Family physicians routinely perform minor surgery to remove tissue. The conventional advice that all tissue should be examined pathologically has been challenged on the grounds that this is a wasteful use of resources. Lowy and colleagues studied 257 general practices in England to assess the rate of detection of clinically important lesions and the costs associated with a policy to examine all tissues.
Nineteen regional pathology laboratories in England agreed to take part in the study. For each laboratory, between eight and 18 referring general practices were randomly selected to participate. These practices agreed to send all tissue removed during a six-month period. The volume and histologic significance of these specimens were compared with tissue sent by the same practices during a six-month period in the previous year.
The 257 practices included 914 general practitioners who submitted 10,153 specimens during the study period. This was a 29 percent increase over the number of specimens submitted during the control period. During the study period, 98 premalignant lesions were detected; 91 lesions were detected during the control period. For malignant lesions, 188 were submitted during the study period and 204 were submitted during the control period. These differences were not statistically significant. The number of referrals for viral warts, seborrheic keratoses and ingrown toenails increased significantly during the study period (2,886 compared with 1,729 during the control period); referral of other benign lesions also increased significantly, from 2,409 during the control period to 2,720 during the study period.
The authors conclude that a policy of “send all tissue” resulted in a significantly increased workload for the laboratories, all of which was accounted for by nonserious lesions. No evidence was found of a change in the detection rate of malignant or premalignant lesions. The authors believe that the study validates the premise that family physicians can appropriately biopsy and send malignant lesions for pathologic examination while selectively discarding other material. In particular, the authors discuss concerns of underdiagnosis of melanoma under a policy of “selective” submission of tissue for pathologic diagnosis. In Great Britain, the impact of increased patient education, availability of clinics for pigmented lesions and comprehensive general practitioner coverage of the population is believed to provide effective mechanisms for detection of melanoma. The authors recommend continuing to send selected specimens from general practices to pathology laboratories and estimate the annual savings to be nearly $7 million.