Two Pathologists, Three Opinions

• “He’s handsome.” “Are you kidding? He’s ugly.” 

  “That’s teal.” “Certainly not. That’s green.”

  “That song is beautiful.” “Good grief. It’s horrid.”

  What do these things have in common? They are subjective disagreements about things that are hard to categorize, can’t be quantified, and are judged simply based upon appearance. When you are given a diagnosis of cancer, what many people don’t know is that the biopsies of tissue taken from your body are looked at under a microscope by a pathologist. And oftentimes, these pieces of tissue are not easily categorized. The pathologist makes their diagnosis based upon appearance. The challenge is that, while most cases are relatively clear, just as beauty or a color can vary subjectively, so can some diagnoses. And this is where expertise is important.

  A recent article in the New York Times described a study that included 115 doctors evaluating 60 cases of breast biopsies. These pathologists were asked to evaluate these cases on their own. Their results were then compared with breast-specialized pathologists who have a lot of experience interpreting breast biopsies, and these breast pathologists served as the ‘reference group’ – meaning that their diagnoses were felt to be the definitive diagnosis and accurate.

  The study evaluated three types of diagnoses: (1) invasive breast cancer, which means its breast cancer that has the capability to spread, (2) noninvasive breast cancer or DCIS (ductal carcinoma in situ) meaning breast cancer that is confined to the ducts that doesn’t yet have that capability to spread, and (3) atypia and completely benign cases. Atypia is a description used to refer to cells that are somewhat abnormal, but not abnormal enough to call DCIS, and treat accordingly.

  For invasive cancer, the surveyed pathologists were excellent, matching the reference group in 96% of cases. For DCIS, 84% matched, but they overinterpreted the tumor in 3% of cases, and in 13% they underinterpreted the results. For atypia, 48% were concordant, but 17% were overinterpreted, and 35% underinterpreted.  For benign cases without atypia, 87% were concordant and 13% were overinterpreted. (You can’t underinterpret something that is already benign.)

  So why did this occur? These variations are a measure of the level of skill and expertise about some of the more subjective aspects of categorizing something you look at. And so what does this mean for the woman having a breast biopsy? It means that the skill level of your breast cancer team as a whole is critical.

  This means that not only are your surgeon, radiation oncologist, and medical oncologist’s skill of critical importance, but so is your pathologist who reads your slides, and your radiologist who reads your X-rays. This is why it is so critical to find out the level of experience of the institution and treatment team you choose; expertise means everything.

  And these studies tell us that where you go first can often make a difference because where you go first is typically where you start your workup and obtain your diagnosis, and even begin treatment. And no one wants to begin the wrong treatment. But remember that while there may be disagreement among doctors – it doesn’t mean there is no right answer. And it doesn’t mean you should forgo treatment when given a diagnosis.

  As noted in my last blog post, the best way to survive breast cancer is to do your homework about your treatment team and the institution where you are seeking care. This is to determine how much breast cancer they see, and how specialized they are. Like everything else we do, the more a doctor sees of a particular disease, the better s/he gets at treating it.

  So do your homework. Maybe get a second opinion (you can get that on your pathology tissue slides as well!). Where you go first matters.