Feature Article

A Second Opinion Should Be Your First Priority

A recent article in the journal Cancer reported on a new medical consortium that provides an online second opinion for pathologists who are faced with difficult diagnoses. Professor Manfred Dietal and colleagues at the University Hospital Charite in Berlin, Germany wrote that pathologists who are challenged with a difficult tumor diagnosis can now send digitized images to the International Union Against Cancer to get an expert second opinion.

One of the organization's pathologists will then make an independent diagnosis and send back their conclusion to the original pathologist. Dietal noted that a precise evaluation of a tumor can sometimes present a diagnostic challenge to even experienced pathologists-and their interpretation can be absolutely crucial to a patient's required course of treatment (if any).

Second Opinions to Catch Mistakes

A few months ago, Clinician Reviews revisited a tremendously important study by researchers at the Johns Hopkins Medical Institutions in Baltimore which found that a small but significant number of biopsies are regularly being misinterpreted. The result is that some people receive unneeded cancer treatments, including surgery, while others are not being treated at all for conditions that could be life-threatening.

The original study, published previously in the journal Cancer, evaluated the records of 6,171 patients who were referred to Johns Hopkins for treatment following a biopsy between April 1995 and December 1996. Eighty-six of the cases (1.4 percent) were diagnosed differently by Johns Hopkins pathologists than they had been by the original pathologists. Eighty (93 percent) of the 86 new diagnoses resulted in a revised treatment plan; 61 (71 percent) of the new diagnoses led to an improved prognosis.

In 23 percent of the cases that were misdiagnosed, patients who were thought to have cancer instead had benign (noncancerous) tumors, and thus avoided unnecessary cancer treatments. In 5 percent of the misdiagnosed cases, tumors said to be benign were in fact cancerous, possibly saving the lives of the patients. Other cases were misdiagnosed as the wrong type of cancer, e.g., a melanoma was misdiagnosed as stomach cancer.

The Hopkins researchers suspect that the true rate of biopsy misdiagnosis in the general population may be closer to 2 percent. As a result, they strongly recommend that second opinions become a standard practice for patients, especially before any major medical procedure is undertaken.

"When a patient finds out that their pathology report was misread, or their mammogram shows a cancer that went undetected, they are shocked-and rightfully so," says Lillie Shockney, RN, BS, MAS, the director of education and outreach at the Johns Hopkins Breast Center.

"This is why we want to see the development of national quality standards for the diagnosis and treatment of breast cancer. Women must be able to have confidence that they are receiving appropriate, high quality care."

Dr. Wendie Berg and colleagues in the Department of Radiology at the University of Maryland came to an even more distressing conclusion regarding the interpretation of mammograms.

Mammography is still the most effective tool for the early diagnosis of breast cancer. However, while several limitations may exist in the delivery of high-quality mammography, one that has received relatively little attention is the actual skill of the radiologist interpreting the mammograms.

Berg's zeal for improving mammography reading came as the result of a disturbing discovery. She took the exact same mammogram to five well-respected mammographers and came away with widely disparate interpretations and recommended courses of treatment. She was alarmed and soon developed an educational program for radiologists that would provide a standard approach for interpreting results.

A few months ago, Berg held a first-of-its-kind training program for 27 participating radiologists. At the start of the day, less than half (44 percent) of the radiologists successfully identified even 70 percent of the cancerous lesions. However, after only a few hours, more than 81 percent of the radiologists were able to identify at least 80 percent of the cancers using Berg's methodology. She hopes to refine and expand the training program in the coming years.

Overriding Physician Bias

Sometimes a second opinion should be pursued for reasons even beyond the risk of misdiagnosis. For example, a recent national survey of urologists and radiation oncologists indicated that these specialists are more likely to recommend prostate cancer treatments in their own field of expertise in cases where current evidence does not support any particular treatment.

According to the report, published in The Journal of the American Medical Association, urologists and radiation oncologists often agreed on treatment options for prostate cancer. However, for men with moderately differentiated, localized cancer who had a life expectancy greater than 10 years, 93 percent of urologists preferred to treat the patient with radical prostatectomy, while 72 percent of radiation oncologists saw no difference between surgery and external beam radiation as treatment options.

Drs. Michael Barry and Mary McNaughton Collins of Massachusetts General Hospital in Boston wrote that for most tumor grades and PSA levels, the physicians were significantly more likely to recommend a treatment in their own specialty than any other treatment. This reiterated the findings of a similar survey undertaken in 1988 that documented equally skewed treatment recommendations.

Collins also noted that a similarly low percentage of both specialists would recommend "watchful waiting," even though this option might be the best treatment for patients in some cases. She said that the best thing for prostate-and other cancer patients-to do is to seek multiple opinions before deciding on a course of treatment.

You Always Have Options

Patients should always seek a second opinion on procedures for which there is any difference in medical opinion. Even when there are no treatment alternatives to sort out, a second opinion can offer a fresh perspective if there's a vexing clinical problem. Or it can confirm a diagnosis or the wisdom of a course of treatment, and thus ease any doubts that you, or your physician, may have.

When seeking another opinion, make sure to discuss this with your primary physician. If you sense reluctance or defensiveness on your doctor's part, that's all the more reason to get a second opinion. Walking away from a physician who leaves you frustrated or angry, or just uncomfortable, may be one of the most important things you can do to take charge of your health.

Unfortunately, many patients are hesitant to get a second opinion because they are afraid of damaging their relationship with their doctor. Yet all patients are entitled to an independent second opinion and to get a copy of their medical records. Your primary physician should not only support this process, but should provide you with a list of specialists that he or she would personally recommend.

SOURCES:

Cancer, Dec. 1, 1999; 86
Cancer, July 1, 2000; 89
Medical Tribune, 1999; 40(21):10
Clinician Reviews, 2000; 10(2):115-123
Journal of the American Medical Association, 2000; 283:3217-3222, 3258-3260

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