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• Reply to Dr. G Stenhouse
  Frank A Carey
  Published on: 18 April 2016
• Comment on 'A Survey of colorectal cancer in Scotland: compliance with guidelines and effect of proforma reporting'.
  Dr. Grant Stenhouse
  Published on: 18 April 2016

• Published on: 18 April 2016

  Reply to Dr. G Stenhouse

  • Frank A Carey, Consultant Pathologist
  • Other Contributors:
    • Yvonne L Woods

  The correspondent points out that the RCPath standards of 2007 were written for a symptomatic population. This is not specifically stated in the standards, which were written just as the UK pilots of FOB screening were concluding. The current proposed standards (2014) are still in draft stage. It seems clear however that it will apply equally to all cancers. The issue of the effect of preoperative therapy on reporting of...

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  The correspondent points out that the RCPath standards of 2007 were written for a symptomatic population. This is not specifically stated in the standards, which were written just as the UK pilots of FOB screening were concluding. The current proposed standards (2014) are still in draft stage. It seems clear however that it will apply equally to all cancers. The issue of the effect of preoperative therapy on reporting of SI, EMVI and node number is important. Unfortunately in our retrospective audit the use of the prefix "y" in staging patients who have had preoperative therapy was not universally applied. It is also true that in many units, including our own, the pathologist is not always informed that the patient has been treated by an oncologist. A tighter prospective study is needed. It should be noted that the revised national standards do not make any allowance for the effect of chemotherapy and radiotherapy. The comment that the failure of some units to meet minimum standards "....is likely to have serious adverse consequences for patient care" is , we feel, justified. There is significant crossover in under-reporting as can be seen by inspection of the tabulated data. Unit 10 on our tables, for example, did not report serosal invasion in any rectal cancer, reports only 10% EMVI and has a mean node yield of 5 for rectum and 10 for colon. It is certain that this will have led to understaging and possibly to denial of treatment to patients who would have benefitted. I agree that electronic reporting systems would be a major asset. We would certainly hope to ask for documentation of preoperative treatment in our follow-up audit!

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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• Published on: 18 April 2016

  Comment on 'A Survey of colorectal cancer in Scotland: compliance with guidelines and effect of proforma reporting'.

  • Dr. Grant Stenhouse, Consultant Histopathologist

  Dear Editor,

  I entirely agree with the authors of 'A Survey of reporting of colorectal cancer in Scotland: compliance with guidelines and effect of proforma reporting'1 that proforma reporting should be standard across Scotland for reporting colorectal caner excision specimens. Although obvious, I feel it should be stated the 2007 RCPath dataset standards 2 were issued for a symptomatic population and, as stat...

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  Dear Editor,

  I entirely agree with the authors of 'A Survey of reporting of colorectal cancer in Scotland: compliance with guidelines and effect of proforma reporting'1 that proforma reporting should be standard across Scotland for reporting colorectal caner excision specimens. Although obvious, I feel it should be stated the 2007 RCPath dataset standards 2 were issued for a symptomatic population and, as stated in the study, these audited cases were both screening and symptomatic. Also, in their conclusions they allude to the potential impact that neo-adjuvant therapy could play in Serosal Involvement (SI), Lymph node retrieval and extramural venous invasion (EMVI) but state that this aspect could not be accurately assessed in this study. All reported cases in our Health Board are staged using TNM5 and, as such, will be prefixed with 'y' to identify them as having had neo-adjuvant therapy. If this was not known prior to reporting, a supplementary report will be issued after the case has undergone MDT discussion when the patient history is reviewed. This may be unique to our health board but, as it is part of the RCPath dataset, it should also be recorded.

  I do find the wording used in 'What this paper adds', where it states that "....this is likely to have serious adverse consequences for patient care." hard to extract from the data presented and this claim is not reported in the article by the authors themselves. The data suggests that there may be a group of patients that are falsely node 'negative' due to insufficient nodal sampling and a further group in whom the EMVI or SI is not identified. However, it does not state the cross over between these groups or if the ones 'missing' the EMVI/SI are node positive patients. Taken together this suggests that a small percentage of patients may have been excluded the option of adjuvant therapy, but without looking at specific patient outcomes and the case slides is it fair to label this as 'serious adverse consequences for patient care'?

  I do look forward to the results of the repeat data collection which will, hopefully, show proformas being used across all NHS Scotland boards as well as an uplift in the percentage of boards reaching all the standards. Further investigation of a national electronic dataset would also be welcomed especially if the data required for such audits can be extracted easily and possibly centrally from this. Given the existence of one in Norway maybe we should be moving to access that and use it throughout Scotland? I am sure the follow up audit will also take into account the influences of neo-adjuvant therapies on the audited adverse factors in the rectum, a treatment which is an established local practice, but also the emerging use of neo-adjuvant therapy in advanced colonic cancers. These data could be collated to allow reporting of all cases together and in different cohorts (Treatment naive V's neo-adjuvant) to try to identify the changes attributable to therapy.

  Conflict of Interest:

  I report GI resection specimens in a health board in Scotland that provided raw data for this survey. (Our board median nodal count is above 17 for both colonic and rectal excisions including post treatment cases)

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  Conflict of Interest:
  None declared.

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