Wednesday, April 1, 2015
If something happens to me, will I have done enough to enable a colleague to continue the care of my patient with newly diagnosed prostate cancer?
As an academic surgeon, I probably get to see more second opinion cases than for most in my field. My university association and digital footprint probably tends to attract these cases although I make absolutely no effort or attempt to attract these consultations. Of course there are some that arise as a result of contact with patients I have previously treated. One thing for sure is that I do not send letters out to GPs asking them to consider asking their prostate cancer patients to switch specialists. Likewise, I do not have second opinion forms on my website goading readers to switch specialists. Maybe I am totally deluded into thinking that I see more second opinion cases and that my load of such is exactly the same as everybody else.
Many of these consultations are for those recently diagnosed with prostate cancer. Recently, I saw a man who had undergone transperineal prostate biopsies and had been diagnosed with prostate cancer. Transperineal prostate biopsies are where the sampling needles traverse the skin of the perineum (patch of skin between the anus and the scrotum) rather than going through the rectal wall with so called transrectal ultrasound guided prostate biopsies.
The samples were labelled A1 through to A8 and B1 through to B8. There was no anatomical indicator as to where these biopsies were taken from within the prostate. To make an intelligent guess, it might be that A represents apex of the prostate gland and B represents the base of the gland but who knows other than the original surgeon doing the biopsies. There was an additional sample which was called the targeted biopsy. This would have meant nothing except for the fact that there was an MRI scan of the prostate that had indicated that there was a tumour suspicious lesion towards the centre of the gland (left transition zone to be more precise).
It was the cancer in the targeted sample that demonstrated that there was cancer that needed treating. There was also a tiny speck of cancer in one the ‘A' samples but it was low grade and probably clinically insignificant - in other words, one that could be ignored. In this situation, knowing what the A and B samples came from was academic. I knew that the cancer was in the middle of the gland and that this patient would likely do very well with so called nerve sparing radical prostatectomy.
This case did get me thinking. All sorts of questions were running through my head. What if there were clinically significant cancer deposits in the A or B sets of biopsies? I would have no idea as to where they were. The naming of these samples was not standard nomenclature but rather a special code used by the surgeon who took those biopsies. I could always write to him if I need to know to plan surgery and therefore avoid having to put a patient through another biopsy to map the cancer. What if the surgeon was not willing or obstructive because he was ‘losing’ a patient? Was this some ploy to make it harder for the patient to switch surgeons? What if something were to ever happen to the surgeon - we are mere mortals and not the demigods that some surgeons think of as themselves. If another surgeon were to have to take over the care of that patient in the event that the original surgeon became serious ill or were to become deceased, access to this ‘secret code’ of labelled specimens could be an issue. I have no answers to these thoughts but I am clear on what I do in my own practice.
I always label my prostate biopsy specimens in a way so it is crystal clear as to where they have come from. If something were to ever happen to me, I could feel assured that a colleague would be in a position to take over the care of my patient. I think that this is a minimum standard of care but there seems to be no appetite to make change.
Why won’t pathologists push their referring urologists to be more diligent in writing better clinical details or appropriately label the specimens? In Australia, the vast majority of prostate cancer are treated in the private sector. In a competitive pathology environment, no pathology provider would be comfortable about demanding improved clinical documentation and labelling of pathology specimens from referrers in whom they depend on for their work. How do you think we can drive change? I certainly have my ideas but I would like to hear yours.