Physicians should take the time to educate their patients about the biopsy process, because most people do not fully understand what happens to a biopsy specimen after it is taken. That is the word from the oncologists interviewed for this article, who say that overall, many patients don't know who examines their biopsy specimen or when a second opinion might be necessary.
The degree to which patients are uninformed varies, of course. “I don't think people are informed at all,” said Christine Pellegrino, MD, an attending physician in the Department of Oncology at Montefiore Medical Center in New York City. “Patients don't understand the differences between various biopsy techniques such as trucut or fine needle aspiration.”
Patients don't seem to understand where a biopsy sample goes after it is taken, noted surgical oncologist Pat Winston Whitworth, MD, Director of the Nashville Breast Center. “Unless they happen to ask, and we tell them,” he added.
This lack of patient knowledge was recently illustrated by a small online survey conducted by Acupath Laboratories, Inc., a pathology lab in New Hyde Park, NY. The company polled 200 consumers age 18 and older online and found that consumers typically take a “don't ask, don't know” attitude about getting a biopsy.
George Hollenberg, MD, Acupath's Clinical Laboratory Director, notes that the lab serves physicians but that he and his colleagues were curious about public knowledge of pathology and the potential fate of a biopsy.
According to the survey, 76% of consumers don't know they can request a second opinion, a specific lab, or pathologist when getting a biopsy. Moreover, 46% of those who had a biopsy did not even know what a pathologist was.
All patients who had a biopsy did not know the name of the lab or pathologist that interpreted their specimen. A mere 11% asked for a second opinion and 11% asked for a specialist. Just 2% requested a specific lab.
Some physicians find these study results somewhat difficult to believe. For example, Richard T. Silver, MD, Professor of Medicine at Weill Medical College of Cornell University and Director of the Myeloproliferative Disease Center at New York Presbyterian Hospital, finds that most of his patients understand what a biopsy is and know that a pathologist examines the biopsy specimen.
“I would think most people would know that a specialist looks at the tissue under a microscope,” said Dr. Silver, who is also Director of the Cancer Research and Treatment Fund.
Because of a potential lack of patient knowledge, informing patients about the whole biopsy process may be necessary, said Jay Brooks, MD, Chairman of the Hematology/Oncology Department at Ochsner Clinic Foundation.
“I explain it to them up front,” he said. “It helps to eliminate anxiety.”
He tells them which pathologist will be analyzing the sample and whether the process will take place in hospital or clinic. He informs patients that most pathologists usually have several of their colleagues review the case.
It's also important to educate patients about biopsy only to the extent that they want to be, Dr. Whitworth advised. Specifically, he said, women in his practice are often in a high anxiety state, so he doesn't want them to feel pressured in learning about the pathology process.
How much information to provide varies from patient to patient, Dr. Pellegrino agreed. She tells patients about the different types of biopsies available for breast tissue, such as trucut and fine needle aspiration, and the differences between a frozen section and final pathology report.
The diagnosis may be negative on frozen section of breast node but the final pathology may find disease in the lymph nodes. Because of this, Dr. Pellegrino starts off by telling patients that biopsy is a multi-step process.
Regarding the specifics about specialists, Dr. Hollenberg informs patients that specialists are involved in the biopsy interpretation.
Adds Dr. Pellegrino: “Patients don't always realize that there are hematologic pathologists and breast pathologists, gastrointestinal pathologists, and so on.” She also makes sure that they understand that she is not making the final diagnosis but that she will sometimes look at it with the pathologist.
Patients may not realize it's a different person conducting the analysis until they get the bill,” Dr. Pellegrino explained.
Additionally, patients should know that not all hospitals, especially community hospitals, have specialists.
Patients need to understand that analyzing a biopsy depends on close discussion between pathologist, surgeon, and radiologist, and that an individual who has no working relationship with the clinician is not evaluating the sample.
For example, much of the accuracy of image-guided breast biopsy is dependent on the concordance of image and pathology findings.
“The doctor needs to talk to the pathologist,” said Dr. Whitworth, and Dr. Brooks notes that he talks to his pathologist half a dozen times a day.
Because of the need for a close relationship, having the clinician and pathologist working at the same facility may be ideal as compared with a free-standing surgery center with a separate laboratory.
Physicians should give patients a copy of their pathology report, Dr. Brooks said. “Every patient walks out of my office with the report. Everyone has a right to see their results and have it in their hands, and many patients have insurance policies that require a pathology report.”
Additionally, patients should be informed about the turnaround time for biopsy results.
“By and large, it's two or three days,” said Dr. Whitworth. “But with some places it's the next day, and with others, it's a week.”
The important thing to remember is not to say that the results will be back in two days, when they actually will end up coming back in three, he explained. “Patients find this intolerable.”
Turnaround time depends on the tissue, Dr. Silver notes. For example, bone marrow needs to be decalcified and can take a few days.
With breast biopsy, the physician may have a preliminary diagnosis in the operating room but needs to inform the patient that more details and a final diagnosis will only be available in a few days, Dr. Pellegrino explained. An ovarian biopsy may require taking numerous samples, which will take more time for a diagnosis.
Clinicians should also inform their patients that although biopsies are generally accurate, patients do have a right to a second opinion.
To help alleviate uncertainty, physicians may want to impart to patients that biopsy interpretation is very accurate, Dr. Silver said. They are relying on the interpretation of one or two people, but these individuals are very well trained.
Despite this accuracy and training, patients have the right to question the doctor about how accurate their diagnosis is.
Often, a patient's instinct is to ask for a second opinion when pathology results come back that are definitive of cancer. “If the pathologist says this is a standard run-of-the-mill breast cancer, the patient panics and wants a second opinion,” Dr. Whitworth said. However, the likelihood that the pathologist would misdiagnose breast cancer is slim.
A situation that warrants asking for a second opinion is when the pathologist is not sure what the diagnosis is, such as with atypical cells.
There are some diagnoses that are unequivocal, and some that are not, Dr. Silver remarked. Lymphomas and hematologic disease may be difficult to interpret, and a second opinion may be warranted
“If there's a question of diagnosis, patients should not be at all reluctant to ask the doctor to ask the pathologist for a second opinion,” Dr. Silver said.
Some cancers are hard to differentiate from others, agreed Dr. Pellegrino. For example, cancer in a lymph node may be from the stomach or pancreas.
Physicians should let patients know that if they want a second opinion, it is very easy to obtain one, such as at a large cancer center or with doctors within physician groups.
Nowadays most patients are savvy enough to know about getting a second opinion on final diagnosis even if they don't understand the analysis that goes into it, Dr. Pellegrino said.
Insurance companies may have some impact on what labs read patient specimens. For example, said Dr. Hollenberg, companies can contract with a large-volume lab where there are a few specialists.
A hematopathologist could end up seeing a skin biopsy, for example. But forward-looking insurance companies are allowing patients to use specialty labs. Additionally, most willing provider legislation is giving patients more options in their health care, including the selection of labs that can view their biopsy specimens.
Dr. Whitworth acknowledged that sometimes insurance companies do contract with a specific lab, so physicians do not have a choice as to where the biopsy sample goes. This is no longer standard practice across the board, however, because the industry recognized it as causing potential problems, he said.
Even if insurance companies play a role, they are not a hindrance, Dr. Silver said, noting that labs are licensed and have a minimum standard, although certain labs may be better than others.
In summary, Dr. Pellegrino said, “It's not the norm for oncologists to sit and explain all of this because of time constraints. But you have to make patients comfortable.”