Human Pathology (2014) 45, 2192–2201

www.elsevier.com/locate/humpath

Education in pathology

Surgical pathology and the patient: a systematic review evaluating the primary audience of pathology reports☆,☆☆ Matthew Mossanen MD a,⁎, Lawrence D. True MD b , Jonathan L. Wright MD, MS a , Funda Vakar-Lopez MD b , Danielle Lavallee PhD c , John L. Gore MD, MS a a

Department of Urology, University of Washington, Seattle, WA 98195, USA Department of Pathology, University of Washington, Seattle, WA 98195, USA c Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle, WA 98195, USA b

Received 27 May 2014; revised 30 June 2014; accepted 9 July 2014

Keywords: Patient-centered outcomes research; Pathology report; Surgical pathology; Cancer; Communication

Summary The pathology report is a critical document that helps guide the management of patients with cancer. More and more patients read their reports, intending to participate in decisions about their care. However, a substantial subset of patients may lack the ability to comprehend this often technical and complex document. We hypothesized that most literature on pathology reports discusses reports from the perspective of other physicians and not from the perspective of patients. An expert panel of physicians developed a list of search criteria, which we used to identify articles on PubMed, MEDLINE, Cochrane Reviews, and Google Scholar databases. Two reviewers independently evaluated all articles to identify for detailed review those that met search criteria. We identified the primary audience of the selected articles and the degree to which these articles addressed clarity of communication of pathology reports with patients. Of 801 articles identified in our search, 25 involved the formatting of pathology reports for clarity of communication. Recurrent themes in proposed improvements in reports included content standardization, variation in terminology, clarity of communication, and quality improvement. No articles discussed patients as their target audience. No study evaluated the health literacy level required of patients to comprehend pathology reports. In summary, there is a scarcity of patient-centered approaches to improve pathology reports. The literature on pathology reports does not include patients as a target audience. Limited resources are available to help patients comprehend their reports. Efforts to improve patient-centered communication are desirable to address this overlooked aspect of patient care. © 2014 Elsevier Inc. All rights reserved.

☆

Competing interests: None. Funding/Support: This work was supported by a grant from the Arnold P. Gold Foundation. ⁎ Corresponding author. Department of Urology, University of Washington School of Medicine, 1959 NE Pacific, Box 356510, Seattle, WA 98195. E-mail address: [email protected] (M. Mossanen).

1. Introduction

☆☆

http://dx.doi.org/10.1016/j.humpath.2014.07.008 0046-8177/© 2014 Elsevier Inc. All rights reserved.

Cancer remains the second leading cause of death in the United States [1]. For patients and their families, a cancer diagnosis can be a traumatic event. Further aggravating the patient's experience is the complexity of information that a

Pathology and the patient patient, his/her family, and their caregivers must absorb as they make decisions about treatment. The complex choices confronting cancer patients require a shared decision-making process, through which information and preferences are discussed by patient and medical provider [2]. Details of the cancer type and other histopathology-related features of importance, that is, tumor stage and grade, are communicated as pathology reports. Thus, to understand the complexities of their diagnosis, delineate their long-term prognosis, and understand relevant management options, patients traditionally rely on the physician's explanation of the pathology report. The pathology report is relevant to patient-centered care and is important for the comfort, confidence, and mental health of the cancer patient [3-5]. Although patients want access to information about their cancer diagnosis [6], medical terminology is often a barrier to patients understanding their reports [7]. Effective communication is critical. In addition to relying upon their physicians to interpret their reports, many patients also use the Internet, which may be a less reliable and less readable source of information than the pathology report [8]. As health-related technologies are increasingly used in hospital systems, efforts are needed to make patient-related information accessible and comprehensible. The Health Information Technology for Economic and Clinical Health Act of 2009 created “Meaningful Use” criteria to stimulate the creation of medical technology that promotes patient engagement and the exchange of information [9,10]. As hospitals adopt Meaningful Use criteria [11-13] and as patients continue to receive unprecedented access to their medical information, patient-centered approaches to electronic health records, including pathology reports, would both satisfy these requirements and would benefit patients. From a health policy standpoint, the delivery of patientcentered communication has been highlighted as a key National Cancer Institute (NCI) research priority [14]. The Institute of Medicine released a report titled: “Delivering High-Quality Cancer Care" [15], in which the challenges of achieving quality cancer care due to limited resources (rising costs), growing demand (by 2030, the incidence of cancer is anticipated to increase by 67% [16]), and increasingly complex treatments are discussed. Patient-centered cancer care, which includes effective communication, has been beneficial to patients—to their quality of life, satisfaction with their health care, and their medical outcomes [17]. Efforts to improve patient-centered care highlight communication as a key aspect of the clinical encounter [18]. Recent studies on the effectiveness of different approaches to improve patient-doctor communication acknowledge the challenge of explaining complex information, with empathy, to patients in the context of progressively tighter time constraints on physicians [19]. We reviewed the literature to identify the primary audience of articles that discussed the clarity of surgical pathology reports. In addition, we identified themes in the

