The Second Opinion Path

"We can cancel your upcoming surgery. The suspicious changes seen on your recent biopsy are completely benign."

This happy turn of events happened in my life yesterday, thanks to a second opinion from a type of physician few patients realize plays a role in their care: the pathologist. 

Pathologists are physicians (MDs) who look through microscopes and use a variety of lab techniques to determine what disease(s), if any, are present in blood or tissue obtained with a biopsy. Their task is not as straightforward as putting a key in a lock and turning ("Yup, the key turns, so this is cancer). Pathology is an art that depends on sleuthing skills and judgment calls.

Some biopsies are straightforward because all the changes are typical and obvious for one specific type of cancer. Even a first year medical student could make the correct diagnosis. Other biopsies, like my most recent one, are difficult (if not impossible), to interpret. In these cases, second opinions help.

Until sophisticated tests are developed that make pathology an exact science, a second opinion from a pathologist has a place in Healthy Survivorship. If a biopsy has only subtle changes, or if the diagnosis is one that is often difficult to make, Healthy Survivors talk with their physicians about getting a second opinion from another pathologist, preferably one who specializes in the disease that is suspected.

As a Healthy Survivor, I hope and pray for accurate news. And if the accurate news is also good news, that's even better.  

Comments

[JBBC]

Wonderful news Wendy and such an important post. This also highlights for me the importance of being treated in specialist breast cancer units, where triple assessment offers women the best chance of survival. And of course, you are so right, never be afraid to ask for a second opinion. http://beyondbreastcancer.wordpress.com/2009/03/18/specialist-breast-centres/

[Wendy S. Harpham, MD]

Healthy Survivors sometimes have to make a difficult judgment: Should I ask for a second opinion on the pathology? Or would I be wasting time and money, and irritating my physicians? Is asking for a second opinion on the pathology putting my hopes in the wrong place?

Your physicians can help you know if the pathology was straightforward or somewhat difficult, as well as if you have the luxury of time needed to obtain a second opinion.

With hope, Wendy

[Dianne Duffy]

Can you ask for a second opinion on mammograms? My cancer was there on the first one that was "negative", about the size of a marble. On the second, 3 months later, it was larger than a walnut.

[Kirk Hartley]

What a great result for you - congratulations !!

One point you do not cover perhaps deserves comment. Did pathologist # 1 indicate the difficulty and suggest a second opinion or did you make that choice on your own, aided I presume by being a doctor?

I raise the topic because my observation through life has been that real experts are more than willing and indeed anxious to highlight when conclusions are in "grey areas," and real experts nderstand and value second opinions to make sure things are done as well as is humanly possible.

Conversely, when doctors avoid or demean the possibility of obtaining a second opinion, a patient probably should ask themself if they really have an expert physician. If not, then it's probably time to think seriously about going to a real center of excellence for the type of cancer involved.

[Felicity Lenes]

This is excellent news! It seems like physicians must have to walk a thin line between making sure they are vigilant and aggressive in treating cancers or possible cancers and making sure that they don't over-diagnose. Perhaps there is rarely a way to make "sure," and experience and professional instincts dictate where clinicians fall along the continuum?

[Wendy S. Harpham, MD]

Dear Kirk,

The biopsy path report indicated minor abnormalities that all the doctors involved agreed can be difficult to call.

I met with the breast surgeon (at a different hospital), who recommended a bigger biopsy.

Before undergoing a surgical biopsy, I wanted a second path opinion to be sure this surgery was necessary, so I requested one at the hospital where the biopsy was done.

Unbeknownst to me, the surgeon had sent for the slides, so she could do the same (i.e., ask a different pathologist to confirm the abnormality was significant enough to proceed with a surgical biopsy).

Pathologists often ask their colleagues to provide a second opinion in cases that are not clearcut, and this happened at both hospitals with my slides.

So even had I not requested the second opinion, it would have happened.

I agree with you about the physicians' responses to patients' requests for second opinions. Physicians should welcome them, especially in cases where the diagnosis is not clearcut.

Two caveats: (1) Patients need to know if they are pinning their hopes on the possibility of a wrong diagnosis, when the diagnosis is clearly correct. And (2) patients need to know if by asking for second and third opinions, they may be losing the window of opportunity for cure or recovery.

My books DIAGNOSIS:CANCER and AFTER CANCER and HAPPINESS IN A STORM all discuss second opinions.

Let me know if this answers your questions. With hope, Wendy

[Wendy S. Harpham, MD]

Dear Felicity,
One of the great challenges of clinical medicine is determining what constitutes too much and what constitutes too little. Physicians' work is a constant balancing act, weighing risks and benefits of every single intervention from dosages of antibiotics prescribed to asking patients about their work stress.

