ACADEMY PUBLIC POLICIES

Just as important as making a proper diagnosis of cancer when it exists is not making the diagnosis prematurely without definitive proof. Although this point may seem obvious, the reality is that medicine can be complex. Pathology results are sometimes not definitive, biopsies may need to be repeated, and a sample may need to be evaluated by several expert pathologists before a correct diagnosis is rendered. A guiding principle in the practice of oncology is that, with rare exception, absolute proof of a cancer diagnosis must exist before any treatment is initiated.

Sometimes the biopsy needs to be sent to outside consultants who require additional time, so a definitive diagnosis may not be obtained for a week or more. Most patients understandably become anxious and upset when they are told, “We still don’t know exactly what type of cancer you have, but we are performing more sophisticated testing, which will take more time.” Yet because of how important it is to be correct, and the fact that the entire treatment plan follows from the diagnosis, this time spent waiting is worth the wait.

J. was referred to me after having been told that she had multiple myeloma, a bone marrow cancer. She walked into the examination room quietly in visible pain owing to a recent fracture of a spine bone. Her face was downcast but showed a mixture of physical discomfort and fear. J. was helped onto the examination table by her husband, D., who stood erect and imposing, right beside her. She let him do most of the talking. He was tough looking. With a fierce gaze, he stared unblinkingly at me as he spoke in short, strong phrases. “This is my baby, she saved my life when I was down,” he said, as he got choked up and brought her snugly to his chest with his arm. “Now it’s your job to save her life. I know you won’t fail us. I won’t let it happen.” A shiver ran down my spine. I told them I would do my best to make her well, because I fight for all my patients as if they were my family. I quickly focused on her situation. J. was thought to have multiple myeloma after an abnormal protein was found in her blood and a biopsy of the fractured vertebra showed some of the cells that are typically found in that bone marrow cancer (myeloma is discussed later). But I was not convinced by the whole picture. I ordered an additional analysis of the cells, and it showed that they were not cancerous but rather were part of the body’s normal immune reaction to injury. Further investigation for myeloma cells in other parts of her body failed to turn up any sign of the disease.

In the end, J. was spared a cancer diagnosis and remains without evidence of myeloma five years later. Her pain was adequately addressed, her condition improved greatly, and she and her husband were grateful. I was extremely happy for them and breathed a sigh of relief for myself. Because of the enormous weight placed on pathology results, I highly recommend that every cancer patient make certain that his or her oncologist is satisfied with the findings and diagnosis of the pathologist. If there is any uncertainty, have the specimen reviewed by a pathology consultant at another hospital.