2193 literature that discussed clarity of these reports, and we looked for citation of patient-centered resources that explained pathology terminology. We hypothesize that most relevant literature, including clarification of report content and synoptic formatting of reports, is primarily directed to a physician audience. The findings of this review may help guide the development of patient-centered cancer education tools and resources including patient-centered pathology reports. Patient-centered pathology reports offer one avenue to increase patient knowledge and retention of important diagnostic cancer-specific information and may increase engagement of patients in the care of their cancer.

2. Methods 2.1. Search strategy The most common cancers in the United States in 2013 are, respectively, for men, prostate, lung, colon, bladder, and melanoma, and, for women, breast, lung, colon, uterus, and thyroid [20]. The search was done in November of 2013. Using PRISMA [21] guidelines to structure the search, we conducted a systematic review of publications using PubMed, MEDLINE databases, Cochrane Database Library, and Google Scholar. Although we initially intended to limit our review to the top 5 malignancies for each sex, because of a dearth of information, we decided to include data from all malignancies. The aim of the literature search was to identify the primary audience of articles that discussed clarity of pathology reports. Potential target audiences were patients, clinicians (ie, the surgeon or medical oncologist), and/or pathologists. In addition, we categorized articles by themes. Specifically, we wanted to determine if patient-centered pathology reports or resources had been described for any cancer. We assembled an expert panel of academic urologists, medical genitourinary oncologists, and genitourinary pathologists to develop a list of search criteria and keywords. An iterative process was conducted using focused interview sessions and electronic surveys. A candidate list of terms to guide the search strategy was made. Each term (ie, bladder cancer, bladder tumor, bladder carcinoma, or bladder neoplasia) for each cancer was sequentially combined with selected search terms, which included pathology report, clinical pathology, surgical pathology, patient-centered, readability, health literacy, meaningful use criteria, template, synoptic, communication, patient engagement, compassionate, primary audience, target audience, and patient-centered outcomes research.

2.2. Selection strategy Two authors (M. M. and J. L. G.) reviewed the articles retrieved from the initial search. MeSH terms and linked

2194

M. Mossanen et al. Clinical topics generated by expert panel: Primary stakeholder of the pathology report Recurrent themes Availability of patient centered resources

Online search performed using search criteria and input from expert panel. Potentially relevant studies identified through review of retrieved articles and reference search. (N = 801)

Study title and abstract screened by two reviewers to determine eligibility and relevance to topics of interest. (N = 147)

Articles reviewed in full-detail to determine potentially appropriate studies to be included in final review. (N = 36)

The top 5 cancers in America according to the American Cancer Society were identified and included in the analysis. Due to a paucity of information, the search was expanded to include all cancer with available relevant literature.

111 articles excluded since: Article not in English = 3 Unavailable abstract = 1 Article could not be obtained =2 Duplicate articles = 18 Editorial comment = 1 Irrelevant content = 89

9 articles involving patient centered medicine but not involving pathology reports were excluded. Excluded topics included: Development of genomic-based pathology reporting, avoidance of errors in pathology specimen processing or reporting not directly related to oncologic specimens.

Candidate studies organized by malignancy type and evaluated for recurrent themes. (N = 27) 2 articles that did not discuss one of four primary themes were excluded. The final articles were analyzed for primary audience, themes, and principal findings. (N = 25)

Fig.

Selection process for articles included in systematic review.

references were also reviewed to identify additional eligible articles. Remaining articles were assessed by review of titles and abstracts to determine potential relevance to the research question and to identify recurrent themes. The selection process is illustrated in the Fig. Relevant studies were reviewed in detail.

