UF researchers highlight role of second opinion
for patients with prostate, bladder cancers


By Melanie Fridl Ross


GAINESVILLE, Fla.---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 of 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."