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Breast Cancer Awareness Q&A with Pathologist Malini Harigopal, MD

October 13, 2021

As we honor breast cancer awareness month, what do you want our patients and families to pause and remember?

Patients and their families need to be aware that although patients almost never meet the pathologist who read their report, as they work “behind the scenes,” pathologists work in close communication with clinical teams to define optimal treatment strategies tailored to each individual patient’s need.

One of the crucial responsibilities of a breast pathologist is to provide a complete and detailed pathologic evaluation of breast tumors. The first question a breast pathologist looks to answer when reading a breast biopsy is whether cancer is present. But the information included in the pathology report goes far beyond the “yes” or “no” diagnosis. Even if a biopsy is benign, we need to ensure that the calcifications seen on imaging correlate with calcifications seen on the core biopsy pathology specimen. The earliest stage of breast cancer, called ductal carcinoma in situ (DCIS), is usually detected in this manner. The patient’s tumor characteristics are reviewed at a weekly tumor board in a multidisciplinary setting to determine effective treatment options. In addition to comprehensive studies and attention to detail to ensure accuracy, difficult diagnoses are reviewed at a daily consensus conference where challenging cases, which includes borderline cases of atypical ductal hyperplasia versus carcinoma and rare or unusual types of breast cancer are discussed. These meetings serve as a sort of “second opinion” that is built into the system at Smilow Cancer Hospital.

How do you collaborate with the Breast Cancer team at Smilow Cancer Hospital to care for your patients?

Pathologists do not work in isolation. Following a patient’s diagnosis of cancer on core needle biopsy, pathologists work with radiologists to address any discordant findings with imaging. For example, if the imaging findings are suspicious and the tissue shows benign findings, pathologists and radiologists communicate to resolve these discrepancies in weekly multidisciplinary radiology pathology conferences. Breast cancer cases which need a multidisciplinary management are discussed at the breast tumor board where experts from various specialties from Smilow Cancer Hospital meet to review treatment options, including surgeons, radiologists, pathologists, and medical and radiation oncologists. At these tumor boards pathologists review slides that will have the potential to impact further management, especially if the cancer is present at the margins and therefore a decision to surgically take additional margins or radiation therapy is made. Important pathology findings such as the number of lymph nodes with metastatic carcinoma and biomarker status is determined.

How do you connect with clinicians treating patients with breast cancer to bridge laboratory research to clinical care?

One of the crucial responsibilities of a breast pathologist is to provide a complete, detailed pathologic evaluation of breast tumors. Key information about traditional pathologic factors such as tumor stage and ER, PR and HER2 status in breast cancers is incorporated into the pathology report. We provide standardized high-quality assays, which reduce the likelihood of false positive or negative results, by participating in quality assurance programs in a CLIA certified laboratory.

As we move closer to the era of targeted therapy, each individual patient’s tumor is identified with its own unique signature and can be further investigated by sophisticated molecular gene expression profiling, which is available here at Yale. The patient’s tumor characteristics are reviewed in a multidisciplinary setting at the weekly tumor board to determine effective treatment options.

Mentorship is an important part of clinical research—what is your favorite way to keep your team engaged, and learning from one another?

A dedicated breast program comprised of an excellent team of breast pathologists with specialized training is important for accurate and precise diagnosis of both benign and malignant breast samples.

The breast team meets daily at the consensus conferences to review borderline and diagnostically challenging cases. Pathologists with different levels of experience receive guidance and mentorship from more senior members of the team. In addition, regular breast team meetings are held where pathologists participate in discussing recent updates in guidelines and choose articles to discuss at monthly journal club. At these meetings discussion includes workflow, clinician feedback, addressing grossing issues, turnaround time, and encouraging faculty participation in national conferences and breast courses.

Submitted by Renee Gaudette on October 13, 2021