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Posted 6/1/2015 2:36 AM (GMT 0)
Just for the sake of conversation....
It occurs to me that .... my Urologist, the one who originally did my biopsy and diagnosed me, sent the biopsy tissue to the lab at the hospital where he works (and is Chief of Uro). It came back with 2 cores G6 and 1 core G8 (3+5).We all know that 3+5 is an unusual combination. And we all know it is a result worthy of a second opinion.

So why did i have to request a second opinion? I'm not thinking just about me, but so many of us know that in many, many situations, in fact probably more often than not, a second opinion on biopsy is warranted. And yet i hardly ever read about olne of our members whose Urologist sent out the slides for a second opinion without it being requested by the patient (us). We've seen it on occasion, but its the exception, not the rule.

Makes no sense, its disturbing to me. End of rant
Posted 6/1/2015 2:54 AM (GMT 0)
I know what you mean...we insisted on a second opinion as well, done by the best person who specialises in prostate pathology and our urologist thought we were crazy. At the end of the day, my view is, we are paying (or rather, insurance is...) And it would give us peace of mind, which is priceless, so... tongue
Posted 6/1/2015 10:42 AM (GMT 0)
My guess is most men who have biopsy and are told they have cancer just do whatever the uro recommends, which is most likely surgery. They're frightened and want it removed asap. The uro has confidence in his lab to the extent that his patient does have cancer and needs surgery. The uro also knows that he could send it out to 5 labs and maybe get back 2 or 3 opinions that agree. He knows too that PC is a multi-focal disease, it's likely his patient has other tumors not yet identified. Let's get you on the schedule and cut this thing out, have a look at the whole mount prostate and see what it tells us.
Posted 6/1/2015 12:17 PM (GMT 0)
Yeah probably best to get one. I didn't. Sometimes I wish I would have but doubt it would have mattered as far as treatment goes.
Posted 6/1/2015 2:28 PM (GMT 0)
I believe that urologists are loathe to recommend a second opinion for pathology because in the closed world of doctors a second opinion denotes a lack of confidence in a local colleague. It is one thing for a patient to ask for a second opinion it's a different thing for a doctor to do so. Patients come and go but the pathologist down the corridor will be there long after the patient has gone.

Perhaps I am being a bit cynical but I think that is how it works.
Posted 6/1/2015 3:18 PM (GMT 0)
Knowledge and self advocacy is the key in any endeavor.
Posted 6/1/2015 4:03 PM (GMT 0)
Oddly enough, back in 2006 when I had suspicious moles biopsied, it worked the other way. The local small hospital pathologist listed "suspicious, not confirmed" and sent the slides to Mayo. My doc called and told me, and then when the report came back from Mayo is when I got the call that went, "Would you be able to come in after work today?"

The question I guess I have is this: how often does the diagnosis change enough to change the treatment choices? I ask as someone who was G6 on 3 of 12 cores, all on the left side. 3 months later, after surgery, I was upgraded to G3+4 with 15-20% organ involvement in all 4 quadrants.
Posted 6/1/2015 4:07 PM (GMT 0)
When I asked my urologist for a second opinion on the biopsy slides, he told me it wasn't necessary since there were two pathologists that routinely read the slides, so I already had a second opinion. As it turns out the slides did get sent out to Johns Hopkins later (after I hooked up with Dr Lam) and I was upgraded from a G8 to a G9.

As a result of all of this, I've learned a tremendous amount about the role of self advocacy.
Posted 6/1/2015 4:52 PM (GMT 0)
Prato, it's disturbing to me as well. Your case is the perfect example of why the second opinions are needed. Even beyond that, one of my peeves is why the urologists don't send the INITIAL samples to labs that are prostate cancer experts. If our little minds on HW can grasp the importance of getting the biopsy pathology right with an expert, what the heck is wrong with all of the presumed big brain urologists who send their samples to a generalist lab? My vent also over...

