Some Cancers, Asthma, Other Conditions Can Be Tricky to Diagnose, Leading to Incorrect Treatments.
When a CT scan showed multiple tumors in Dawna Harwell’s pelvis, abdomen and spine in 2008, her doctors in Dallas told her she might have ovarian cancer, which can be especially deadly.
A biopsy came back with inconclusive results, and Ms. Harwell wasted no time in seeking a second opinion at MD Anderson Cancer Center in Houston. “I went through every test in the book,” says Ms. Harwell. Still, doctors couldn’t be sure what she had. Finally, she underwent a surgical procedure to diagnose her case: It wasn’t ovarian cancer after all, but a rare form of lymphoma. The 47-year-old horse trainer in Collinsville, Texas, underwent a rigorous regimen of chemotherapy that ended last spring. At her first six-month checkup in October, she received a clean bill of health.
Evidence is mounting that second opinions—particularly on radiology images and pathology slides from biopsies—can lead to significant changes in a patient’s diagnosis or in recommendations for treating a disease. Some malignancies, including lymphomas and rare cancers of the thyroid and salivary glands, are notoriously tricky to diagnose correctly; test results can be inconclusive or return false results. After a decade of annual mammograms, more than half of women will receive at least one false positive recall on a breast-cancer screening, a recent study found. And nearly half of malpractice claims at Harvard University’s medical institutions that resulted in serious patient harm or death in the past five years were diagnostic errors, according to its liability company Crico/RMF.
Thomas Feeley, vice president of medical operations at MD Anderson, says as many as 25% of patients who arrive at the center with diagnoses for certain cancers such as lymphoma may receive a different diagnosis. Overall, 3% of MD Anderson patients each year end up with a significant change that affects what treatment they receive. “When you get cancer, the first thing you may want to do is jump to get treatment with the first person you talk to,” Dr. Feeley says. “But taking the time to get a second opinion about the diagnosis you have and a careful evaluation of what treatments there are can be lifesaving.”
Kim Henderson, a paralegal in Houston, came to MD Anderson to be treated for cervical cancer after being diagnosed elsewhere. Pathologists performed another biopsy that revealed she had a noninvasive precursor to cervical cancer—and not the far more serious invasive type as previously believed. Although she still needed surgery, her doctors told her she could skip the radiation and chemotherapy that had originally been part of the treatment plan.
“I felt like it was a miracle and I was spared from this unnecessary treatment,” says Ms. Henderson, who had lost a sister to cancer.
Second opinions are important for other diseases, as well. National Jewish Health, a Denver medical center, found in a study that more than half of patients it diagnosed with chronic obstructive pulmonary disease had previously been misdiagnosed with asthma, leading to inappropriate treatments. A form of dementia is often incorrectly diagnosed as Alzheimer’s, and studies show that doctors may misdiagnose coronary artery disease as other conditions.
Not everyone should have a second opinion, of course. Health-care costs would soar if they did, says Robert Wachter, chief of the division of hospital medicine at the University of California, San Francisco. “There is also a risk you can get overwhelmed by conflicting opinions when you are in a terribly vulnerable position.” In the end, he says, patients must pick a doctor they trust and go with his or her recommendation.
Many health insurers require a second opinion before approving major surgery or expensive treatments. Patients shouldn’t hesitate to tell a doctor they want a second opinion, and they are entitled to their slides, pathology reports and other information to take elsewhere. Major medical centers, including Johns Hopkins Medicine and MD Anderson, have second-opinion services that doctors can refer patients to, or patients can contact directly, to get an independent assessment.
Hardeep Singh, chief of the health policy and quality program at Michael E. DeBakey VA Medical Center in Houston, says a growing number of centers are requiring an internal second review of pathology reports to prevent misdiagnosis. If the second opinion differs markedly, a third opinion may be necessary to get a consensus on what course of treatment is best.
Misdiagnoses can come about for various reasons. Pathologists and radiologists may misread slides and scans or fail to use the latest tests or technology. Sometimes doctors may simply get stuck on the idea of one diagnosis and ignore or overlook evidence it might be something else. This month, the president of Argentina had her thyroid removed after being diagnosed with cancer from a biopsy, but the doctors announced after the surgery that she in fact had a benign condition.
Jonathan Lewin, chief radiologist at Johns Hopkins Hospital, says that on an annual basis, his group sees a significant discrepancy in diagnosis in about 8% of cases, such as a brain tumor mistakenly thought to be an infection or a stroke or multiple sclerosis that initially is diagnosed as a brain tumor. “The last thing a surgeon wants to do is take out a piece of brain and find out this isn’t what we thought it was,” Dr. Lewin says.
For Ms. Harwell, the Texas horse trainer, it took more than a month before MD Anderson finally identified her condition. Because certain markers for ovarian cancer weren’t present, doctors began to consider a form of lymphoma, although tests for that were inconclusive. Lymphoma expert Rick Hagemeister says he told Ms. Harwell the only way to get a firm diagnosis would be from a surgical biopsy of the tumors massed in her pelvis.
Ms. Harwell says gynecologic oncologist Kathleen Schmeler told her the surgery needed to be a hysterectomy, which would also be the treatment for ovarian cancer on the chance that was the problem. Seven days later, pathology reports from the procedure came back: follicular lymphoma, a rare form of the disease that would require eight rounds of chemotherapy regimen R-CHOP followed by two years of a maintenance drug, Rituxan.
Ms. Harwell says she was grateful that MD Anderson didn’t begin treating her with what might have been the wrong regimen. Shortly after starting chemotherapy, Ms. Harwell showed at the Appaloosa World Show. When she took off her hat, a lot of her hair came off, too.
Changing the Diagnosis
Pathologists changed the diagnosis of 9% of 742 cancer cases in a recent study. Some original diagnoses—and the percentage of them that were changed on second opinion.
- 16% of thyroid cancers
- 10% of neck cancers
- 11% of salivary-gland cancers
- 9% of liver cancers
- 8% of pancreatic cancers
- 6% of lung cancers
Source: American Cancer Society; Cancer Cytopathology
What to Ask When Seeking A Second Opinion
- Have you reviewed all the materials related to my case?
- Was the lab test/image/biopsy specimen adequate to make a firm diagnosis? Would a repeat test give us more information?
- Are we certain that this is the disease that I have? Could there be another explanation for these symptoms or results?
- If you agree with the initial diagnosis, can you confirm or suggest modifications to the first doctor’s proposed treatment plan?
- Can you reassure me that we have explored all the options?