Missing Elements in Surgical Pathology Reports: Breast, Colon and Stomach Cancers


Pathology, Iran University of Medical Sciences, Tehran, Iran


Cancer pathology reports play an important role in choice of patient care. They provide crucial information concerning diagnosis, therapy options, and prognosis. Professional pathology institutions, such as the College of American Pathologists (CAP), have developed checklists to ensure the presence of all the required elements in reports. In this study, 438 surgical pathology reports of patients with breast (148), colon (147), and stomach cancer (143) were evaluated with respect to the presence of mandated elements according to CAP checklists. The most common missing element in all the three types of cancer was 'staging' (73.6, 53.1, and 56.6% in breast, colon, and stomach cancer reports missed 'staging', respectively). The second most missing element was 'tumor site' in breast (64.2%) and stomach cancer (30.1%), and 'procedure' in colon cancer (29.3%). 'Perineural invasion' was the third most missing element in the three types of cancer (25.7, 17.0, and 22.4% in breast, colon, and stomach cancer, respectively). Only 11.4% of reports included all key elements required by CAP. The use of checklists was associated with higher rate of completeness. This study demonstrates that the key elements requiring the information on the requisition forms from the clinicians are commonly missed, leading to ambiguity.