BEWARE: NOT ALL LABS ARE CREATED EQUAL
"There is a major epidemic of skin cancer in the world today. In the United States alone, millions of skin cancers will be diagnosed just this year," said Clay J. Cockerell, MD of Cockerell Dermatopathology. Furthermore, it is estimated that approximately 1 in 50 individuals born this year will develop malignant melanoma, the most dangerous and often life-threatening form of skin cancer in their lifetime. This cancer is the leading cause of death in young women in their 20's and 30's. However, skin cancers are most common in older people over the age of 50. Because of the gravity of this problem, it is vitally important that all individuals, especially those in the highest risk groups, understand how to recognize the signs of skin cancer and call it to the attention of their doctor, preferably someone with expertise in skin disorders. If there is suspicion that a spot may be skin cancer, a biopsy must be performed to make a diagnosis before treatment is undertaken. Getting an accurate diagnosis from the biopsy is critical as different treatments are used for different skin disorders, and if the lesion turns out to be benign, no treatment at all may be required.
What many patients and surprisingly many doctors, especially non-dermatologists, do not understand, however, is that there is significant variation in the accuracy of different pathology labs depending on who is performing the examination of the biopsy. Many doctors try to reassure their patients that they are "sending the specimen to the lab." What you should ask your doctor is, "Which lab and who's going to be reading my biopsy"?
Years ago and still in many cases today, doctors, especially dermatologists, developed close working relationships with pathologists known as dermatopathologists, who are specially trained to interpret skin biopsies. With the ongoing evolution of health insurance companies, national laboratory companies made bids to provide laboratory services, mainly blood tests, for managed care plan patients. Because health insurance companies often look at all lab services as one, many of the specialized areas of pathology, such as dermatopathology, where an expert performs the service, were lumped into the same category as blood tests performed by a machine with no need for physician interpretation. Furthermore, there are cost pressures that discourage non-experts from seeking consultative second opinions from experts.
A misread specimen can have serious consequences for a patient. Failure to diagnose skin cancer, especially melanoma, can result in a disease that can be cured, turning into a deadly process. On the other hand, overdiagnosis of something benign as cancer can lead to loss of insurance or significantly increased insurance premiums, not to mention unnecessary and sometimes disfiguring surgery. In some cases, patients simply go for months, sometimes years, with no diagnosis or an erroneous one. In addition to poor patient care, inaccurate lab results can lead to legal liability and increased health care costs.
DEPENDING ON EXPERT DERMATOPATHOLOGISTS
The most critical key to accuracy involves the expertise of the person who is reading your biopsy. While board-certified dermatopathologists are certainly the best trained to read skin biopsies, some general pathologists with interest and experience in dermatopathology can do a good job, especially if he or she has access to consultation with a board-certified dermatopathologist. In the ultimate analysis, it's not the label of the person who evaluates the slide that matters but his or her competence, said the late A. Bernard Ackerman, M.D. As a rule, Dr. Ackerman always noted that a board-certified dermatopathologist is best equipped to render an accurate diagnosis of a skin lesion that is difficult to diagnose under the microscope, a phenomenon that is surprisingly common.
Expertise becomes even more crucial in lesions that are difficult to interpret. Some subtle skin disorders, such as mycosis fungoides, a rare type of skin lymphoma, require very special expertise to make the right diagnosis. Non-cancerous skin diseases due to inflammation, such as rashes, can be diagnosed accurately only by dermatopathologists. Other challenging diagnoses are diseases that produce blisters such as bullous pemphigoid, pemphigus, and epidermolysis bullosa.
Some health insurance companies require physicians to send specimens to a specific lab that may or may not have an individual with expertise in dermatopathology. Many health insurances have instituted programs to penalize physicians who fail to utilize contracted laboratories, a practice that has received criticism from many physicians across the U.S. Many dermatologists choose to opt-out of contracts in which the biopsies are "steered" to a non-desired lab. They fear that these labs might not provide complete service for their patients and pose a malpractice risk to them.
