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Summer 2017 : Double-checking a diagnosis
Second opinions and second chances
Maybe it was Antonia Shiffman’s background in nursing, or her natural inclination to get to the bottom of things that spurred her to seek a second opinion from MD Anderson.
Curtis Pettaway, M.D.
photo by Wyatt McSpadden
Maybe it was Antonia Shiffman’s background in nursing, or her natural inclination to get to the bottom of things, that spurred her to seek a second opinion from MD Anderson.
Or maybe it was because she had watched too many residents of her small-town community in upstate New York succumb to cancer too soon – and too easily.
Whatever the reason, Shiffman, then 53, felt uneasy about her prognosis for endometrial cancer. So much so that she paid for a full-body scan out of her own pocket to see if the cancer had spread since her hysterectomy and radiation therapy. It came back clear for metastatic cancer. But Shiffman needed to be 100% sure. So she sent her scans and pathology slides to MD Anderson for answers.
In contrast, Arthur Triche had confidence in his diagnosis of kidney cancer at age 51. But the producer of a popular sports radio show in Atlanta, renowned for being the first African-American director of public relations for an NBA team, didn’t relish the thought of having his entire kidney removed, as advised by his physicians.
A decade earlier, he was successfully treated at MD Anderson for a rare urological cancer. Triche called his MD Anderson oncologist, Curtis Pettaway, M.D., professor of Urology, to get his take on the surgery.
Second opinions from MD Anderson dramatically changed both patients’ lives.
In Shiffman’s case, a second opinion detected an overlooked, suspicious mass on her adrenal gland, an area where endometrial cancer rarely spreads. It was determined to be clear cell carcinoma – an aggressive form of cancer with a high rate of recurrence. The groundbreaking surgery and targeted radiation that followed at MD Anderson saved her life.
And Triche learned he was a candidate for a surgery that removed only a part of his kidney – saving him from losing a vital organ.
Second opinions common at MD Anderson
Surprising second opinion stories such as these aren’t out of the ordinary at MD Anderson, where pathologists review an average of 30,000 outside pathology diagnoses, and another 40,000 initial biopsies and resections, each year.
It’s not uncommon for patients seeking a second opinion at MD Anderson to receive a significantly different diagnosis, says Lavinia Middleton, professor of Pathology.
She credits the cancer center’s sophisticated multidisciplinary approach to patient care – built around subspecialization, radiologic and clinical correlation, and extensive experience with patient outcomes – for helping recognize discrepancies.
A 2011 review of some 2,700 patient cases revealed that in 25%, discrepancies between the original pathologists’ reports and MD Anderson’s were found. And a 2015 study showed clinically significant discrepancies in diagnosis in 10% of breast cancer patients at MD Anderson.
Rarely does a diagnosis change from benign to malignant or vice versa, Middleton says, although it does happen in about 5% of cases. More common are differences in the staging of a tumor, or classifications of biomarkers – molecules that subdivide tumors into groups that have different prognoses and can be used to guide the selection of the most effective therapy.
“We need second opinions to become a normal part of the health care process. We need a second opinion revolution!”
Nancy Perrier, M.D.
photo by Adolfo Chavez III
“The stage and the anatomical extent of the tumor will guide surgical, radiation and medical oncologists on how to approach treatment,” Middleton says. “It can determine if that patient will undergo chemotherapy first, or surgery. About 25 percent of the time, a patient’s treatment plan will change based on review of the outside pathology.”
Many patients also seek second opinions from MD Anderson to see if they’re eligible for innovative new therapies that aren’t available where they live.
Patients can send their scans and test results directly to MD Anderson for a second opinion, or schedule an in-person consultation. If they decide to continue treatment at MD Anderson, they meet with a multidisciplinary team of cancer specialists to determine an individualized treatment plan.
‘I owe my life to that second opinion’
In Shiffman’s case, her treatment team recommended chemotherapy followed by an innovative surgical procedure known as retroperitoneal laparoscopic adrenalectomy to remove the tumor on her adrenal gland. German surgeon Martin Walz, M.D., an international expert in minimally invasive surgery, pioneered the technique. He trained MD Anderson surgeons Nancy Perrier, M.D., Douglas Evans, M.D. and Jeffrey Lee, M.D., on the approach.
