angeles, California. The author has no relevant financial interest in the products or companies described in this article. Reprints: Mahul B. Amin, MD, Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Suite 8728, Los Angeles, CA 90048 (e-mail: aminm@cshs.org). Editorial