Second pathologic opinions: do they change patient management?

We have long known that prostate cancer specimens (and specimens for other urologic malignancies) can be very difficult for pathologists to evaluate with accuracy, and that second pathological opinions can be helpful in ensuring an appropriate diagnosis prior to treatment and/or an appropriate prognosis after radical surgery.

Wayment et al. set out to evaluate the practical utility of second opinion pathology in patients seen at their institution for a urologic cancer between August 2002 and April 2008 by retrospectively reviewing the records of all relevant patients.

At their institution, when a patient requests a second-opinion for urologic malignancy, all available pathologic slides are customarily reviewed by the urologist and pathologist at the time of consultation and compared with the original diagnosis. Where there is a difference in opinion about the diagnosis (a discrepant diagnosis) all slides are reviewed by at least 2 pathologists at the authors’ institution. Diagnostic disagreements were graded as minor or major according to the significance of their effect on treatment or prognosis.

The authors report the proportion and types of diagnostic discrepancies and their impact on patient care:

  • A total of 264 patients were seen in consultation.
  • 213/264 patients had pathologic material available for review
    • 117/213 of these patients (55 percent) had prostate cancer
    • Other patients had diagnoses of one of five other urologic malignancies.
  • Disagreement with the original diagnosis was found in 22 cases (10 percent), of which 18 (8 percent) were classified as major, and 4 (2 percent) were classified as minor.
  • Interventions avoided or delayed, as a direct result of second opinion pathology, were a prostate biopsy in one patient, management of metastatic prostate cancer in one patient, seven interventions in patients with other cancers.
  • Interventions recommended or performed were radical prostatectomy in one patient and radical cystectomy (surgical removal of the bladder) in another.
  • Additional pathology from subsequent biopsy or surgery was available in 12/22 patients, and the second opinion pathologic diagnosis was supported in all patients.

The authors conclude that a “second opinion review of surgical pathology for urologic malignancy can result in major therapeutic and prognostic changes, which can impact patient care.” The “New” Prostate Cancer InfoLink is actually somwehat suprised that the number of changes in proposed intervention in the prostate cancer patients is a low as it was (3 changes among 115 second opinion consultations for prostate cancer). If we had been asked to guess the number of changes in intervention one might expect as a consequence of second opinion consultations generally, we would ahve expected something closer to 5 percent.

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