Mandatory second opinion in cytopathology

Abstract

BACKGROUND:Mandatory review of outside pathologic material is intended to detect interpretive errors that may have a clinically significant impact on patient care. Prior to definitive treatment of referred patients, the University of Iowa Carver College of Medicine requires a review of pertinent pathologic material previously obtained at outside institutions. The aims of this study were to determine if this local standard of practice has a measurable impact on patient care.METHODS:The pathologic diagnoses of 499 second opinion cytology cases seen at the University of Iowa Carver College of Medicine were studied. Each second opinion was classified as “no diagnostic disagreement”, “minor disagreement”, or “major disagreement” with respect to the originating institution's interpretation. The clinical impact of major disagreement cases was determined by pathologic and clinical follow‐up via chart review.RESULTS:Second opinion cytology resulted in 37 cases (7.4% of total cases) with major diagnostic disagreements. Clinical and pathologic follow‐up was available in 30 of the major disagreement cases; second opinion diagnosis was better supported in 22 of these cases compared to the outside diagnosis. The second opinion in 6 major disagreement cases prompted changes in clinical management.CONCLUSIONS:Major disagreements in second opinion cytology are common, likely reflective of the challenges inherent in the interpretation of cytologic specimens. Although mandatory second opinion of outside cytologic material prompted changes in clinical management in only a small fraction of cases (1.2%), this rate was similar to those previously published for surgical pathology second opinion. These findings support the notion that mandatory second opinion policy as an important part of patient care. Cancer (Cancer Cytopathol) 2009. © 2009 American Cancer Society.

Lung Cancer Patients Benefit from Second Opinions by Improvement of Diagnosis and Therapy

“…Second opinions solely on lung cancer have never been investigated and in other reports with mixed/miscellaneous patient populations, the number of lung cancer cases was too limited to draw specific conclusions in this group (Maaskant et al, 2009;Lueck et al, 2009;Manion et al, 2008;Mellink et al, 1999;Tsung, 2004). Although it is difficult to compare present results with general second opinion data, it is striking that our percentages discrepancies and their potential impact on patient outcomes are higher than reported in literature.…”

“…Second opinions have proven to be of value for a number of different diseases, especially in oncology (Briggs, Flynn, Worthington, Rennie, & McKinstry, 2008;Kronz, Westra, & Epstein, 1999;Lueck, Jensen, Cohen, & Weydert, 2009;Manion, Cohen, & Weydert, 2008). The percentages of discrepancies after a second opinion vary between 1% and 60%, depending on the disease and anatomic site, the nature and quality of pathological specimen (cytology or histopathology), the applied definition criteria for the changes (in diagnosis, stage or therapeutic advice), their clinical impact on therapy and/or prognosis and the patient population (Tattersall et al, 2009;Briggs et al, 2008;Kronz et al, 1999;Lueck et al, 2009;Manion et al, 2008;Frable, 2006;Kronz & Westra, 2005;Zembowicz, Ahmad, & Lyle, 2011).…”

Evaluation of Indeterminate Thyroid Cytology by Second-Opinion Diagnosis or Repeat Fine-Needle Aspiration: Which Is the Best Approach?

“…Jing et al [5], for instance, reported that intradepartmental consensus review of 50 thyroid aspirates previously classified as AUS/FLUS resulted in a definitive diagnosis in 74% of the cases with a consequent improvement of diagnostic accuracy. Indeed, examination of pathological material, including cytological specimens, is an accepted practice in many institutions, especially in the context of a second opinion for referred patients before clinical management [6,7,8,9,10,11]. In a large series of institutional consultations for 3,885 thyroid FNAs, Olson et al [12] showed that the second review significantly decreased the rate of indeterminate cytological diagnosis with an increase in numbers of nondiagnostic (unsatisfactory), benign and malignant diagnoses.…”

The “Second Opinion Medical Network”

“…The term "second opinion" has been widely reported also in histology [10,11] and pathology (e.g. thyroid pathology) [12][13][14][15][16][17][18][19][20] where the diagnosis is often difficult, misunderstood and strongly based on the healthcare professionals' experience.…”

“…However, the internet sites are often lacking of adequate information concerning disease complications and aftercare [4]. This web-searching behaviour is often continuous, compulsory, somehow obsessive, leading to the "Web Babel Syndrome", defined as a physician-patient communication gap frequently occurring when the patient affected by multiple synchronous pathologies, feeds back heterogeneous and misleading informations and prescriptions with the risk to drop in a confusionary state [5][6][7][8].In 1999, the Institute of Medicine report cited fatal medical errors in some 40,000-98,000 Americans PER year [8] supporting once more the concept that a further consultation or specialistic second opinion may be useful antidote to lethal misdiagnosis [9].The term "second opinion" has been widely reported also in histology [10,11] and pathology (e.g. thyroid pathology) [12][13][14][15][16][17][18][19][20] where the diagnosis is often difficult, misunderstood and strongly based on the healthcare professionals' experience.…”