Together, they laparoscopically removed Shiffman’s adrenal gland through three tiny incisions in her back, instead of the front of the body. The operation worked well for Shiffman because it allowed the surgeons to avoid cutting through scar tissue from her hysterectomy, and shifting her still-healing organs.
Shiffman was the first MD Anderson patient to undergo the procedure, which became the standard surgical treatment for removing adrenal tumors after its 2005 debut.
“We were able to remove the tumor, and the source of disease,” says Perrier, professor of Surgical Oncology and chief of Surgical Endocrinology. “In other words, she had a quick recovery, and the operation did not affect her quality of life, which was really important to her.”
Six months after surgery, Shiffman had a cancer recurrence, but a type of targeted radiation called intensity-modulated radiation therapy (IMRT) was used to knock it out. More than a decade later, she is cancer free and appreciates her second chance at life, and the opportunity to see her six grandchildren grow up.
“I owe my life to that second opinion,” says Shiffman, now 66. “And every day when I wake up, every morning, my first utterance is gratitude. Just pure gratitude.”
Shiffman is officially retired, but stays busy advocating for patients newly diagnosed with cancer. She accompanies them to physician visits to take in important information, ask questions, request additional imaging and, when necessary, to encourage second opinions.
“I talk to so many people who don’t ask for second opinions, or their doctors don’t encourage them,” she says. “We need second opinions to become a normal part of the health care process. We need a second opinion revolution!”
‘I’m very thankful I made the call’
Triche was enjoying one last pre-surgery celebration when he received a call back from Pettaway.
“He said, ‘Why are you not having the procedure at MD Anderson?’” recalls Triche. “‘I don’t think it is necessary to have your entire kidney removed.’”
Preserving kidney function was important, Pettway explains. As we age, medical conditions such as high blood pressure and diabetes accelerate the loss of kidney function, and may ultimately lead to the need for dialysis or transplant. However, many cancer patients aren’t candidates for organ transplants until they have been cancer-free for several years.
“Because Mr. Triche already had some diminished kidney function, I wanted to make sure that the kidney had to be removed, and there was no possibility of saving it,” Pettaway says.
Triche put the brakes on the surgery and traveled to Houston to meet with Surena Matin, M.D., professor of Urology, who recommended a partial nephrectomy to remove just the areas of the kidney containing cancer. While Triche’s surgery called for using an open incision, the procedure also is commonly performed using minimally invasive robotic surgery.
“It’s just as effective of a cancer operation as a complete removal, but with the added benefit of preserving the kidneys,” Matin says.
Two weeks after surgery, Triche was ready to return to work and to his life in Atlanta. He’s happy he sought a second opinion from MD Anderson.
“I am very thankful that I made the call to Dr. Pettaway,” says the 55-year-old Triche. “If I hadn’t, I could be walking around right now without a kidney, and in the long term it may have meant that I would have had to go on dialysis.”
Paving the way for easier second opinions
Middleton is hopeful that telemedicine may make it easier to get a second opinion. Support for the practice is growing nationwide. In May, the Texas Legislature passed a bill eliminating the need for an in-person consultation, easing restrictions on remote diagnosis and treatment.
“Telepathology is a natural extension of telemedicine,” Middleton says. “It lets us share our expertise in a manner that is sufficient and timely for people who may not have access to experts in their local environment.”
In the meantime, Middleton encourages patients confronting cancer to seek out second opinions whenever possible.
“A cancer diagnosis and its staging are the foundation on which all future treatment will be established. You want to make sure you’re making a decision based upon accurate information. That way, oncologists can appropriately treat the tumor,” Middleton says. “If you have any doubts, or even if you have none, get an expert second opinion. The diagnosis is a life-changing event, but it doesn’t have to be a death sentence.”
How to get a second opinion
Most insurance companies reimburse the cost of a second-opinion consultation for cancer. And many insurers require a second opinion before covering some treatment costs. Patients can ask their treating physician to send their pathology slides or related materials directly to MD Anderson. To learn how, visit MD Anderson's "Second Opinion Pathology" page. Patients can also book an in-person consultation with an MD Anderson oncologist through the website.
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