Rationale and Objectives
To determine the impact of second-opinion assessment on cancer staging and patient management in patients with pancreatic ductal adenocarcinoma.
Methods and Materials
This retrospective study was approved by our institutional review board with a waiver of informed consent. Second-opinion reports between January 1, 2009 and December 31, 2013, alongside outside reports for 65 consecutive cases of biopsy-proven pancreatic adenocarcinomas, were presented in random order to two experienced abdominal surgeons who independently reviewed them blinded to the origin of the report, images of the examinations, and patient identifier. Each surgeon filled in a questionnaire for each report recommending cancer staging and patient management. Recommended patient management and staging were evaluated against reference standards (actual patient management at 6 months following second-opinion assessment, and pathology or other clinical and imaging reference standards at 6 months or longer, respectively) using Cohen kappa.
Results
Cancer staging differed in 13% (9 of 65) of cases for surgeon 1 and in 18.4% (12 of 65) for surgeon 2. Patient management changed in 38.4% (25 of 65) of cases for surgeon 1 and in 20% (13 of 65) for surgeon 2. When compared to the pathologic staging gold standard, second opinion was correct in 85.7% (six of seven) of the time for both surgeons. Recommended patient management from second-opinion reports showed good agreement with the reference standard (weighted k = 0.6467 [0.4014–0.892] and weighted k = 0.6262 [0.3954–0.857] for surgeon 2).
Conclusion
Second-opinion review by subspecialized oncologic radiologists can impact patient care, specifically in terms of management decision.
Introduction
The increasing complexity of medical imaging has led to organ or disease subspecialization within the subfields of radiology. One of the latest subspecialties to emerge is oncologic imaging . The discrepancy between two radiologists reporting on the same images is a phenomenon that has been known since 1949 . Different studies have reported clear clinical benefits in introducing second-opinion imaging review in abdominal radiology, gynecolocical imaging and neuroradiology . In most clinical practices, it is not possible for every imaging study to be interpreted by a radiologist with subspecialty training. In this setting, general radiologists often fill the gap of subspecialty radiologists. However, it is common practice at many tertiary referral institutions for clinicians and surgeons to request second-opinion review of images by subspecialty radiologists, most of the time without writing a new formal report. This is possible because no new imaging is needed, but only new image interpretation . This informal radiologic opinion is often reported in the patients’ chart by the clinicians and surgeons, but without the chance for the second-opinion interpreting radiologist to review it. Furthermore, there is no reimbursement for this type of subspecialty second opinion to the interpreting radiologist. Another type of second opinion is asked for during or before multidisciplinary disease management team (DMT) meetings. Nowadays, many tertiary referral centers rely on DMTs for discussion of management of different types of cancers. During these meetings, outside radiologic examinations are reviewed by a subspecialty-trained radiologist without the issue of a formal report, often changing the management of the disease. In case of other specialties such as surgery or clinical specialties, a second-opinion practice is commonly accepted and reimbursed, whereas the rationale for reimbursing radiologic reassessments and for new reports issuing is still under debate . Multiple studies have reported a 1%–20% discrepancy in image interpretation . A disease-based formal study is needed to assess the benefits of such second-opinion reads in terms of changes in patient management.
Our study focused on biologically proven pancreatic ductal adenocarcinoma (PDAC), one of the most lethal cancers with an overall survival at 5 years as low as 5% in the United States . We focused on a single type of cancer because of the lack of literature regarding second-opinion imaging review of this cancer and because pancreatic cancer treatment is heavily dependent on staging, which has a pivotal role in deciding the management of patients with PDAC. Additionally, a significant difference in short- and long-term outcomes has been noted when a pancreatectomy is performed at high-volume PDAC treatment centers . Many reasons can account for this better long-term outcome, it might be related to better surgeon skills as well as to the fact that subspecialized radiologists might provide better assessment of tumors in high-volume cancer centers. Lastly, general radiologists who often stage this type of cancer may not have the adequate expertise for interpreting all the different imaging patterns that pancreatic cancer can present on cross-sectional imaging, particularly when related with vascular involvement by the tumor (abutment, encasement, vessel deformity, and venous teardrop deformity) . Pancreatic cancers are approached by surgeons with a three-way decision model: resectable, borderline resectable, unresectable . According to TNM stage, stages I and II are resectable by definition because the tumor is confined within the pancreas. Stage IV is unresectable because it is characterized by distal metastases. Stage III is the most susceptible to radiologic interpretation mistakes, and it is defined as localized tumor with involvement of a major artery: celiac trunk, common hepatic artery, and superior mesenteric artery. It is further divided into two categories—locally advanced unresectable and borderline resectable. A borderline resectable tumor is defined by a contact between the tumor and the arterial circumference of no more than 180°. However, this definition of borderline resectable is not universally accepted and it might change among institutions, depending on the vessel involved, surgical skills and experience, and on patient status . When the tumor surrounds the arterial circumference for more than 180°, the vessel is considered encased and the tumor unresectable .
