Dermatology World: I’m sure many of our dermatopathology colleagues are familiar with your recently published study, but for those who may have not yet read it, can you describe your study design? What questions were you seeking to answer?
Dr. Shinohara: Pathology reports are important for documenting results but are also a form of communication between those who perform the biopsies (“clinicians”) and the pathologist who is reading the slide. There’s often a “coded language” of terms that may only be understood when there is a longstanding relationship between pathologists and clinicians. As a clinician and dermatopathologist myself, I have seen issues arise from both sides, particularly when this coded language isn’t clear.
By definition, biopsies are performed in order to make a diagnosis and help formulate a treatment plan. Given this, there is controversy as to whether margins on biopsies should be reported at all. Many pathologists do include comments on margins for biopsies, though, because it can be helpful to the treating clinician’s medical decision making. We hypothesized that the specific words used to describe margins are vitally important and can even change clinician behavior.
In order to look at this, we surveyed the stakeholders (clinicians) about their preferences around reporting of margins. We showed them images of basal cell carcinomas (BCCs) and asked how they would describe the margin status. Then we gave some clinical scenarios of squamous cell carcinomas (SCCs) with different ways of describing the same margin status (some more ambiguous, such as “approximates margin,” and some unambiguous, such as “margin free”) and asked how the clinician would manage the SCCs differently, if at all.
Dermatology World: Briefly, what were your major findings?
Dr. Shinohara: We found that most clinicians surveyed preferred that margins be included in their dermatopathology reports, particularly for malignancies like BCC and SCC. Those surveyed also had a preference for unambiguous language to describe margins, such as “margin involved/margin positive,” and “margin free/margin negative.” This was especially true if the margin is involved. Similarly, we found that when posed with margins described in an ambiguous way, clinicians showed more variance in how they might manage a skin cancer compared to when they are presented with margins in an unambiguous way, validating our hypothesis.
“We were surprised that the majority (82%) indicated that they want pathologists to include treatment recommendations in their pathology reports. I think this highlights the desire for clinicians to partner with their pathologists in the care of their patients.”
─ Michi Shinohara, MD
Dermatology World: Were you surprised by any of the responses?
Dr. Shinohara: We were surprised that the majority (82%) indicated that they want pathologists to include treatment recommendations in their pathology reports. I think this highlights the desire for clinicians to partner with their pathologists in the care of their patients.
Dermatology World: You queried both physicians and advanced practice providers (APPs). Did you distinguish between their responses and, if so, did you note any differences in their preferences?
Dr. Shinohara: We did distinguish between these groups, however, weren’t able to make any conclusions as the number of APPs in the survey sample was too small.
Dermatology World: I was as surprised as you were to see that most of your respondents value microscopic reports. Does this argue against the use of templated reports?
Dr. Shinohara: I think it highlights that clinicians want to know what the pathologist is thinking, not just get a diagnosis. If there is a good relationship between the pathologist and clinician, it probably doesn’t matter as much how the report is formatted. In this busy world, though, the clearer we dermatopathologists can be, the better it will be for patients and clinicians.
Dermatology World: Did this study make you rethink the way you report your biopsy results?
Dr. Shinohara: Although this was a small group and likely subject to regional preferences, my take-home is to use “unambiguous” terms whenever possible when reporting margins for BCCs and SCCs. Not all situations in life or medicine are clear, of course, but we, as dermatopathologists can help by not using veiled language.
Michi Shinohara, MD, is associate professor at the University of Washington Dermatology Division, Michael W. Piepkorn Endowed Chair in Dermatologic Research, director of Inpatient Dermatology Consultation Service at the University of Washington Medical Center, and associate residency program director. Dr. Shinohara does not have any relevant financial or commercial conflicts of interest.
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