A new University of Florida study shows that seeking a second opinion after a diagnosis of prostate or bladder cancer can sometimes spell the difference between radical surgery or more conservative treatment -- even watchful waiting.
In rare instances, pathologists also disagree on whether cancer is even present, according to research published recently in the Journal of Urology.
UF cancer specialists found that referring and consulting pathologists agreed on the diagnosis in 81 percent of the 150 urologic cases they evaluated. In the remaining cases, treatment recommendations differed almost half the time.
Physicians say it's important for patients to know that medical diagnoses often are matters of judgment, not right and wrong. Even when practitioners agree on the diagnosis, philosophies regarding patient counseling and treatment frequently vary, said Zev Wajsman, M.D., a professor of surgery and chief of urologic oncology at the UF Shands Cancer Center.
"In urologic oncology today, many patients undergo radical surgery such as removal of the prostate or bladder," Wajsman said. "This is all based on the biopsies one does before surgery is undertaken. This is quite difficult pathologic interpretation. There are not many people who finish pathology training who are experienced with the fine details of urologic pathology, especially as it relates to prostate cancer and even bladder cancer."
"An additional problem is there are different options today for the treatment of prostate cancer or even bladder cancer, and the type of pathology -- the grade of the tumor or depth of the tumor -- may determine which treatment modality we choose," he added.
"This is a very subjective profession. It's not like mathematics, black and white; we don't have computerized methods to define something in very precise terms. So the pathology interpretation is very frequently based on training, personal experience and impressions. It's a very fine line there sometimes and I think it's worth it, before patients make a decision like that, to have a second opinion."
UF researchers studied the records of 150 patients referred by urologists at other institutions or in private practice. An expert in urologic pathology reviewed patients' specimens, assessing them without knowledge of the original diagnosis or clinical circumstances. The final interpretation, however, was rendered only after all information available was known.
All diagnostic discrepancies were recorded and grouped according to whether they had no effect on care or changed patients' prognosis or their diagnosis and recommended treatment.
Of the 150 cases evaluated, 29 resulted in diagnostic disagreement; UF practitioners altered treatment recommendations in 14 cases. The most common variation in opinion involved the grading of cancerous prostate cells obtained through needle biopsies.
"Sometimes it was even as dramatic a situation as cancer was actually not diagnosed on a specimen in our hands versus diagnosed outside, and vice versa," said Wajsman, citing four cases UF experts considered malignant rather than benign, and four others they found benign, not malignant. "In some instances, the type of cancer changed and the staging or grading changed, which made treatment very different, going from a very aggressive approach to a more conservative one."
Furthermore, UF researchers found that when the direct costs of pathologic review and changes in treatment were totaled, the overall savings to patients, presuming they followed the second opinion, would be $29,000.
"What (pathologists) do is not a science. What we are is art critics, in a way," said William M. Murphy, M.D., a professor of pathology, immunology and laboratory medicine at UF's College of Medicine who specializes in urologic pathology. "The public gets the idea that some people see more than others. That's not true.
"Some people interpret things differently but we all pretty much see the same thing. The pathologist differs from an art critic in that he or she only receives a small portion of the picture and must reconstruct the scene by inference and deduction. Considering all factors involved in a pathologic interpretation, it is amazing how accurate these interpretations are."
Pathologists' interpretations "may not be simply matters of right and wrong, as if every specimen would have a correct diagnosis were it only to be reviewed by the appropriate expert," UF researchers wrote in the Journal. "Nor is it necessarily wise to assume that patients would always benefit from additional opinions, as if a tally of several would be definitive."
Often, whether to seek a second opinion comes down to patients' trust in their practitioners, Murphy said.
"I think it's important for people to have faith in the medical group they are consulting, and if they find they have no faith then they need to find a group in which they do have faith," he said.
It's a good idea for patients to educate themselves but not to try to become experts in an area, either, he added.
"If they try to make themselves experts, they will be functioning as their own physician and that is not a good thing," Murphy said. "There's an old saying, 'The physician who treats himself has a fool for a doctor.' "
A second opinion doesn't necessarily mean a better opinion, Wajsman said.
"We don't claim we are better than others; it's just that it's common sense if you have a diagnosis of cancer and need to make a decision regarding treatment to get another pathologist experienced in this field to look at it," he said.
The health-care industry has largely promoted the concept of a second opinion as a means of decreasing costs, said J. Edson Pontes, M.D., chairman of urology at the Wayne State University School of Medicine.
"In an era of the Internet where the public has access to the latest information, often the amount of data available can be overwhelming, conflicting and confusing," he added. "Furthermore, the latest technology or new therapies not yet fully tested have the tendency to excite patient's imagination and cloud the decision process.
"Clearly, patients need to be informed of all options in order to make a competent decision; however, they need to know that medicine is not an exact science due to the complexity of biological systems. Ultimately they need to develop a trust in their physicians and together make a decision about the best options to be applied for their particular problem." - By Melanie Fridl Ross