It's not unusual for a patient to arrive at MD Anderson with one diagnosis and leave with a different one.
For example, when approximately 2,700 patient cases were reviewed during September 2011, 25% showed discrepancies between the original pathologists' reports and our pathologists' reports. While the changes in diagnosis were minor in 18.7%, in the other 6.2%, the diagnosis change made a major difference.
"In some of those cases, we changed the diagnosis from malignant to benign or vice versa," explains Lavinia Middleton, M.D., professor in Pathology. "That adds up to approximately 2,000 cases per year where we can say that our pathologists' reviews have impacted patients' treatment.
"Changing the diagnosis from malignant to benign is the best call to make. This makes us feel really good."
"Review of outside material is a major component of the work done by our Pathology and Hematopathology departments," adds Stanley Hamilton, M.D., division head in Pathology/Laboratory Medicine. "The correct pathologic diagnosis and stage of each tumor are key to high quality care for patients."
How we make the correct diagnosis
So why do we find things overlooked by other health care institutions?
"Our system here helps us make the right cancer diagnosis. It's based on three things: sub-specialization, volume and redundancy," Middleton explains.
In the late 1990s, then-President John Mendelsohn, M.D., supported the sub-specialization of our pathologists, Middleton reports. Since that time, the vast majority of our pathologists have focused on just one organ system, like breast or lung. They review disease site-specific pathology and attend multidisciplinary conferences where pathologic and clinical findings are correlated.
Our pathologists review a large volume of pathology and get very good at spotting cancer and its mimickers. Every year, our 60 faculty in the Pathology department perform approximately 30,000 second opinion reviews, plus another 40,000 initial biopsies and resections. And the numbers are growing.
Our pathologists also become accustomed to dealing with rare or unusual cancers that are reviewed at intradepartmental conferences, providing redundancy of experience and expertise.
"We have a lot of respect for the community-based pathologist who has to be good at recognizing everything," Middleton says. "What some pathologists at other places see once in a lifetime, we probably see one or two times a month, so we become very familiar with it. And we work in a collaborative environment that allows us to benefit from one another's expertise."
Making our system even better
As both section chief of quality for the Pathology/Lab Medicine division and medical director of Quality Improvement for the Pathology department, Middleton spends a great deal of time tracking the reviews and processes performed by our pathologists.
"We do a lot of workflow analysis to help us work smarter, eliminate waste and make sure we get the diagnosis right," she says.
For example, one project instituted barcode labeling of all biopsy specimens and incorporated a "forcing function" system to ensure accurate patient identification. We're all familiar with such systems, whether we realize it or not. If you're filling up your car's gas tank, get distracted and drive off without removing the hose from the tank, the pump automatically shuts down, disassociating the hose from the source. That's a forcing function.
Our review system operates on a similar principle, Middleton explains. If someone starts to dictate a biopsy specimen and uses the wrong patient identifier, he or she immediately hears a loud alarm and is no longer able to continue.
Middleton also is working with Tracy Spinks, program director, Clinical Operations, to take 2011's second opinion project outside MD Anderson and involve the 12 hospitals that make up the Alliance of Dedicated Cancer Centers. They hope to demonstrate the value of second opinions to payors as well as patients.
And she's currently involved in a pilot study with a free-standing community-based diagnostic imaging center that will enable patients to get their initial biopsies evaluated at MD Anderson, instead of coming here later for second opinions.
"We can do this with our existing structure and current staff," Middleton says. "And in the long run, it probably would take less time than repeating or re-reading biopsies."
All these projects have the same goal: to share MD Anderson's expertise and expand our services beyond our Texas Medical Center Campus and make our pathology review process even better for patients. After all, patients' futures often depend on us getting the diagnosis exactly right.
This story originally appeared in Messenger, MD Anderson's bimonthly employee publication.