DIGNITY HEALTH
A breast cancer diagnosis can be devastating. A suboptimal breast cancer treatment plan can be deadly.
The free second opinion program at St. Mary's Medical Center in San Francisco gives women the confidence that their diagnosis, good or bad, is at least correct; and it lays out the best options for first-order treatment.
"Cancer is too serious to not know that what you're doing is the right direction to go," said oncology nurse Cheri Goudy, St. Mary's cancer-care navigator. "Patients don't want to ask years down the road, 'Should I have done something different?' The time to ask that is now" before initiating treatment.
For almost 20 years, a panel of specialists has convened weekly to review the pathology and imaging studies of newly diagnosed breast cancer patients. The patient need not have insurance or a physician referral. Nor, for that matter, does she need to be a St. Mary's patient. Anyone is welcome.
"It can be a confusing, anxious time," said breast pathology expert Dr. Michael D. Lagios, leader of the second opinion program. "But we make sure every patient gets the same attentive care and level of review and it's done gratis."
The typical multidisciplinary weekly panel includes pathologists, radiation oncologists, medical oncologists, nurses and nutritionists. Experts from neighboring hospitals Seton Hospital in Daly City and Saint Francis Memorial Hospital in San Francisco and Sequoia Hospital in Redwood City may participate via videoconference.
The panel reaffirms the original diagnosis and treatment plan in the majority of cases. However, in some 20 percent of diagnoses, the panel has discovered an error that could have led to ineffective treatment.
"We start with the pathology first," said Lagios. "A colleague of mine once said the diagnosis is like an architect's drawing — if it's wrong, the entire structure will collapse."
Turning the tide
Lagios conceived of the second opinion panel while serving as a pathologist at the Breast Health Center at California Pacific Medical Center some 25 years ago. The concept, quite frankly, did not endear him to his colleagues.
"I would have to watch myself when I took off on my bicycle by some physician accelerating out of the garage," said Lagios, with a laugh. "It was akin to Martin Luther tacking his thesis on the door. It was not seen as an appropriate venture. There was a lot of hostility to the idea that patients deserved an independent opinion. It still happens today. We still have physicians who don't believe their patients should be presented at any sort of multidisciplinary conference because they are their patient."
Most physicians, however, have changed and so have their patients. Lagios remembers a time when some women hesitated to get a second opinion for fear they would offend their physician. Today, he is heartened by the patients who take an active role in their own care planning.
"I think increasingly patients are aware that they need to get a second opinion," said Lagios. "Certainly there are patients who don't want to offend their physicians, and I try to tell them it's their body and their life and not just the feelings of their GP" at stake. "That is why we welcome self-referrals. Material can be retrieved and the whole thing can be reviewed basically in confidence."
Both the American Cancer Society and the National Cancer Institute recommend patients receive a second opinion especially for some types of cancer. That's not a slight against physicians, just an acknowledgement that medicine's understanding and treatment of complex breast cancers have changed radically through the years.
"Breast cancer is not always clear cut," said Lagios. "For instance, when I got out of the service in 1972, every patient had modified radical mastectomy. The entire breast was removed. In 1978, there was the first glimmer of a lumpectomy as an alternative. Then in 1991, needle core biopsy was introduced. And in 1996, we went to sentinel node biopsy. So all of these changes have occurred and in the process we became aware of smaller, microscopic changes that gave us important information that we could pick up mammographically."
Collective wisdom
The panel has done its part to advance St. Mary's treatment of breast cancer. Based on its findings, the panel recommends all St. Mary's surgeons perform sentinel node biopsies. The panel also plans to recommend physicians use the Oncotype DX Test, a genomic test to determine the effectiveness of chemotherapy for some cancers.
That said, panel members frequently disagree about the best course of treatment. The debates, Lagios said, do not undermine the panel's authority, but broaden each member's knowledge of the complicated disease.
"Each discipline learns from each other. I know that I've learned a lot myself," said Lagios. "The patients see it as more open and honest review of their material. They see that people don't always agree. They see they can reach a consensus."
Patient power
After the panel reviews a patient's scans, the patient and her doctor, if she has brought one, are encouraged to ask questions. Each patient receives an easy-to-understand report. The process can be painful and emotional, but patients are universally appreciative, said Goudy, the cancer navigator.
"I can say people are nervous about coming in to panel but once they are there, they leave with a smile because they know other people are interested in them and giving them information," said Goudy. "It's very powerful — 'Here is a panel of people, and they are talking about me and my breast cancer and looking at my disease.' There can be tears, but I always feel information is power, and I tell patients that when I talk to them."