With respect, I disagree. Of course I agree with the premise that we as pathologists are not optimally consistent when it comes to atypical ductal lesions. However, the vitriol that many pathologists (including myself) are expending to bring to light the flaws with this study is not undue, nor misplaced. We don’t need to rehash all the reasons why it’s not a valid study. The more important issue at hand is the court of public opinion. Once this study broke the newspapers latched on and put some poor woman’s face to accompany a hatchet article about how pathologists are as good as guessing with your breast biopsies.

I don’t agree with the analogy of the board exam. The stakes are very different. If you don’t pass your boards you can take it again, no harm, no foul. Even if you never get it right the worst that happens is that you don’t get board-certified. Get a breast biopsy wrong and the outcomes are different. I think a more apt analogy (and one that is pertinent) is the pap smear. A similar furor arose over the diagnoses rendered on cervical cytology specimens and now we have a mandated annual exam to take in order to diagnose cervical cytology specimens. I think we can all agree that particular test is not an assessment of how well we can diagnose paps. It’s a ridiculous regulatory hoop that takes time and money from practicing pathologists without ultimately benefiting patients.

This brings me to the final point. If the article is taken seriously it’s not unreasonable to draw the conclusion that more regulation is needed with the diagnosis of breast biopsy specimens. It may be cynical of me, but precedent has been set as mentioned above with paps. One day there may be mandatory pathologist proficiency testing to sign out breast biopsy specimens. Time and money that doesn’t benefit patients, but rather lines the pockets of the regulatory organizations. Even more cynical of me would be to note that perhaps it will be required that all atypical cases are reviewed by an “expert”. And who certifies these experts? Regulatory organizations for a price. Or the ultimate in cynicism – you can send your cases to a national expert, such as one of the experts who was a pathology contributor to the paper.

Bottom line – my opinion is that it’s in JAMA not because it’s good, but because it’s big and controversial. If we accept its conclusions we move further down a shady path to perdition for our specialty. I refute the paper conclusions because they are drawn on poor study design. If we don’t speak out as a specialty as such we risk being railroaded into more regulation without benefit to patients.