In recent months, widespread media coverage regarding second opinions for breast cancer diagnosis has sparked a dialogue about if — and when — a patient requires a second opinion. Seventy percent of all medical treatment plans are driven by laboratory test results, and every treatment begins with a diagnosis.

That’s where pathologists come in. As professor and chair of pathology at Albert Einstein College of Medicine and Montefiore, I think it is important to share how pathologists work and how they can help patients make crucial healthcare decisions, even though they will most likely never meet.

Pathologists understand that their diagnoses will drive treatment decisions, and they work closely as part of a team with physicians who treat patients, while using clinical history to help make accurate pathologic diagnoses.

What does a pathologist do?

Pathologists make diagnoses based on analyses of laboratory test results and tissue specimens in the context of the clinical presentation, and discuss cases with treating physicians. They frequently consult with other pathologists and work in accredited, externally inspected laboratories that routinely employ quality assurance processes to ensure accuracy.

Surgical pathologists make diagnoses based on examination of tissue removed, either as biopsies or as resections. The most important part of this examination is microscopic evaluation of the tissue, which requires processing to preserve details down to the level of single cells within tissue specimens. Tissue processing is a well-controlled, rigorous, reproducible process carried out by skilled technicians.

When should patients or physicians seek second opinions?

A second opinion should be obtained by a physician for a challenging case in an attempt to arrive at an accurate diagnosis leading to optimal treatment. And second opinions should be requested by patients when diagnoses require life-altering therapy, to ensure accurate diagnoses and proper treatment plans.

Let’s first look at how doctors work with pathologists.

Two types of challenging cases when physicians need second opinions

Challenging cases — those that cannot clearly be diagnosed via a characteristic cellular microscopic pattern — can be divided further into two more categories: somewhat and really challenging cases. Somewhat challenging cases have tissue specimens for which a standard microscopic examination alone does not give a clear answer. For these cases, the pathologist has additional tools to examine the biochemical and genetic properties of a specimen that will distinguish it from look-alikes and reveal its identity. Also, the expertise of a second pathologist will be called in, and this review will either confirm the diagnosis made by the first pathologist or offer other ideas. This type of second opinion from a pathologist is standard practice at Montefiore and throughout the country.

A really challenging case is one where neither microscopic examination nor any of the special tools just described allow the pathologist to make a definitive diagnosis. Why does this happen? Some diseases take time to develop and may not show their true appearance early in their course. For example, a normal cell does not suddenly become a cancer cell; it may progressively undergo genetic changes over a period of time, existing in stages between normal and cancerous. These intermediate stages do not have the characteristic microscopic appearance of either normal or cancer cells, and differing opinions can arise. This is when another pathologist in a practice group is called upon by the first pathologist to review a case. It’s also standard practice to include external consultants, since the lead pathologist’s main concern is for diagnostic accuracy that will result in the best treatment for each patient. Montefiore, being an academic medical center, often receives such challenging cases from other pathologists for review.

When a patient needs a second opinion

From the patient’s perspective, an accurate diagnosis that requires life-altering therapy (e.g., cancer requiring surgery, chemotherapy, radiation therapy or some combination of all three) is devastating. A patient may want a second opinion to confirm the diagnosis and understand the treatment options. Dr. Michael Misialek, associate chair of pathology at Newton-Wellesley Hospital and assistant clinical professor of pathology at Tufts University School of Medicine, published an excellent article informing and guiding patients on breast cancer diagnosis. He advises patients to take the following steps in securing a second opinion:

• Inquire about the pathology laboratory that will examine your tissue samples. Is the laboratory accredited? The CAP accredits more than 7,600 laboratories worldwide and provides an online directory for patients.
• Make sure the pathologists who are examining your tissue samples are board certified.
• Find out if your hospital has a multidisciplinary breast conference. This is a team of physicians and other healthcare professionals that meets regularly to discuss diagnosis and management of patients with breast disease, guaranteeing more consultation about the best approach for your care.
• If your hospital doesn’t have a multidisciplinary breast conference, consider getting a second opinion. Second opinions are always welcome. Have your doctor send the biopsy slides to another laboratory and request that they be read by a pathologist who specializes in breast pathology.
• Seek out accurate and credible resources to help you understand your pathology report and diagnosis, such as the CAP’s “How to Read Your Pathology Report.”
• Most accredited surgical pathology laboratories include second-opinion slide review as part of their quality management programs. Ask about this.

This is a lot to take in, I know, but my hope is that patients seeking second opinions, and the doctors who treat them, will better understand how the pathologists who are making life-changing diagnoses operate.

Michael Prystowsky is chair, department of pathology, Albert Einstein College of Medicine and Montefiore Medical Center.  He blogs at the Doctor’s Tablet.

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