Jim
Posted 6/1/2015 5:04 PM (GMT 0)
Well, see, that's part of the problem Tudpock, you already think that the minds on HW grasp the importance but urologists who deal with many patients day to day, dare I say possibly even more than HW, and see it close up by definition are smarter than any urologist without regard to his personal experience. It is possible, after all, that uros have indeed gotten second opinions from Epstein and found very few instances of regrading. We don't know what their experience has been. What is wrong with them? It may very well be that they , in fact, do know more than you do.
Posted 6/1/2015 5:13 PM (GMT 0)
Sheepguy...what percent of slides would have to be re-graded for it to be worthwhile to send out slides for a second opinion?
Posted 6/1/2015 5:15 PM (GMT 0)
Sheepguy, yes...it is certainly possible and eminently reasonable to expect that these urologists know more than I do. Heck some days my dog knows more than I do. Yet...in this situation I will continue to recommend that our newly diagnosed brothers here get second opinions from experts because I have seen far too many situations where the second opinion was important to the decision making process. Call me naive, but I think full and correct knowledge is important...

Jim

P.S. Here is what Dr. Epstein has to say about second opinions based on his studies and his review of the literature:

"...for every 200 men diagnosed with prostate cancer there are 3 men who may not have cancer. This number, while low, is not rare. More frequently, even for the cancer cases with an accurate diagnosis, the grade may be changed in about 1 in 5 cases by expert review which could have a major impact in treatment and prognosis."


www.cancernews.com/data/Article/701.asp
Posted 6/1/2015 5:54 PM (GMT 0)
How would any urologist be able to claim he knows what % of his hospital's biopsy slides would have gotten changed had he sent them to Bostwick or Epstein, unless his path lab did a randomized clinical trial? And if they did, he would be happy to tell the patient about it. Doctors are subject to the same cognitive biases we all are. While doctors may not take it upon themselves to get a second opinion, I've never heard of one objecting to it. It's all part of the empowered patient's duty to question the source of the doctor's "knowledge." I don't discount judgment based on experience - in fact, that's what we have to use when higher quality evidence isn't available.

- Allen
Posted 6/1/2015 7:16 PM (GMT 0)
He would be able to know because he has had his patients' slides sent for a second opinion at Epstein/Bostwick and has not seen a difference. Not exactly randomized strictly speaking..not a percentage of his hospital's slides overall but his patients. Not a big N probably ,in my particular case my uro has seen second opinions on 500-600 cases from the local pathologists. I think mostly Bostwick...but not sure. Of course he thinks of freePSA as a useless parameter as well. Again based on experience..he didn't just pull that out of his rear end. I do think I would get a second opinion if it were not 600-700 dollars out of pocket.
Maybe
Posted 6/1/2015 7:44 PM (GMT 0)
It's about $200-$250.

I would go by Epstein's actual stats on the number of revisions he makes, rather than your uro's gut feeling. It may be that your uro's local pathology lab is one of the few that are totally accurate - but why on earth would anyone assume that of his own uro's lab? It's not about getting just a second opinion from some other local guy - it's about getting an opinion from one of the acknowledged world experts - Bostwick or Epstein. Again, I've never heard of a Uro who was against it - why would he be? After all, it's not the uro who reads the slides, and a pathologist dedicated to PC is sure to be more accurate.

- Allen
Posted 6/1/2015 8:27 PM (GMT 0)
It's not a gut feeling...he says that maybe 5% of the time there was a change...he looks at the numbers. Namely what was the number of biopies revised/ the number of biopsies submitted. So he's not against it simply does not see the value. But then again he is not in favor of spending $10,000 on genomics either. Maybe he is hopelessly out of date and trying to kill me..who knows ? I have no idea of the competency of the local pathologists , not having researched it on the internet, one way or the other, but I certainly would not ignore the opinions of local doctors' combined experiences. Even Epstein is not totally accurate.
Posted 6/1/2015 8:32 PM (GMT 0)
...and I refuse to be branded as an uninformed, naive, patient without the intelligence to advocate for myself because I don't necessarily agree that you MUST have Epstein read your slides. Not saying that anyone has branded me as such..but just sayin'. I appreciate the hard work TA and all put in researching everything and keeping track of the most recent developments and do listen to their opinions. Even if they are not uros. :)
Posted 6/1/2015 9:02 PM (GMT 0)
Sheepguy, it would seem that the lab your urologist uses is significantly better than average. Epstein's and others' studies say it is more like 20%. Unfortunately most of us don't know if "our lab" is better or worse or average. Hence the logic to have the slides read by an expert who specializes in reading and understanding prostate cancer pathology.

