2nd opinion from major center leads to better breast cancer detection, treatment changes

December 04, 2003

CHICAGO - Women with breast cancer who seek a second opinion on their mammograms from experienced specialists at a major cancer center frequently get a new plan for their care, a new study shows. Some even learn that they have cancer in more locations than they think.

After a consultation, 7 percent of all patients in the new study found out that they had more cancer in the same breast - or a previously undiscovered tumor in the other breast. Many other patients received advice from the consulting physicians that altered their imaging or treatment plans.

These new research findings, made by a team at the University of Michigan Comprehensive Cancer Center, will be presented Dec. 4 at the national meeting of the Radiological Society of North America.

The data show that seeking a second opinion for breast cancer may make a big difference in a patient's diagnosis and treatment. Second opinions are often covered by insurance, but patients usually need to seek them on their own.

"Although many patients' diagnostic and treatment plans stayed the same after a consultation, enough of them changed that we see added value from seeking the opinion of a specialized team with extensive experience," says Amy Rochester Guest, M.D., the U-M radiologist who led the study. "This is especially true for complex cases, but any patient may benefit from a second opinion, whether she returns to her original physician and care plan or transfers to the larger center."

For the study, the team looked back at the medical records of 148 women who came to the U-M Breast Care Center for a consultation after being diagnosed with, and in some cases treated for, breast cancer at other institutions. They compared the findings and recommendations of the outside doctors with those made by the U-M team.

The data that Guest will present at RSNA focus on the results of the imaging portion of the consultation, and recommendations made based on initial and additional breast images. All the radiologists at the U-M center see hundreds of consultation cases each year.

The U-M team conducts a one-day radiology, surgical and pathology consult for every women who seeks a second opinion, including further images and tests if necessary.

Two-thirds of the patients in the study had additional imaging performed at U-M during their consultation, usually a combination of mammograms and ultrasound. The radiologists used these additional images to further evaluate the tumor and the remainder of the breast before making a final interpretation.

When the outside and the additional images were reviewed by the specialized breast imagers at the University of Michigan, their interpretation differed from the original reading in 45 percent (67) of the patients.

That change in interpretation made a difference in recommendations for 43 patients, representing 30 percent of the entire group. The U-M physicians advised additional or different biopsy procedures, additional follow-up imaging, and changes to treatment including surgery, chemotherapy and radiation therapy.

"Our imaging findings had varying levels of effect on the patient's care," says Guest, a lecturer in the Department of Radiology at the U-M Medical School. "While some had additional abnormalities, others had the size of their lesion reclassified which affected their eligibility for breast conservation therapy and neoadjuvant chemotherapy. Two patients underwent neoadjuvant chemotherapy resulting from an increase in the determined size of their cancer, which allowed them to undergo a lumpectomy instead of a mastectomy. However, some patients had no change in their care due to the change in their imaging interpretation."

Of the 28 additional biopsies that the U-M consult team recommended, full records were available for 24. Ten of the recommended biopsies were positive for malignancy - cancers not found by the patient's original doctor.

Six of the ten patients had another cancer in the affected breast. Four of the ten had a second primary breast cancer in the opposite breast. The ten patients represent 7 percent of the entire study group, giving the consulting radiologists a 7 percent incremental cancer detection rate over the patients' original physicians.

In all, 42 percent of recommended biopsies showed malignancy, which is similar to the positive predictive values expected in mammography. This indicates that the number of patients who were biopsied in order to detect the additional cancers was appropriate.

All in all, Guest says, the results show that many women may benefit from a second opinion by radiologists who are highly experienced in evaluating numerous and often complicated breast cancer cases.

But, she adds, "The further scrutiny given in a consultation, on top of the evaluation done by a woman's initial physician, may just confirm that the original diagnostic and treatment plan is on the right track. Or it may also reveal subtle findings that can change the course of care dramatically." Guest emphasizes that the surgical and pathology consults that also make up a comprehensive second opinion may also change the patient's care, not just the radiology findings.

She also notes that getting a second opinion at a major cancer center like U-M, even if it yields different recommendations, doesn't mean a woman has to continue with all her care there. Patients may have surgery, chemotherapy and radiation therapy at the University or may return to their home area for any or all components of their treatment.

Says Guest, "We educate each patient about her options, and let her decide what she wants to do."
Reference: RSNA presentation Q01-1207

University of Michigan Health System

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