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Lymphoma and Pets
Who is Your Other Pathologist?
According to the American College of Pathology, over 70 percent of all decisions about a cancer patient's diagnosis, treatment, hospital admission, and discharge rest on the pathology report. This arguably makes the pathologist the most influential health care professional in the life of a cancer patient.
Strangely enough, I have never met a cancer patient who knew their pathologist's name.
Of all the folks who are part of a patient's health care team, the pathologist is one that FEW will never meet. They will never learn their name or anything about their professional or educational background. It isn't that this information is kept hidden from them; it just never gets prioritized.
But should it be? Just how important is it to know your pathologist?
Pathologists play an enormous role in the care of a person with cancer. Not only do they reach the initial cancer diagnosis from the biopsy, they also serve on multi-disciplinary tumor boards that help guide treatment plans. They are also often the ones who are creating the kinds of specific lab tests used in lymphoma diagnosis.
How Good Are They?
In an interesting study that appeared in the 2014 British Journal of Haematology, researchers wanted to test the diagnostic accuracy (concerning lymphoma diagnoses) of pathologists who do not work at major medical centers. They looked at 1,010 cases, all of which were then referred to a top academic medical center for second opinions. Would there be any changes? Would the changes result in different treatment decisions?
- - In 861 cases, the second opinion confirmed the diagnosis (85•2% of cases).
- - In 149 cases, the second review resulted in a major diagnostic change (14•8% of cases).
- - Out of these 149, 131 of them also would have resulted in a therapeutic change (12•9% of cases), meaning a change in treatment recommendation.
So rightly or wrongly the average person might say, well, it sounds like the pathologist working out of my local hospital is right 85 percent of the time, and that by not getting a second opinion, I have a 13 percent chance of being misdiagnosed and then undergoing a treatment plan that is wrong for me.
A podcast at the American Society of Clinical Oncology features two pathologists addressing their role in cancer care. While they do so with all the charisma of a Petri dish, they do communicate some important points.
After informing listeners of the professional requirements of pathologists (including the fact that they are indeed Medical Doctors) and detailing the ways in which pathologists take part in the treatment of a cancer patient, they broach the subject of pathologist-patient interactions.
"One time you may actually see us is if you undergo aspiration of a lesion in, for example, interventional radiology," says Dr. Carey August, using a phenomenally specific and totally unrelatable example. Terms like lesion and aspiration aren't, in their medical contexts, in the vocabularies of most people; nor is interventional radiology. "Or a pathologist may either actually do the procedure or they may be on site while another doctor performs the procedure..."
Being in the same room with one's pathologist almost sounds as rare and as thrilling as a chance celebrity sighting.
"Patients should know that pathologists can and are willing to talk to patients any time needed," says Dr. August. "You should feel free to contact your pathologist and ask to speak to them because [they] will be happy to discuss with you - even show you - what your slides look like under the microscope."
A nitpicking, hypercritical sort might wonder why, given the importance of their work, it is the patient's responsibility to pursue the pathologist.
The Other Pathologist
Is it really so crucial for a patient to know his or her pathologist? Would it have any effect on that 85.2 percent success rate if suddenly pathologists were required to have a meet-and-greet with every former owner of the tissue samples they examine?
The issue here is not whether patients knows their pathologists. The issue is improving patient outcomes. If most of a patient's treatment is determined from the initial pathology report, then this seems like a really good place for improvements, since a mistake will corrupt everything down the line.
So maybe the issue is also whether patients know what their other pathologist thinks ... the one giving the second opinion.
There is no standard practice regarding second opinions; they aren't built into the process. Some insurance companies will pay for them, some will reimburse the patient, some will do neither. Doctors should encourage or insist upon them but generally do not. Currently, the best a patient can do is seek second pathology opinion from a major cancer institution. Among many others, MD Anderson offers them.
Prying specifics from them on how it works and how much it might cost is almost enough to frustrate anyone out of doing it. Still, it presents what seems like the best route in assuring one's diagnosis.
Lacking a registry, nobody knows with any degree of accuracy just how many incorrect cancer diagnoses are made every year in the United States.
One of the authors of the 2014 study mentioned above is Dr. James Armitage of the University of Nebraska. Armitage is a world renowned expert in lymphomas. In 2007, he told Cure Today's Curtis Pesmen that blood cancer diagnosis is complicated. While he was unaware of a percentage, "the number of blood cancer patients who have their diagnoses changed is substantial."
Not every patient wants to see their disease or have it mapped out by a socially awkward pathologist. But every patient ought to be given the opportunity to say yes or no to such a meeting. Patients deserve to be better informed about the role of the pathologist, just as pathologists deserve the opportunity to do better than 85 percent.
Experts like Armitage say they only treat lymphoma patients whose diagnosis has been reviewed by a pathologist with subspecialty classification in hematology (a hematopathologist). Contrary to this, the American Board of Pathology claims that "the achievement of subspecialty certification does not reflect on the ability of other pathologists to practice in that area" ... but you are under no obligation to accept that.