2.3. Selection criteria We categorized the target audience (patient, clinician, and/or pathologist) of literature regarding pathology report clarification and recurrent themes in reformatting pathology reports. In addition, potential literature that discussed potential approaches to patient-centered pathology reports or formatting were evaluated. Candidate studies included randomized control trials, retrospective cohort studies, systematic reviews, editorials, and opinion pieces. Only articles that were not available in English were excluded. If articles that had been selected by title and abstract were not available, we attempted to retrieve the article by

contacting the authors or requesting articles through the health sciences library.

2.4. Data analysis The intended audience of each article was identified as either a pathologist or a clinician in medical or surgical oncology. We included articles that discussed report formatting for a comprehensive search. We classified the selected articles by theme (Table 1).

3. Results Of 801 articles identified for review of abstract and title (Fig.), 147 were read. Thirty-six selected articles were then examined in detail. Recurrent themes were highlighted. Twenty-five articles were included in the final selection. Candidate studies were categorized into expert opinion (Table 1) or experimental design (Table 2).

Pathology and the patient Table 1

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Literature review: articles based on expert opinion

Author, year [citation]

Site of cancer

Relevance to oncologic pathology report formatting

Leong, 2001 [22]

Breast

+

Hanby, 2005 [23]

Breast

+

Corben, 2013 [24]

Breast

++

Compton, 1999 [25]

Colon

+

Epstein et al, 2007 [26]

Prostate

+++

+

Shah, 2009 [27]

Prostate

+

+++

Hansel et al, 2013 [28]

Bladder

+

Variation Content standardization a

b

Communication

+

++

++

++

Guinebretier et al, 2012 [30]

Bone

+

+

Compton, 2003 [31]

Pathology +

+++

+

Powsner et al, 2000 [32]

Pathology ++

++

++

Ruby, 2000 [33]

Pathology +

+

+

Synopsis of primary points

Quality improvement d

+

+++

Huben and Gaeta, Bladder 1996 [29]

c

+

Traditionally narrative reporting must be replaced with synoptic or checklist reporting to increase reproducibility. Histopathology is subject to morphological interpretation, impacted by molecular categories. Taxonomy of pathology is diverse and inherently subject to variability. Heterogeneity of histologic subtypes and the biology of the respective tumors have important implications for differences in prognosis. Consistent data reporting optimizes health care cost-benefit to patients, determination of prognosis, and communication to surgeon. Variation is prevalent despite a trend for standardization. The article offers a checklist of critical elements that must be included in reports. Sampling variability, tumor heterogeneity, and interpathologist variability account for inherent differences in grading. Varied reporting persists despite standardization efforts. Synoptic reporting, multidisciplinary approaches, and fostering communication between providers improve quality of care. Clear communication between pathologist and surgeon is critical to understand clinical circumstances around obtaining pathologic specimen. Varied interpretation of terms in reports presents a challenge. Reporting can be improved by standardized techniques involving multidisciplinary approaches and digital systems. Tremendous variability in pathology reports adversely affects patient management and progress in clinical cancer management and research. Formatting consistency can improve content standardization and promote efficient communication among subspecialties. Clear communication is crucial. Variation in pathology reports persists (comment on article by Powsner et al [32]).

Abbreviations: +++, high relevance; ++, moderate relevance; +, some relevance. a Content standardization refers to articles focused on reformatting the organization of pathology reports and includes changes that encourage synoptic reporting. b Variation refers to articles that acknowledge the marked differences in surgical pathology report among institutions. c Communication refers to articles that emphasize the importance of communication of key information between pathologists and clinicians. d Quality improvement refers to articles that recognize the association between increased standardization of reports and quality of pathologist reports.

2196 Table 2

M. Mossanen et al. Literature review: articles based on experimental design

Author, year [citation]

Site of cancer

Quality of evidence

Relevance to pathology report formatting Content Variation standardization a

Wilkinson et al, Breast 2003 [34]

Retrospective cohort study

+

Caldarella et al., Breast 2013 [35]

Retrospective cohort study

+

Apple, 2006 [36]

Retrospective ++ cohort study

+

Breast

b

Communication

c

Quality improvement d ++

+

Ellis et al, 2006 Breast [37]

Prospective cohort study

+

++

+

Bjugn et al, 2008 [38]

Colon

Prospective cohort study

+

Aumann et al, 2013 [39]

Lung

Retrospective + cohort study

Aumann et al, 2013 [40]

Prostate

Retrospective + cohort study

+

++

Hansel et al, 2013 [41]

Bladder

Literature review

++

+++

+

Valenstein, 2008 [42]

