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Physician Update - Why Second Opinions Rule

Physician Update Winter 2010

Why Second Opinions Rule

Date: January 31, 2010

Jonathan Epstein and colleagues
Jonathan Epstein, center, and his pathology colleagues well understand why another look can change a patient’s prognosis.

Looking back, it seems clear that Jonathan Epstein scored a direct hit. Since his group’s report about biopsy errors was published in Cancer a decade ago, the move toward obtaining second opinions on pathology specimens has all but swept American medicine. “Our recommendations have helped form the bedrock of what goes on today,” Epstein says. “The findings are still valid.”

The numbers were alarming. After reviewing biopsy slides of 6,171 patients sent to Johns Hopkins for cancer, Epstein’s group found a disagreement with 86 of the diagnoses. Studies from other groups both before and after the Epstein paper found similar trends. Especially in high-stakes cancer cases, they all seemed to agree, second opinions should become more rule than exception.

Though the margin of error in the Hopkins study was relatively low, at 1.4 percent it signaled the prospect of 30,000 medical mistakes in the United States every year. These numbers also do not show the full extent of the problem. In the initial Hopkins study, they only looked at catastrophic changes in the diagnosis, such as cancer versus no cancer. They did not look at changes in diagnosis relating to grade or extent of the cancer, also critical in a patient’s management.

Subsequent studies have shown a higher percentage of changed diagnosis when reviewing for these factors.

As a result, says Epstein, clinicians now more routinely seek out consultations, and even patients themselves increasingly ask for a second look at their own materials. This means the traffic in Epstein’s laboratory is robust. Last year alone, he says, they reviewed pathology materials for 30,000 cases at the request of third parties. A full 16,000 of those were reviewed by Epstein himself.

Accurate diagnosis of some cancers can be elusive; notoriously difficult are those that afflict the prostate, bladder, head and neck, soft tissue, skin and lymph system. Epstein, an expert in detecting prostate cancer, says his team once found major errors in the pathology reports of six of 535 men, sparing them from needless surgery.

While the margin of error is about the same as it was a decade ago, Epstein says the higher volume of double-checking is also improving treatment. All of the variables can change the treatment modalities. In just one recent day, he says, his group made big revisions in three cases, sparing two from major surgery.

At Hopkins, the rules for pathology are now a hospital-wide policy. “Anyone treated here—whether by surgery, radiation therapy or oncology—first has to have the outside pathology reviewed.”

Hopkins pathology administrator Al Valentine says his division taps 130 full-time faculty members to handle about 125 pathology reviews every day, serving clinicians at nearly 700 hospitals. “They can send us anything,” he says.

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