Medicine is an art based on science. Progress in clinical medicine (evidence-based treatments) shift the balance in favor of science. Yet, in most cases art still plays a role. Given that physicians don't treat DISEASES -- no, physicians treat PEOPLE with diseases, and given that each individual is unique, there will always be a place for the art of medicine.
With hope, Wendy

[Kate]

Nothing makes me happier than reading a paragraph like your first. Medicine continues to be a balance of science and art, doesn't it. Congrats and enjoy the day!

[Ronni Gordon]

Wendy,

Congratulations on getting a good report. That's the bottom line for me. I wonder if following through with a second opinion was a way of helping you to stay calm and focused. In any case, I'm so glad it turned out well. I don't think too much about second opinions now because at Dana-Farber there's a whole team of them who discuss patient treatment.

[Wendy S. Harpham, MD]

Thanks, Ronni.
Following through on the second opinion did calm me, but not because I felt I was "doing something." It calmed me because a second opinion (whatever the result) would lead me to confidence in my final decision. If I proceeded with the surgery, I would know it was the wisest move.

As a physician-scientist I am aware of -- and accepting of -- all the uncertainty surrounding diagnostics and treatments. So I don't look for guarantees. I aim to do the best I can do. The second opinion enabled me to relax, knowing I was doing the best I can do.

Make sense? With hope, Wendy

[Wendy S. Harpham, MD]

Dear Dianne,
I've had that experience, too. A CT scan was read as "within normal limits." A few months later, when I developed obvious cancer near my stomach, a re-read of the old CT found subtle changes that had progressed and were now obvious.

Your best approach is to make sure your mammograms are being performed on good, up-to-date equipment and are being read by reputable radiologists.

This is no guarantee that nothing will be missed (my subtle abnormality mentioned above was on a state-of-the-art CT scanner and read by a superb radiologist), but it minimizes the chance of missing something subtle.

Wishing you the best. With hope, Wendy

[Trisha Torrey]

Wendy - I had two pathology opinions that confirmed each other - rare, deadly lymphoma - months to live, needed chemo.

Turns out BOTH labs were wrong. I had no cancer at all - the NIH eventually confirmed it.

You now have two opinions - you need a third to confirm one or the other.

My story: http://patients.about.com/od/misdiagnosis/a/misdiagnosis.htm

[Wendy S. Harpham, MD]

Dear Trisha,
Thanks for sharing your story with my readers. You'll be happy to know that I got a total of five second opinions on the pathology. I am totally confident of the findings and our plan of action. I am sorry to hear of your rollercoaster ride. If it is any comfort, you can remind yourself that you are the patient that people with definite cancer wish they could be. With hope, Wendy

[Roz]

Your good news made my day!
I got a second opinion on my initial slides, and the second opinion (from a nearby university with an excellent cancer center) was the same as the first (from my HMO), as was the recommendation for treatment.

[Trisha Torrey]

Aha -- then Wendy -- you've been opinioned-to-pieces! It's the confidence level we must seek, and you clearly have that.

Well done -- and happy day! So pleased to hear your news is so positive.

Trisha

[Wendy S. Harpham, MD]

Thanks again, Trisha. And if our stories help other patients get good care, that's a good thing.

With that in mind, I'll be sharing your blog with others.

[Kairol Rosenthal]

A few years ago, well into my cancer stint, I got a second opinion from a doc who said, "Oh, sometimes when these guys in a path lab are looking at slides they are talking on the phone with their girlfriend and eating a sandwich at the same time... they can be sloppier than one would hope." He decided to go back to the same hospital lab, use a different pathologist and speak with the pathologist before and after they reviewed the slides. And of course: totally different opinion. Pathologists are the folks behind the curtain whose opinions often have the largest impacts on our treatment plans. I always empower and encourage patients to get second path reports if something does not make sense or they want confirmation.

Congrats on your great news.

Best,
Kairol

blog - http://everythingchangesbook.com/

[Finn]

Great news, Wendy!

When I was diagnosed with ovarian cancer, I didn't get a second gyn/onco opinion because it took so long to get in to see another doctor and I didn't want to delay my surgery. I did get a second pathology opinion. My doctor hadn't recommended it, but because the path results were so different from the initial frozen section results, and the path results were delayed (suggesting the possibility of overworked pathologists), I didn't feel completely confident in the results. She understood that and happily sent off my samples to the second pathologist.

On the other hand, I felt confident enough to begin chemo. I figured the path report was most likely right and, if the second opinion disagreed, I could figure out then whether to continue chemo or put it on hold until I got a third opinion. But the second agreed with the first so I went merrily along in treatment.

[Wendy S. Harpham, MD]

Dear "Finn"
Your comment illustrates perfectly the notion of balancing the need to be sure the diagnosis is correct and the need to proceed with treatment. You bring up one point not mentioned before: You can proceed with treatment while getting the second path opinion, and then you can change course, if warranted. This approach respects the risks of waiting to long to begin treatment. Thanks for sharing this. With hope, Wendy