The pathologist is the physician who is least understood by the patient. For many people, the only interaction they have with a pathologist is not pleasant – they get a bill for services that they do not comprehend from a physician they have never met.
The pathologist works behind the scenes
Because pathologists work behind the scenes, patients don’t have any method of assessing what the pathologist has diagnosed. It is not like assessing your physician’s ability; patients get a feel for the physician’s competence by the direct interaction in the usual manner one assesses all people. But the pathologist is completely hidden. For most patients, their physician reads the pathology report and transmits the diagnosis to the patient. Rarely, the patient actually reads the report. In both situations, the pathology report has a diagnosis, which is always taken at face value as being scientific and accurate. Surely, the patient thinks, this comes from the lab and is the same as my blood glucose or hemoglobin value.
And plays a critical role in GERD diagnosis
In patients with GERD, biopsies are taken when they have an endoscopic examination. Most gastroenterologists take biopsies only when they see an abnormality. If endoscopy is normal, there is no biopsy taken and there is no pathology report. If a biopsy is taken at endoscopy, the tissue taken is sent to the pathologist who looks at it, processes it in a tissue processor, makes a microscopic slide, and examines it under the microscope. This results in a pathologic diagnosis, and those lab results are reported to the physician who generated the biopsy.
At present, pathologic diagnosis is critical for the management of patients with GERD in the following situations:
- When a diagnosis of Barrett’s esophagus is made. This diagnosis requires the identification of a cell known as a goblet cell in the abnormal columnar lining of the esophagus that is seen at endoscopy. The diagnosis of Barrett’s esophagus indicates that there is an increased risk of cancer (approximately 0.5% per year). This risk is considered sufficient to recommend an endoscopic surveillance program that requires regular endoscopy, usually at 1-3 year intervals. The diagnosis, therefore, significantly impacts the patient’s life: increasing worry about cancer, increasing discomfort by requiring repeated endoscopy, and increasing cost of care.
- When biopsies taken during endoscopic surveillance of a patient with Barrett’s esophagus shows a pathologic change called dysplasia. The presence of dysplasia increases the risk of cancer further. Patients with low-grade dysplasia are required to have more frequent surveillance endoscopies. Patients with high-grade dysplasia may be advised to have radio-frequency ablation or endoscopic mucosal resection. These are significant endoscopic procedures with worry about having a procedure as well as a heightened worry about cancer, risk of complications, and cost that affect a person’s life significantly.
- When biopsies show cancer. This is a life-changing event for the patient that turns his or her life upside down and becomes an all-consuming worry about future survival. It can lead to chemotherapy, radiation, and surgery that may be dangerous and associated with significant complications.
But accurate diagnosis requires expertise
When a pathology report has one of these diagnoses, should one ask the question: Is this diagnosis correct? Similarly, and less obviously, when a biopsy is done and reported as normal, should one ask the same question?
The answer to this depends on whether there is an error rate in pathologic diagnosis. Pathologists, like all humans in all endeavors, vary greatly in their training, experience, and ability. This does not matter if the diagnosis is easy. For example, any pathologist can accurately make a diagnosis of acute appendicitis. However, as complexity of diagnosis increases, it becomes likely that pathologists with high expertise have a lower error rate than those with less expertise in this area.
False negatives are rare
In the patient with GERD, it is almost certain that if a pathologist reports a biopsy as being negative for Barrett’s esophagus, dysplasia or cancer, this diagnosis will be accurate. It is extremely uncommon for any pathologist to miss these entities if they are present in the biopsy.
But positive lab results are more likely to contain errors
However, if the pathology report has a diagnosis of Barrett’s esophagus, low-grade dysplasia, high-grade dysplasia, or cancer, there is a small but significant error rate in the pathologic diagnosis. This error rate is well recognized. In fact, health insurers encourage pathologists who are uncertain about these diagnoses to seek expert consultation. They have a special code that allows the expert to be reimbursed for their opinion. The reason for this is that error in any of these diagnoses leads to a significant increase in health care cost that can be avoided if the correct diagnosis is made. The small cost of an expert consultation is cost effective because it detects a significant number of false positive diagnoses and can prevent costly surveillance and treatments. For the patient, a correct pathologic diagnosis avoids the increased worry and added procedures that result from diagnostic error.
So what should you do if your biopsy is positive?
RefluxMD advises all its members to look into their pathology diagnosis with the same degree of care that they use for any other health care choice. If their physician informs them that their biopsy has resulted in a positive diagnosis of Barrett’s esophagus, dysplasia, or cancer, and recommends treatment dictated by that biopsy, stop for a moment. Ask your physician about the possibility of pathologic error. If any question remains in your mind after this discussion, request that the pathology slides be sent to an expert for a second opinion to confirm the diagnosis. In most cases, this review will be covered by your insurance. Even if it is not covered by insurance, the cost for expert review is reasonable.
I have personally encountered innumerable cases over the years where an incorrect diagnosis of Barrett’s esophagus, low-grade dysplasia, and high-grade dysplasia have been made. It is extremely uncommon to have a false positive diagnosis of cancer, but this is such a life-changing event that those lab results might be worth confirming despite a very low error rate.
How do you find an expert?
Your treating physician may advise you that expert review is not needed because the pathologist who read your slides was an expert. If this is not true, your treating physician or the pathologist who read your slides may know of an expert. RefluxMD can direct you to expert pathologists in the diagnosis of GERD and its complications.
The expert review process is simple and does not require any action on your part. An expert review requires only that the pathology slides with a request for review is mailed to the expert. You do not need to meet with or have any interaction with the expert pathologist. The slides are sent and within a few days your physician will have the expert review as a written report that you can see. The news can only be positive: if the expert review confirms the diagnosis, you can proceed with more certainty; if the expert review detects an error, an unnecessary treatment may be avoided.