Second opinion strategies in breast pathology: a decision analysis addressing over-treatment, under-treatment, and care costs

Anna N.A. Tosteson, Qian Yang, Heidi Nelson, Gary Longton, Samir S. Soneji, Margaret Pepe, Berta Geller, Patricia (Patty) Carney, Tracy Onega, Kimberly H. Allison, Joann G. Elmore, Donald L. Weaver

Research output: Contribution to journalArticle

5 Scopus citations


Purpose: To estimate the potential near-term population impact of alternative second opinion breast biopsy pathology interpretation strategies. Methods: Decision analysis examining 12-month outcomes of breast biopsy for nine breast pathology interpretation strategies in the U.S. health system. Diagnoses of 115 practicing pathologists in the Breast Pathology Study were compared to reference-standard-consensus diagnoses with and without second opinions. Interpretation strategies were defined by whether a second opinion was sought universally or selectively (e.g., 2nd opinion if invasive). Main outcomes were the expected proportion of concordant breast biopsy diagnoses, the proportion involving over- or under-interpretation, and cost of care in U.S. dollars within one-year of biopsy. Results: Without a second opinion, 92.2% of biopsies received a concordant diagnosis. Concordance rates increased under all second opinion strategies, and the rate was highest (95.1%) and under-treatment lowest (2.6%) when all biopsies had second opinions. However, over-treatment was lowest when second opinions were sought selectively for initial diagnoses of invasive cancer, DCIS, or atypia (1.8 vs. 4.7% with no 2nd opinions). This strategy also had the lowest projected 12-month care costs ($5.907 billion vs. $6.049 billion with no 2nd opinions). Conclusions: Second opinion strategies could lower overall care costs while reducing both over- and under-treatment. The most accurate cost-saving strategy required second opinions for initial diagnoses of invasive cancer, DCIS, or atypia.

Original languageEnglish (US)
Pages (from-to)1-9
Number of pages9
JournalBreast Cancer Research and Treatment
Publication statusAccepted/In press - Sep 6 2017



  • Breast cancer diagnosis
  • Cost
  • Decision analysis
  • Overdiagnosis
  • Pathology
  • Second opinion

ASJC Scopus subject areas

  • Oncology
  • Cancer Research

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