Breast Cancer: The Importance of A Second Opinion

http://womensvoicesforchange.org/breast-cancer-the-importance-of-a-second-opinion.htm  

July 22, 2010 by Eleni Tousimis, M.D.

 

It estimated that in 90,000 cases, women who receive a diagnosis of  

D.C.I.S. or  invasive breast cancer either did not have the disease or  

their pathologist made another error that resulted in incorrect treatment.

 

This week, the New York Times published an article, by Stephanie Saul, about a woman who was misdiagnosed by a pathologist as having early breast cancer.  She subsequently underwent a disfiguring lumpectomy only to learn that she did not have cancer after all.

 

Even though rare, this is not an entirely uncommon event. The New York Times piece, “Prone to Error: Earliest Steps to Find Cancer,” emphasizes the importance of seeking a second opinion to review your biopsy slides and being treated by an experienced physician. The pathologic diagnosis of an early breast cancer called Ductal Carcinoma In Situ (DCIS) can be quite difficult for a pathologist.

 

Screening mammography has helped detect DCIS as small as a couple of millimeters in size; with such little amount of disease for the pathologist to examine, and given similarities between an early breast cancer cell and an atypical non-cancer cell, the definitive diagnosis can be quite challenging for the pathologist. The difficulties were first outlined nearly 20 years ago, in a hallmark study by Yale University pathologist Dr. Juan Rosai.  Rosai surveyed five pathologists, to test the degree of interobservor variability when reading breast pathology slides of early breast cancers.  He surprisingly found the variability amongst the five pathologists to be quite high.  His study highlighted the fact that an element of subjectivity exists in pathology interpretation.  Dr. Rosai concluded that at times, there is no sharp distinction between early cancer and non cancer lesions.

 

That study illustrates why a second opinion of the pathology slides is near-essential; in some cases, a third opinion may be necessary as a “tie breaker.” If a consensus cannot be reached, the surgeon may recommend excisional biopsy to examine more tissue.   These opinions must come from an experienced breast pathologist: The patient in the New York Times article, who had a very disfiguring result after lumpectomy, was treated in rural Michigan, most probably by a general surgeon who may perform as few as ten breast surgery cases per year.

 

In addition to a second opinion on the pathology slides, Saul’s article also emphasizes the importance of being treated by an experienced surgical specialist who has been trained in breast cancer surgery.  There is nothing more satisfying for a surgeon than performing a surgical biopsy on a patient after two pathologists disagreed on the diagnosis only to confirm that the patient does not have cancer and her scar is barely visible.

 

Eleni Tousimis is a breast surgeon at the New York Presbyterian Weill Cornell Medical Center, and an Assistant Professor of Surgery at Weill Medical College of Cornell University. She plays a very active role in resident training, serving as Associate Program Director of Surgical Education. Dr. Tousimis graduated from Albany Medical College in 1996. She was a Fellow at Memorial Sloan Kettering Cancer Center from 2001 to 2002 and then spent the last year as an International Fellow at the European Institute of Oncology in Milan, Italy. A highly skilled clinician, researcher and teacher, Dr. Tousimis is trained in the latest technological advances in the treatment of breast disease, specializing in minimally invasive techniques. She received the City of New York Achievement Award in 2009 as well as the Best Doctors and Top Surgeon Recognitions.

 

RESOURCES

Look Again: The Importance of Second Opinions in Breast Pathology

Prone to Error: Earliest Steps to Find Cancer

http://www.nytimes.com/2010/07/20/health/20cancer.html?pagewanted=all  

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