Elsevier

Human Pathology

Volume 35, Issue 10, October 2004, Pages 1179-1188
Human Pathology

Perspectives in pathology
Evidence-based medicine, medical decision analysis, and pathology

https://doi.org/10.1016/j.humpath.2004.06.004Get rights and content

Abstract

Recent advances in molecular pathology and other technologies such as proteomics present pathologists with the challenge of integrating the new information generated with high-throughput methods with current diagnostic models based mostly on histopathology and clinicopathologic correlations. Parallel developments in the field of medical informatics and bioinformatics provide the technical and mathematical methods to approach these problems in a rational manner. However, it remains unclear whether pathologists or other medical specialists will become primarily responsible for the development and maintenance of these multivariate and multidisciplinary diagnostic and prognostic models that are hoped to provide more accurate, individualized patient-based information. Evidence-based medicine (EBM) and medical decision analysis (MDA) are relatively new disciplines that use quantitative methods to assess the value of information, differentiate fact from myth, and integrate so-called best evidence into multivariate models for the assessment of prognosis, response to therapy, selection of laboratory tests, and other complex problems that influence individual patient care. We review from an epistemological viewpoint the current approach to information in pathology and describe some of the concepts developed by the practitioners of EBM and MDA.

Section snippets

Do pathologists, internists, and surgeons read comparable literatures?

A review of the current medical literature may reveal information that is surprising to some pathologists. For example, there is a significant gap in perception regarding the features of neoplasms that are felt to be important by pathologists and those on which internists and surgeons tend to focus. For example, the most recent edition of Prognostic Factors in Cancer, published by the International Union Against Cancer (UICC), categorizes, in a chapter written principally by oncologists, lung

The current state of the art of pathology practice: an epistemological view

Epistemology is the branch of philosophy that studies knowledge itself and attempts to address fundamental questions pertaining to it; for example, what distinguishes true or adequate knowledge from false or inadequate information?23, 24, 25 Longstanding theoretical questions can be translated into inquiries regarding scientific methodology. For example, which is the best method for integrating variables into an adequate theory or model, and how does one optimally evaluate the relative values

Need for an evidence-based approach in pathology; decision analysis theory in integration of complex information

Pathology is certainly not the only clinical specialty that is being challenged by an explosion of information. Our colleagues in other areas face similar problems in using new diagnostic procedures and in assimilating new medications and other treatments. EBM and MDA have been developed to address these challenges with quantitative methods derived from statistics, epidemiology, and information science.9, 38 A survey of the Internet with a standard search engine yields a robust representation

Evidence-based medicine

EBM has been defined by Sackett and associates as “the integration of best research evidence with clinical expertise and patient values”.8, 9, 10, 38, 44, 58, 59, 60, 61, 62, 63, 64, 65, 66 It is an evolving discipline that applies the analytical and quantitative methods of statistics, epidemiology, and information science (“informatics”). The overall goal of EBM is to replace the traditional authority-based paradigm of medical education with an analytical approach predicated on the analysis of

How is medical information approached from the standpoint of EBM?

Sackett & associates9 have suggested the use of 5 steps for the integration of designated best-research evidence with clinical expertise and clinical values. The first involves the formulation of specific questions regarding diagnosis, prognosis, causation, and other aspects of any given clinical problem. The second concerns a search for information in the scientific literature that specifically addresses those questions. The third step involves a critical appraisal of the validity of the

Medical decision analysis

There is now an interest in understanding the concept of intelligence, as a result of advances in computer technology.26, 27, 28 Several cyberapproaches have attempted to simulate the abilities of the human brain with mathematical tools such as algorithms, multivariate statistics, artificial neural networks, fuzzy logic, and Bayesian belief networks.30, 31 The ubiquity of personal computers has also broadened the use of statistical tools, as made available in spreadsheet and other software.

Development of the database infrastructure needed to perform population-based studies of large patient cohorts

The future development of diagnostic and prognostic tools based on MDA techniques requires the availability of large amounts of data, necessary for the design of grade I and II studies. That type of information is difficult to collect, and a need exists for pathologists to improve the manner in which the information in pathology reports is stored in laboratory information systems.80, 81 Current text information is fraught with incomplete data and somewhat inaccurate terminology that is

Assessment of the clinical relevance of new immunohistochemical and molecular tests in clinicopathologic subsets of patients with a disease

A critical review of the literature regarding the use of “new and promising” prognostic-predictive markers, such as the immunohistochemical assessment of invasive breast carcinomas for overexpression of the HER-2/neu/c-erbB-2 gene, provides a good example of how pathology practice could benefit from a more critical approach to the incorporation of new tests into practice.

The Her-2/neu gene codes for a transmembrane tyrosine kinase receptor that is closely related to the epidermal growth factor

Acknowledgements

The authors thank Dr. Ann Walts and Dr. John Srigley for critically reviewing the manuscript.

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