Many patients with melanoma are first diagnosed by general practitioners, dermatologists or plastic surgeons. A biopsy sample of the suspect lesion might then be sent to a general pathologist for further diagnosis, explained a team from the Jonsson Comprehensive Cancer Center at the University of California, Los Angeles (UCLA).
However, getting a second opinion from a pathologist specially trained in skin lesions - a dermatopathologist -- yields the most accurate results, the new study found.
"A diagnosis is the building block on which all other medical treatment is based," said study co-leader Dr. Joann Elmore, a professor of medicine and a researcher at the cancer center.
Her team noted that, of all pathology fields, analysis of biopsies for skin lesions and cancers has one of the highest rates of diagnostic errors. Those errors can affect the lives of millions of patients each year.
"On the other end of these biopsies are real patients: patients answering the late-night, anxiety-inducing phone calls when we inform them of their diagnosis; patients undergoing invasive surgeries; patients weighing their next clinical steps," Elmore said in a UCLA news release.
"All patients deserve an accurate diagnosis. Unfortunately, the evaluation and diagnosis of skin biopsy specimens is challenging with a lot of variability among physicians," she added.
Dr. Michele Green, a dermatologist at Lenox Hill Hospital in New York City, agreed.
"A diagnosis of skin cancer can be overwhelming," said Green, who wasn't involved in the new study. "It is imperative that patients know the training of the pathologist reviewing their specimen to ensure the accuracy of the diagnosis given."
In their research, Elmore's team found that getting a second opinion from pathologists who are board-certified, or have fellowship training in dermatopathology, can greatly boost the accuracy of a melanoma diagnosis.
The study included 187 pathologists - 113 general pathologists and 74 dermatopathologists - who examined 240 skin biopsy lesion samples. Misclassification rates of the lesions was lowest when first, second and third reviewers were subspecialty trained dermatopathologists.
On the other hand, the most misclassifications were made when reviewers were all general pathologists without the subspecialty training.
"This is definitely something that health care providers should consider when faced with these complex and challenging-to-diagnose skin biopsies," Elmore said. "Our results show having a second opinion by an expert with subspecialty training provides value in improving the accuracy of the diagnosis, which is imperative to help guide patients to the most effective treatments."
Green agreed. Reading over the findings, she said that "it is safe to conclude that second opinions performed by trained dermatopathologists yield more accurate diagnoses."
Dr. Scott Flugman is a dermatologist at Northwell Health's Huntington Hospital in Huntington, N.Y. He said the new study "reinforces what many dermatologists consider to be true about the care of patients with pigmented lesions."
But he noted that for many Americans, the first inkling that they might have melanoma does not come from a dermatologist - and that can lead to problems.
"The overwhelming majority of dermatologists will insist on having their biopsies read by a board-certified dermatopathologist," Flugman explained. "But this practice is not always followed when biopsies are done by plastic surgeons, general surgeons or family practitioners. It is important for these other specialists to request a second opinion by a dermatopathologist when diagnosing pigmented lesions read by general pathologists."
And, as the study showed, a general pathologist should not be the final stop in the diagnostic journey.
As Flugman noted, the UCLA study found that even though more than 70% of the general pathologists interviewed had more than a decade of experience, "only 13.3% of general pathologists stated that their colleagues consider them an expert in melanocytic skin lesions."
According to Flugman, "this reinforces the importance of having the input of a board-certified dermatopathologist when diagnosing these potentially difficult cases."
Of course, even the best diagnostic approach is not foolproof, the experts said.
"While these findings suggest that second opinions rendered by dermatopathologists improve overall reliability of diagnosis of melanocytic lesions, they do not eliminate or substantially reduce misclassification," Elmore said.
The study was published online Oct. 11 in JAMA Network Open.
Sources: Scott Flugman, M.D., dermatologist, Northwell Health's Huntington Hospital, Huntington, N.Y.; Michele S. Green, M.D., dermatologist, Lenox Hill Hospital, New York City; University of California, Los Angeles, news release, Oct. 11, 2019.
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