Pathology

Literature review

++

++

++

++

Nakhleh, 2011 [43]

Pathology

Literature review

+

+

++

+

+++

+

+

Synopsis of primary points

Pathology reports vary widely. College of American Pathology guidelines are often not followed resulting in omission of key points adversely affecting quality of care. Molecular subgroups exist within histopathology subtypes. These are associated with prognostic implications. Despite College of American Pathology Guidelines, pathology reports vary between community and university hospitals. Adoption of a national standardized reporting scheme led to improved consistency and quality assessment initiatives. Electronic template–based reports result in improved consistency, efficiency, and report quality among pathologists. Standardization of templates results in improved consistency, more detailed information, and better report quality. Providing reminders of necessary data items by template-based synoptic reporting resulted in improved clarity and content of essential data. Defining standards elements that must be in reports is evolving. Multidisciplinary approaches are encouraged. Describes 4 evidencebased, practical strategies for improving communication in pathology reporting across all disciplines. Highlights components of effective

Pathology and the patient

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Table 2 (continued) Author, year [citation]

Site of cancer

Quality of evidence

Relevance to pathology report formatting Content Variation standardization a

Karim et al, 2009 [44]

Melanoma Retrospective + cohort study

Idowu et al, 2010 [45]

Pathology

Kang et al, 2009 Head and [46] neck

Crosssectional study

+

Prospective cohort study

+

+

++

b

Communication

++

c

Quality improvement d

++

+

+

Synopsis of primary points

communication including synoptic reporting and availability to discuss critical data directly with surgeon. Synoptic reporting (vs nonsynoptic) resulted in more complete reporting of pathologic features and prognostic indicators and was preferred by providers. However, a free-text section is still necessary. Approximately 30% of cancer reports (from lung crest, prostate, colon) omit elements stipulated by American College of Surgery Commission on Cancer. Description of advantages and disadvantages of a tailored institutional, electronic system for synoptic reporting.

Abbreviations: +++, High relevance; ++, moderate relevance; +, some relevance. a Content standardization refers to articles focused on reformatting the organization of pathology reports and includes changes that encourage synoptic reporting. b Variation refers to articles that acknowledge the marked differences in surgical pathology reporting among institutions. c Communication refers to articles that emphasize the importance of communication of key information between pathologists and clinicians. d Quality improvement refers to articles that recognize the association between increased standardization of reports and quality of pathologist reports.

3.1. Methodological quality Most articles were reviews, cohort studies, editorials, and opinion pieces. Of these articles, 12 were expert opinion pieces, and 13 concerned experimental design. There were 4 types of methodology study: retrospective cohort study (6), prospective cohort study (3), cross-sectional (1), and literature review (1). Of the literature reviewed, most articles were published in journals that had a predominantly pathologist readership. Almost all articles (1 exception) had been published within the past 13 years, reflecting the recent nature of this trend in the literature.

3.2. Discipline characteristics Twenty-five articles discussed the clarification of pathology reports. Of these articles, 20 discussed a specific malignancy. Breast cancer was the most common cancer that was discussed (7/25 articles, 28%).

The primary audience of most literature concerning pathology reports was pathologists. Clinicians were the target audience in 2 of the articles. Not a single article addressed the patient as a stakeholder in the content of the pathology report. Nor did any article discuss the need for patient-centered pathology reports.

3.3. Thematic content of selected articles We identified 4 recurrent themes: content standardization, variation, communication, and quality improvement. Content standardization refers to articles focused on reformatting the organization of pathology reports (such as with synoptic reporting). Variation refers to articles that acknowledge the discrepancies in surgical pathology reporting across institutions. Communication refers to articles that emphasize or examine the importance of communication of information between pathologists and clinicians. Quality improvement refers to articles that examine the association between content standardization and

2198 quality of pathology reporting. Content standardization was the most common theme identified. There were no patient-centered themes in the pathology literature.

