SECOND OPINIONS: Researchers Say Second Review Needed
A study published in the December issue of the journal Cancer revealed that a fair percentage of pathology reports are incorrect, leading to inappropriate treatments. In the study, more than 6,000 patients' original pathology reports were compared to second reports done by Hopkins researchers. Eighty-six patients, or 1.4%, came to Hopkins with a diagnosis that was "totally wrong." Dr. Jonathan Epstein, who led the Hopkins research team, said, "That's not a huge number, percentage-wise, but the fact that it's as high as it is remains significant..." Epstein believes that the actual number is nearer to 2%, and that the study's numbers are conservative. It did not track patients wrongly pronounced free from cancer because patients don't "typically come to a large medical center for treatment." Twenty-three percent of the questionable diagnoses shifted from "decidedly malignant" to "decidedly benign," and in 5% of the cases, the reverse was found; patients had been given benign diagnoses that were changed to malignant ones. Other errors included misdiagnosing the type of cancer a patient had. To avoid the risk of misdiagnosis, Epstein suggests that hospitals institute policies necessitating a "review of the original biopsies before patients undergo surgery or other major therapy." Epstein also mentioned an earlier study done at Hopkins that revealed that in prostate cancer cases, a second opinion eliminated the need for surgery in 6 out of 535 patients, saving nearly $2 for every one dollar spent on the second pathology report. He added that patients need not undergo the "risk of getting the wrong treatment, including surgery or chemotherapy. That's not to mention the psychological trauma of having the wrong prognosis for an illness or the financial burden of the wrong treatment."
Is Anyone at Fault?
The study didn't find any pattern in the kinds of institutions making incorrect diagnoses. It found errors from community hospitals, commercial laboratories and large teaching institutions, as well as Hopkins itself. Epstein says that it's easy to place blame on the changing health care system, especially as HMOs and hospitals are cost-cutting and a second opinion "has come under attack." But he says that the cause of many misdiagnoses may be attributed to technological progress. "With earlier diagnosis of suspect tissue, it's now much more difficult ... to separate out the mimics from the true cancers. Also, we used to get larger samples ... now we get needle biopsies. ... That's good for patient recovery ... but harder for the pathologist," he said. He also mentions that patients have a role in requesting a second opinion, and that they need to realize that pathologists are human and fallible (Johns Hopkins release, 11/30). Dr. Marshall Posner, medical director of head and neck oncology at Boston's Dana- Farber Cancer Institute said the report was the "first official record of what we have all known." He added that at Dana-Farber, biopsy readings are scrutinized by their own pathologists, because they end up changing 3% to 5% of the diagnoses. But Posner doesn't support the idea that all biopsies should undergo review. "Can it be done in a way to maximize the return? The most standard tumors, such as invasive breast cancer, don't need to be reviewed again. I don't want the public to panic about all pathology reviews" (Hsu, Boston Globe 12/1).