Pathological Reporting of Radical Prostatectomy Specimens Following ICCR Recommendation: Impact of Electronic Reporting Tool Implementation on Quality and Interdisciplinary Communication in a Large University Hospital

Round 1

Reviewer 1 Report

The manuscript is well-written, and I really appreciated the idea of a standardized software that can improve clinical practice and scientific reports. Just a few comments:

1.     I would advise to insert the English version of the software used.

2.     I would insert patients who received neoadjuvant therapy: relevant data about staging, nodes, vesicles, and margins can be given to the surgeon even if ISUP grade is not available.

Some answers about the software itself:

3.     Is it possible to insert within the software rare entities, such us neuroendocrine neoplasm?

4.     Is it possible to insert frozen section analysis results?

Author Response

Thank you very much for your kind, thoughtful and very helpful comments. We have taken careful note of the and would like to provide you with answers below.

Reviewer 1

1. I would advise to insert the English version of the software used.

Response: Thank you for this valid comment. The used software was developed in Germany for the creation of German reports, so unfortunately there is currently no English version available. In the future, however, such a version is planned.

A comment about the template was added (page 3, lines 120-121, highlighted in yellow): “(original template, German)”.

2. I would insert patients who received neoadjuvant therapy: relevant data about staging, nodes, vesicles, and margins can be given to the surgeon even if ISUP grade is not available.

Response: We totally agree with you that the inclusion of patients who received neoadjuvant therapy could advance the study.

However, our aim was to create homogeneous cohorts to allow for good comparability. The requirements for radical prostatectomy findings with and without neoadjuvant therapy show clear differences and thus lead to poorer comparability and might create bias. In our evaluation scheme based on the ICCR guidelines, the number of relevant findings differs between patients with primary resection and patients that received neoadjuvant therapy. For this reason, we decided to exclude the patients with neoadjuvant therapies from our study.

Some answers about the software itself:

3. Is it possible to insert within the software rare entities, such us neuroendocrine neoplasm?
4. Is it possible to insert frozen section analysis results?

Response:  Thank you for your interest in our software, these are very interesting and valid questions. In principle, both questions can be answered with "yes".

The software can be used to create all kind of pathology reports. Here we decided to create a template based on the current ICCR protocol. Due to the template creator, the software is flexible and can be adapted and all kind of additional findings (e.g. non-typical subtypes or additional analysis results such as frozen section) can be inserted.

Reviewer 2 Report

The authors compare in a retrospective cohort the narrative pathology reports (NR) of radical prostatectomy specimens with a prospective cohort of standardized structured reports (SSR) also on radical prostatectomy specimens. The study is interesting showing the weaknesses of NR.

Before accepting the manuscript for publication, the authors should address the following questions and comments:

-          Why were the NR done as a retrospective study involving 12 different pathologists (I assume not aware of the study design and purpose) and the SSR as a prospective study where the reading was performed by one single experienced pathologist (presumably aware of the purpose of this study)?

In a pilot study like this it would be more reasonable to assign both reading techniques (NR and SSR) to a balanced number of pathologists (not in a ratio of 12 to 1).

-          The NR cohort had 101 cases and the SSR cohort 33 cases, 134 combined (3 cases were later excluded, n = 131). However, the clinician’s perception part of the study was done on 62 cases only (30 NR and 32 SSR).

a.)     For the reader it is not well explained, whether these 62 cases are recruited from the same previous 131 cases, or were these 62 cases recruited separately. The authors should specify this issue in ‘Materials and Methods’.

b.)    The authors should also explain why the clinician’s perception part of the study was not done on all of the previous 134 cases (101 NR and 33 SSR)?

-          In the Discussion section the authors mention that SSR studies were also performed in other institutions/countries. The authors should provide more details of these other SSR study results and directly compare them with their study results (were the other SSR studies also done on radical prostatectomies?).  

Author Response

Reviewer 2:

The authors compare in a retrospective cohort the narrative pathology reports (NR) of radical prostatectomy specimens with a prospective cohort of standardized structured reports (SSR) also on radical prostatectomy specimens. The study is interesting showing the weaknesses of NR.

Before accepting the manuscript for publication, the authors should address the following questions and comments:

• Why were the NR done as a retrospective study involving 12 different pathologists (I assume not aware of the study design and purpose) and the SSR as a prospective study where the reading was performed by one single experienced pathologist (presumably aware of the purpose of this study)? In a pilot study like this it would be more reasonable to assign both reading techniques (NR and SSR) to a balanced number of pathologists (not in a ratio of 12 to 1).

Response: This is a very valid point with completely correct assumptions.

In the retrospective part of the study reports from 12 different pathologists, that were not aware of the study design and purpose, were included, since we took already existing reports on radical prostatectomy specimens unselected from those reaching the pathology department every day in a selected time period. Thus the retrospective part closely reflects the daily work in a large pathology institution.

The prospective part of the study was performed by a single pathologist who was aware of the purpose of this study, as at that time only one pathologist was using this innovative software to generate pathological reports. As the used software is not yet integrated into the system of the pathological departments daily business, this innovative approach served as a proof of concept.  Given the positive outcome of the study, further implementation of the software is planned.  

• The NR cohort had 101 cases and the SSR cohort 33 cases, 134 combined (3 cases were later excluded, n = 131). However, the clinician’s perception part of the study was done on 62 cases only (30 NR and 32 SSR).

• For the reader it is not well explained, whether these 62 cases are recruited from the same previous 131 cases, or were these 62 cases recruited separately. The authors should specify this issue in ‘Materials and Methods’.
• The authors should also explain why the clinician’s perception part of the study was not done on all of the previous 134 cases (101 NR and 33 SSR)?

Response: Thank you for pointing this out. For the clinician´s perception part of the study, all 32 SSR cases were compared to a total number of 30 out of 99 NR cases (randomly selected, neoadjuvant cases were excluded from the study). After careful consideration and critical discussion with experts in the field, we decided to include a balanced number of SSR and NR reports for this part of the study to avoid bias. The selection process has now been clearly stated in the Material and Methods section (page 4. Lines 144-145): “To investigate clinician’s perception, 62 reports (all 32 SSR and 30 NR reports, randomly selected from the NR cohort) were evaluated.”

• In the Discussion section the authors mention that SSR studies were also performed in other institutions/countries. The authors should provide more details of these other SSR study results and directly compare them with their study results (were the other SSR studies also done on radical prostatectomies?).

Response: It is true that there are some other studies on standardized structured reporting (see introduction). However, as our study is the first study based on the ICCR template for radical prostatectomy specimens, most of the other studies already published show a completely different focus, which makes comparability difficult. Moreover, we present the first study using the described software for pathological reporting- Nevertheless, the relevance of the topic is supported by the diversity of these studies.