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Thyroid Nodules: When It's Time for a Second Opinion on a Pathology Diagnosis
An Interview with Dr. Barry M. Shmookler

by Mary Shomon

Barry M. Shmookler, M.D., is a surgical pathologist and founder of, a Web-based service that matches patients with expert pathologists who will review and evaluate biopsy specimens (tissue, cells or fluids) taken for evaluation of possible cancer. Dr. Shmookler was a presenter at the September, 2000 Thyroid Cancer Survivors' Association (ThyCa) conference, in Washington, D.C. I had an opportunity to talk with Dr. Shmookler about evaluating potential thyroid cancer, and the role of second opinions.

Mary Shomon: Thank you, Dr. Shmookler, for taking the time to speak with us today. First, can you tell us a bit about what motivated you to create

Barry M. Shmookler, M.D.: As a practicing surgical pathologist for 18 years in a major cancer hospital, I realized that disagreements occasionally occur regarding the cytologic or tissue diagnosis of cancer. It also became clear that most patients are not aware that such errors can be made at this first crucial stage of cancer management. Therefore, I felt that development of such a Web site would fulfill two important objectives:

  1. Educate patients on the role of pathology in cancer diagnosis and on how to obtain expert second opinions to confirm or revise cancer diagnoses.
  2. Provide access via the Web site to individual experts who are available to serve as consultants to patients and family members.
MS: Are there many errors in reading and interpreting samples? What do you think the reasons are behind that?

BMS: Recent studies from major medical centers disclose an average error rate of 1.4% to 4% (references are available on the Web site). Fortunately, this is a low number. Nonetheless, for the individual patient with an incorrect diagnosis, this can lead to serious medical complications and less than optimal outcomes. The accuracy of a pathology diagnosis depends on the training, experience and judgment of the individual pathologist. As with all human endeavors, this varies from person to person. Also, many highly competent pathologists do not have a lot of expertise in the more uncommon types of cancer. For example, thyroid cancer accounts for only 1% of all malignancies. The diagnosis of uncommon cancers is just one situation in which a second opinion for a pathology diagnosis may be prudent.

MS: With regard to thyroid cancer, most patients start with a nodule or lump, and diagnosis begins with a fine needle aspiration (FNA). In your experience, if a patient gets a reading that their nodule or lump is benign, should they get a second opinion? Are there any warning signs or factors that would make it even more important for a patient to consider getting a second opinion by a pathologist to review their samples from the FNA?

BMS: The experience of the physicians who perform and evaluate fine needle aspiration (FNA) is of the highest importance. Your treating doctor should be able to provide this information to you. The diagnosis on a FNA must be correlated with the clinical findings, scan studies and other tests. In other words, if your clinician was concerned about thyroid cancer, a "benign" diagnosis on FNA should be reviewed by an expert in thyroid FNA.

MS: What about when there's a finding of cancer? Should a patient also get a second opinion at that point? Frequently, there's a push to move forward, a rush to schedule surgery. Should a patient take the time for a second pathology evaluation? Is there a chance that they are being told incorrectly that they have cancer when they don't, and that surgery would be unnecessary?

BMS: Again, experience of the pathologist with thyroid FNA is crucial. If a pathologist does less than 100 thyroid FNAs a year (you can ask), a patient may want to request referral to a medical center with an active thyroid cancer program. If the FNA has been performed, you can then request a second opinion. In most situations, the few days delay will not be harmful. Of course, discuss this with your doctor.

MS: If I were a thyroid patient who had a recent diagnostic procedure (FNA, Surgery), and for whatever reason I have decided that I would like a second opinion regarding my sample and diagnosis, can you walk me through how your service could be of help to me?

BMS: has established a network of over 50 nationally recognized pathologists with expertise in essentially all areas of cancer diagnosis. For example, if a patient wanted a second opinion evaluation for a thyroid biopsy specimen, we would provide him or her with the names and contact information of up to three experts in thyroid pathology. We also give the patient detailed instructions on how to proceed with requesting and expediting a second opinion, as well as examples of forms that may be necessary. Remember that patients do not have to travel for a second opinion in pathology- only microscopic glass slides are sent by express mail service. It's that easy.

MS: In your opinion, what makes a great pathologist? If you were going to have your test results reviewed for you or a member of your family, what sorts of qualities do you consider required for a pathologist you would trust or recommend? And what do the pathologists your service recommends have to offer versus a local pathologist that might be recommended by a patient's doctor?

BMS: Certainly most pathologists maintain a broad competence in many areas of their field. However, a very select group of pathologists has achieved a level of expertise that qualifies them as nationally recognized consultants. This reputation is achieved as a result of training, research, publication and teaching activities. Such individuals are distinguished by their publication of original articles and chapters, affiliation with a university or major cancer center, appointment to editorial boards of medical journals and recognition among peers as valued consultants for difficult cases. ALL the pathologists in our network meet these qualifications. On the Web site, we provide guidelines for patients and family members on how to evaluate any physician for true expertise in any specialty.

MS: Some patients might be intimidated to ask for a second opinion, or afraid that they will anger or alienate their doctor. What are your thoughts for those patients? If a patient asks for a second opinion, and his or her doctor does seem to be resistant, or even angry, how do you think patients should handle that situation?

BMS: It is important to begin my response with this fact: A patient has the right to request a second opinion from the physician of his or her selection. I believe most treating doctors will be supportive of their patient's desire to confirm a diagnosis or to assure optimal treatment. On occasion, frank discussion and insistence may be necessary. Patients must not be intimidated or left with a sense of guilt or betrayal to the original doctor. A patient's well being, and possibly life, may be at stake.

MS: Do you have anything else to share with thyroid patients that you feel is important for them to know?

BMS: Many cases of thyroid cancer can be successfully treated today, thanks to sophisticated methods leading to early detection and diagnosis. However, success often depends on receiving the best available care from the outset. Since thyroid cancer is not common, it is recommended, if at all possible, to undergo treatment at a center with an experienced multidisciplinary team. Team members include pathologists, endocrinologists, surgeons, medical oncologists and radiation therapists.

I would like to thank Ms. Shomon and About for permitting me to discuss this important aspect of thyroid cancer diagnosis. For visitors who have questions about pathology, our Web site has a feature called "Ask a Pathologist."


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All information is intended for your general knowledge only and is not a substitute for medical advice or treatment for specific medical conditions. You should seek prompt medical care for any specific health issues and consult your physician or health practitioner before starting a new treatment program. Please see our full disclaimer.