Second Opinion May Aid Breast Cancer Treatment


breast cancerA second opinion from a team of specialists after an initial diagnosis of breast cancer resulted in a significant change in the recommended surgical treatment in more than half of cases, a new study has found.

Disagreement involved everything from the interpretation of mammograms to the necessity for mastectomy, and 6 of the 149 women in the one-year study were found on second consideration to have no breast cancer at all. The report was published in the Nov. 15 issue of the journal Cancer.

All of the women had been referred by their doctors to a specialized cancer center for a second opinion, and all arrived with biopsy slides, X-rays and a surgeon’s recommendation for treatment.

“The number did surprise me — that there were actually half the patients who had a change in management,” said Dr. Michael S. Sabel, the senior author of the paper and a surgical oncologist at the University of Michigan Comprehensive Cancer Center, where the study took place. “But a lot of it just has to do with having a second pair of eyes. Having two radiologists read a mammogram is better than one.”

Teams that review cancer diagnoses and treatment recommendations, called multidisciplinary tumor boards, usually include cancer doctors who specialize in treatment and diagnosis, including surgeons and nurses. They review a case and arrive at a consensus treatment recommendation. Dr. Sabel said that many hospitals, not just specialized cancer centers, routinely use such boards.

Dr. Eileen Rakovitch, an assistant professor in the department of radiation oncology at the University of Toronto, said the study added to an increasing body of evidence that a multidisciplinary approach was beneficial. “When they are seen by a team of specialists,” Dr. Rakovitch said, “patients at lower risk may receive less aggressive treatment, and patients deemed at higher risk may get more aggressive treatments. This is not unique to breast cancer. There’s evidence for this in other life-threatening diseases as well.”

She continued, “When a person sees only one specialist, they’re only exposed to treatments within that person’s realm of expertise. Knowledge takes time to diffuse, especially across specialties.”

In the study, radiologists who specialized in reading breast cancer X-rays offered differing interpretations for 45 percent of the patients. The most common was the finding of an additional cancer site. Six patients had residual cancer at the site of a previous tumor removal; one was upgraded from benign disease to invasive cancer; and two had their diagnoses of ductal carcinoma in situ, a noninvasive form of disease often treatable without mastectomy, changed to invasive cancer.

Reinterpretations of images resulted in a change in surgical procedures for 11 percent of the patients. Differences in interpreting microscopic views of tissue drawn from biopsies led to changes for an additional 9 percent.

The tumor board found that five of the patients recommended for mastectomy were good candidates for breast conservation surgery, and that two women recommended for breast conservation would be better treated with mastectomy.

For 32 percent of the women, the change in recommendation was based not on disagreement about the radiology or pathology findings, but rather on interpretation of the standards for care endorsed by the National Comprehensive Cancer Network, an alliance of 20 cancer care centers in the United States that publishes treatment guidelines and educational materials for physicians.

Dr. Hiram S. Cody III, acting director of the breast service at Memorial Sloan-Kettering Cancer Center in New York, was impressed with the study. “This is a very nice paper,” Dr. Cody said, “and very well done. The message here is that when a patient has a cancer diagnosis, getting a second opinion is very good bang for the buck.”

Were the decisions of the tumor board that contradicted the original diagnoses correct? “The follow-up on these patients is too short right now to really know the outcome,” Dr. Sabel said, “and of course in many cases there is no way of knowing what would have happened had a change not been made.”

source - NY Times 


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