We just have an honest difference of opinion based on the facts presented.

Jim
Posted 6/1/2015 9:40 PM (GMT 0)
Fair enough
Posted 6/1/2015 11:17 PM (GMT 0)
Interesting discussion out of this thread, as would be expected. Obviously, different pathologists have different experiences of change in Gleason on second opinion. For some it's not necessary, I suppose. But for others it clearly is, based on Epsteins stats posted by TA.
Which leads me to wonder, since prostate cell pathology is so specific and subjective , more so than so many other types of cancer, wouldn't it be a worthwhile endeavor to offer specific training in prostate cell pathology to pathologists who are so inclined? This might yield a few more Epsteins.

Michael_t's question, what % of regrades would justify a second opinion, is a good question. How would we feel if we were one of those guys who was told on second opinion that they didn't have cancer. As valuable as my regrade was, I can't imagine how those guys would have felt if they had unnecessary surgery.


BTW, in my case, it was an issue of what I consider INCOMPETENCE on the part of the first pathologist. The second opinion from Epsetin disputed the very PREMISE which the first pathologist used to give me a secondary grade of 5. And the second opinion of Epstein was RECOMFIRMED, with a third opinion by pathologists at MSKCC.

So it sort of sticks in my craw.
Posted 6/1/2015 11:20 PM (GMT 0)
Interesting discussion. Thanks to all.
Posted 6/2/2015 12:25 AM (GMT 0)
One of the problems is that we, as patients, rarely if ever have an actual conversation with the pathologist. From what I've read, pathologists as a group are the true scientists of the hospital culture. They generally welcome outside experts opinions of their work...because they all want to get better. Before anyone jumps on me for using "all", that may be somewhat inaccurate, but not terribly so.

The issue, as I see it, is that there are still a lot of surgeons in particular who have a big God complex, and they can't handle anyone....particularly a patient...who dares to question them. The problem isn't the pathologist..it's the surgeon.
Posted 6/2/2015 1:58 AM (GMT 0)
Yeah, Halbert, but I think that goes with a surgeon's territory...that is part of what makes them competent surgeons. You have to treat them as mechanics...not artists. Although there may be an artistic component of surgery...but then that's what makes actors, musicians and such act oddly on occasion..it 's part of being who and what they are. As in many things that may be changing with the newer generations. Let's hope so, not every patient is going to research their conditions very much.
Posted 6/2/2015 2:31 AM (GMT 0)
sheepguy, What I really, really like in modern medicine is the movement (in some places) towards a true team approach, where every specialist involved with a particular patient is actually in the same room at the same time. This has been proven to avoid nasty drug interactions for one thing, as well as helping prevent some of the synergistic things that happen in complex cases. Besides, I like the idea that in that scenario, you can get insights from the least likely directions.
Posted 6/2/2015 4:02 AM (GMT 0)
Sometimes I wonder if some uros are so close to this stuff on a day to day basis that they "just deal with it as it comes". I.e.... "Those guys do a good job. I know them. They're good enough. I wonder what we're having for supper tonight?"

I also wonder if "inter-office politics" enters into it.
I.E...would a uro working at any given health care facility really want a reputation at work as someone who openly "distrusts" it's own pathologists?

It's a good question though. 2 of my cores came back as "atypical". Epstien says he can categorize atypical findings "80% of the time."

And he did mine. He put one at G6 and one at HGPIN.)

These guys have to know this stuff.
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