4. Discussion Virtually none of the literature that we reviewed identified the patient as a target of pathology reports. The majority of literature pertaining to formatting pathology reports targeted pathologists and clinicians as the primary audiences. For many patients, the pathology report represents a sentinel document in their care. The pathology report dictates diagnosis, guides clinical management, and informs prognosis. Despite the importance of this information for the patient, the information in reports is determined and transcribed by the pathologist, read by the treating physician, and then ultimately shared with the patient. Although the decision quandary confronting patients with a new cancer diagnosis is a shared decision-making process, through which information and preferences are exchanged between patient and provider [2], the fidelity of this process is subject to multiple challenges. For example, patients may not be able to grasp the explanation provided by the health care professional. A study evaluating clarity of communication by residents reported that the average resident used 2 jargon terms per minute and that residents overestimated the clarity with which they communicated with patients [47]. For patients with a diagnosis of cancer, the importance of clear, accurate information about their diagnosis cannot be overstated. Patients with a diagnosis of cancer must often learn and process a large amount of complex medical material. Although patients want access to information about their cancer diagnosis [6], medical terminology is often a barrier to patients' understanding [7]. The Internet may not offer help. The readability of online cancer information is often as high as the 13th grade level, despite recommendations that medical print materials be written at 5th or 6th grade reading levels [48-50]. Low health literacy may disproportionately confound oncology care given the complex multidisciplinary clinical information that must be understood, not to mention financial and legal documents associated with care [51,52]. Much of the material available to patients may be difficult to understand [8], requiring that patients read at a high level [53]. Poor health literacy is associated with poor self-reported health, lack of knowledge about medical care, poor compliance, increased hospitalizations, and increased health care costs [54]. Development of patientcentered resources for oncology care, such as patient-centered pathology reports, may contribute to addressing these disparities. Educational information on the Internet that may help translate pathology report content is often beyond the ability of the average American to comprehend. For example, information from the NCI relating to breast cancer is written at a 10th to 12th grade reading level. However, most material should ideally be written at a 5th to 7th grade reading level to ensure universal readability [55]. The findings in patient information pamphlets

M. Mossanen et al. for women with breast cancer are similar; these pamphlets may be incomprehensible to patients with limited health literacy [56,57]. Several formatting changes have been proposed to improve the design of pathology reports. Valenstein [42] describes 4 evidence-based strategies that would theoretically improve the communication of information in a pathology report. These strategies are (1) headings to highlight important information, (2) consistent layout formats, (3) appropriate material density, and (4) reduction of clutter [42]. Additional recommended changes to pathology report formatting include streamlined versions that emphasize clinical findings by placing them at the top of the report (ie, adjacent to the name of the patient in large font) [32]. To date, most literature on the formatting of pathology reports is directed to the clinician as the primary stakeholder [32,33,42,43,58]. Yet, surgeons misunderstand up to 30% of pathology reports despite having the report available to answer questions [32]. In 2004, the American College of Surgeons Commission on Cancer mandated that surgical pathology reports adhere to the formatting style of the College of American Pathologists. Nonetheless, examples of discrepancies in pathology reports are common. Within the National Cancer Data base, 18% of cases omitted tumor stage, and 24% of cases omitted node status [31]. A review of more than 7000 pathology reports found that 92% reported margin status and only 77% reported lesion size [59]. An audit of more than 1200 colorectal reports found adherence to minimal reporting standards of grade, stage, and lymph node status by 78% of colon cancer reports and 47% of rectal cancer reports [60]. Deficiencies in the communication of surgical pathology have been associated with diagnostic errors [61] and decreased satisfaction of physicians [58,62]. Indeed, the accurate communication of pathologic data represents a challenge for both pathologists and clinicians. We were not able to identify any physician-oriented resources that describe strategies for discussing the content of pathology reports with patients. Physician-to-patient communication is critical to the experience of patients receiving oncologic care [3,19,63-71]. Improved provider communication increases patient's coping, satisfaction with care, informed consent, and cooperation with care and reduces the probability of malpractice and professional burnout [4,19,68,72,73]. Moreover, improved pathology reports may help not only patients better understand their diagnosis but also providers from other specialties, for example, a primary care provider discussing a prostate biopsy report. Thus, the benefit of improving the readability of pathology reports is not limited to patients but also extends to other audiences who use the information for decision-making. We found several other examples of efforts to promote patient-centered care and communication. In Table 3, we summarize topics that may contribute to the improved design and implementation of patient-centered pathology reporting. Ensuring pathology reports are constructed with a standard structure may help ensure all critical elements of the report are addressed [74]. For example, organizational and content formatting of medication instructions has been associated with

Pathology and the patient Table 3

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Strategies that would help the implementation and design of patient-centered pathology reports

Strategy

Description

Clear section headings Organizing each section of the [42,74,75] report with straightforward titles Formatting of the report [42] Ensuring the report fits 1 page may help eliminate confusion and simplify the document Minimize distracting details Omitting portions of the pathology report, which may not be necessary and superfluous to patient understanding information [42] Include images to illustrate Pictures designed by physicians concepts [76-78] with the input of patients