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Materials and Methods
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Inclusion Criteria
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TABLE 1
Population Characteristics and Inclusion Criteria
Population Characteristics and Patient Selection_n_ Total number of patients after database search 307 Number of patients in the time frame considered (01/2009–12/2013) 86 Patients excluded because of extra clinical information available (eg, surgery performed before the study started) 15 Patients excluded because of lack of follow-up 6 Final number of patient considered (M:F) 65 (39:26) Total number of CT examinations 51 Total number of MRI examinations 14
CT, computed tomography; MRI, magnetic resonance imaging; n , number.
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Second-opinion Assessment
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Retrospective Data Interpretation
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TABLE 2
Questionnaire to Fill in Provided by the Two Junior Radiologists to Two Oncologic Surgeons
Item Response1. Further imaging recommended to better evaluate an area or finding? (Circle one) Y N2. Resectability status (Circle one)
3. Stage (Circle one) I IIa IIb III IV4. Management (Circle one)
5. Grade of report (Circle one) Poor Excellent
1 2 3 4 5
The two surgeons were asked whether they needed further imaging studies to propose a certain management on the sole basis of the reports (if yes, they were asked about resectability status, staging according to the TNM staging system, and recommended management), and whether they were satisfied with the report on a scale from one to five.
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Statistical Analysis
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Results
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Review by Surgeons—Combined Results
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Review by Surgeons—Individual Results
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TABLE 3
Results of Questionnaire Filled in by Surgeons, Question 1: Number of Further Imaging Scan Examinations Asked by Surgeons Based on the Reports (Percentage and 95% Confidence Interval)
Surgeon 1 Surgeon 2 No further imaging scans asked based on the reports 27/65 (41.5% CI: 29.6–54.4) 27/65 (41.5% CI: 29.6–54.4) More imaging asked based on outside reports 21/65 (32.3% CI: 22.2–44.3) 9/65 (13.8% CI: 7.4–24.2) More imaging asked based on second reader reports 3/65 (4.6% CI: 1.5–12.7) 2/65 (3% CI: 0.8–10.5) More imaging asked for both reports 14/65 (21.5% CI: 13.2–32.9) 3/65 (4.6% CI: 1.5–12.7)
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TABLE 4
This Table Shows How Surgeons Changed the Management of the Patients After Reading Second-opinion Reports, Compared to What Was Proposed After Reading Outside Reports: Number of Cases (Percentage and 95% Confidence Interval)
Surgeon 1 Surgeon 2 Concordance between outside and second reader reports 44/65 (67.6% CI: 55.6–77.9) 52/65 (80% CI: 68.7–87.9) Change of therapy: from surgery to chemotherapy 15/65 (23.1% CI: 14.5–34.6) 6/65 (9.2% CI: 0.4–18.7) Change of therapy: from chemotherapy to surgery 0/65 (0% CI: 0–0.58) 4/65 (6.1% CI: 2.4–14.7) Change of therapy: from neoadjuvant chemotherapy to chemotherapy 5/65 (7% CI: 3.3–16.6) 1/65 (1.5% CI: 0.2–8.2) Change of therapy: from chemotherapy to neoadjuvant chemotherapy 1/65 (1.5% CI: 0.2–8.2) 2/65 (3% CI: 0.8–10.5)
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TABLE 5
Agreement Between Three Categories of Patient Management Proposed by Surgeons Based on Outside and Second-opinion Reports, Compared to Actual Patient Management as Found on the Clinical Report System (Surgery Summaries, Pathology, Blood Tests, and Additional Imaging Examinations)
Patients’ Clinical Management After 6 Months From Radiologic Assessment Surgeon 1 Surgeon 2 Surgery Neoadjuvant Chemotherapy Chemotherapy Weighted Kappa (95% CI) Agreement Surgery Neoadjuvant t Chemotherapy Chemotherapy Weighted Kappa (95% CI) Agreement Management as proposed after reading outside reports Surgery 6 2 10 3 2 6 Neoadjuvant chemotherapy 1 0 8 0.426 (0.2489–0.6031) 3 0 7 0.4136 (0.2149–0.6129) Chemotherapy 0 0 38 1 0 43 Management as proposed after reading second-opinion reports Surgery 3 0 1 5 0 3 Neoadjuvant chemotherapy 3 2 7 0.6467 (0.4014–0.892) 2 2 9 0.6262 (0.3954–0.857) Chemotherapy 1 0 48 0 0 44
Weighted kappa with squared weights was used to assess agreement.
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Discussion
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