Use comprehensible language to improve readability [48-50,79] Including a patient-centered report with the original report [14,64]

Using simple language and avoiding medical jargon to reach patients with limited health literacy Summarizing results in an attached report allows inclusion of elements deemed important by physicians

Cognizance of psychosocial Empathetic detailing of clinical impact of cancer [80] results to ensure humanistic approach Conduct patient advisory board focus groups [78] Humanistic cancer care [64,81,82]

Enlist patient with a history of the condition to establish an iterative process Cancer care devoted to appreciating value of patient experience

improved comprehension and patient communication [76]. The addition of illustrations to medical documentation improves patient comprehension [77]. Well-designed illustrations enhance communication with patients who have low health literacy [78]. Patient-centered communication has been promoted by the Institute of Medicine as an essential component of improved health care delivery [80]. Currently, there are few guidelines for patient-centered care of patients with cancer. To provide a conceptual framework, the NCI published a monograph titled “Patient-Centered Communication in Cancer Care: Promoting Healing and Reducing Suffering” [83]. Six domains were identified that impact the experience of patients and their clinical outcomes. These domains include exchanging information, making decisions, fostering healing relationships, enabling patient self-management, managing uncertainty, and responding to emotions. Clinicians who routinely deliver oncologic information to patients might improve their patients' experiences by adopting the NCI conceptual framework during clinical encounters. Introduction of a patient-centered pathology report could impact the exchange of information, decision-making, relationship building, and patient self-management. Recent trends toward digitalized pathologic information suggest that the transfer and storage of anatomical and histologic

Aim

Potential application

Create distinct and easy to identify section headings Allow patients to more easily navigate the document outside of the original clinical encounter Improve patient retention by increasing attention spent on salient details

Use of clear titles that are in bold and underlined font Creating a condensed, 1-page document with all relevant information Omitting gross pathologic descriptions and immunohistochemistry staining information Well-positioned pictures can aid Including an illustration of a physician explanations bladder with the extent of tumor involvement may help patients conceptualize the disease. Optimizing the amount of information Ensuring medical jargon is through clear, simple wording will avoided and using language that increase understanding is clear Establishes a patient-centered element Addition of a patient-centered to cancer care by uniting both pathology report to the standard documents pathology report provided to physicians Compassionate explanation of terms Using a narrative format will may alleviate anxiety and fear while help patients understand the information in the report improving retention Allow input of patients to guide the Directly allowing focus groups development of documents and to review potential reports and resources offer feedback Improved communication and Efforts to explain a diagnosis compassion are associated with more empathetically build improved patient satisfaction rapport and trust between patient and provider

data will offer tremendous diagnostic and educational opportunities [84,85]. In 2009, the Health Information Technology for Economic and Clinical Health Act put forth a national goal that interoperable electronic health records (EHRs) be universally adopted [86]. The goal of the legislation is not limited to simply adopting EHRs but recommends “Meaningful Use” of EHRs to improve health care delivery and health outcomes [9]. Meaningful Use objectives were developed after extensive public and professional comment. Implementing these goals will allow patients the ability to readily access, view, download, and transmit their health information online. Pathology reports will be accessible through personal health records (PHRs). Providing this information in patient-centered formats would further increase patient engagement and satisfy Meaningful Use criteria. Patients interact with and digest information in different ways and at different times. Someone newly diagnosed with cancer may revisit information repeatedly at different times as they try to understand this information. Developing patientcentered pathology reports would allow patients to revisit and reflect on the information they received rather than having to remember the content of their discussions with their cancer provider. This would also help patients communicate this information to others, that is, friends and family.

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5. Conclusions There is a paucity of scientific literature focused on ensuring patient understanding of health-related documents, including pathology reports. Most material that discusses the improvement of pathology reports proposes organizational and layout changes. Currently, the effect of these format changes on patient comprehension has not been systematically studied. In the context of Meaningful Use objectives and patient access to health information through PHRs, it is imperative to critically evaluate the patient centeredness of health information documents. Identification of deficiencies in the readability of health information documents would stimulate patientcentered outcomes research to develop documents better geared toward patient-facing views, such as through PHRs. This will require a multidisciplinary effort that engages clinician and patient stakeholders to craft these documents and produce tools that improve information exchange and patient-physician communication.

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