THE IMPORTANCE OF COMMUNICATION
Communication is another important factor in making sure your doctor gets the "right" answer in your skin biopsy. When your doctor, especially a dermatologist, performs a biopsy, he or she is not sending out a simple blood test to a nameless lab. He or she needs to know who the pathologists are and work with them. Some specimens can present subtleties that are quite difficult to interpret. Arriving at a correct diagnosis requires a good treating physician who can relay information between the doctor performing the biopsy and the pathologist. Lines of communication have to be open both ways so that the doctor can call the pathologist to ask questions about a result, and the pathologist can call the doctor when he needs clinical clarification. Unfortunately, in many labs, it is difficult to reach any pathologist to discuss a case. Furthermore, it is often necessary for a slide to be sent back to the doctor because the patient is going for a second opinion or for additional treatment. "It is often difficult to get slides from some labs," notes Dr. Clay Cockerell.
OTHER SIGNS OF QUALITY
High-quality labs perform daily quality control, and most perform special studies when required, such as immunophenotyping. They also comply fully with state, federal, and other regulations. A lab having accreditation is also a sign of quality because obtaining and maintaining certifications takes time and requires the passage of rigorous inspections.
As many health insurance companies attempt to "steer" biopsies to large corporate labs with which they have a contract, it is quite possible that your doctor is not happy with the quality of the lab but feels compelled to use it nonetheless, especially if there is a risk of a penalty. If you or your doctor is not happy with the quality of service from a lab, a number of different steps can be taken. Generally, the first step is a letter from your doctor and, in some cases, from the patient addressed to the health insurance company expressing complaints.
In response, the health insurance company may agree that your doctor can send the specimen to the lab of his choice. Another, although less satisfactory solution, is that your doctor can insist that the lab have a board-certified dermatopathologist on staff. That's not a substitute, though, for having someone read your specimens whom your doctor knows and trusts.
Finally, another option is for the patient to pay for the biopsy interpretation out of pocket. Surprisingly, however, many patients are reluctant to do so because they feel as if they need to "get their money's worth" and go with what the insurance plan will pay for, even if the expense is relatively low. Many people have no problem shelling out $100.00 or more for things such as a dinner out on the town, but when it comes to paying for an expert interpretation of a skin biopsy that could save his/her life or that of a family member, they balk.
Ask your doctor where he or she would send the biopsy if it was from one of his or her family members. Then request the same for yourself.
ABOUT CLAY J. COCKERELL, MD
Dr. Clay Cockerell is a board-certified dermatologist and a Fellow of the American Academy of Dermatology. He currently sits on multiple boards and committees. Dr. Cockerell is internationally recognized for his contributions to both dermatology and dermatopathology. He is the past president of the American Academy of Dermatology. For many years, Dr. Cockerell has overseen an educational program designed to train the next generation of dermatopathologists. He has served as Associate Editor of the Journal of the American Academy of Dermatology, and he is on the editorial boards of several medical journals, including the American Journal of Dermatopathology.
Dr. Clay Cockerell serves as Founder & Medical Director Cockerell Dermatopathology in Dallas, TX. Since joining the group in 1988, Cockerell Dermatopathology has grown into one of the nation’s most respected dermatopathology practices by always focusing on the needs of referring clinicians and their patients.
He has two children, Charles and Lillian, and he and his wife have been married for forty years. Besides being very active within the dermatology and dermatopathology specialties, Dr. Cockerell and Brenda enjoy traveling, golf, and winter sports.
ABOUT COCKERELL DERMATOPATHOLOGY
Cockerell Dermatopathology, located in the heart of Dallas’ medical district, was founded by Dr. Clay J. Cockerell, former president of the American Academy of Dermatology and internationally recognized dermatologist and dermatopathologist. Cockerell Dermatopathology offers diagnostic excellence and unparalleled service in evaluating dermatologic disorders ranging from the routine to the most difficult.
Cockerell Dermatopathology continues to invest in the future by implementing advanced technologies within the laboratory to best serve referring clinicians and their patients. These new technologies produce higher quality slides to diagnose, improves turnaround time on routine cases, and allows for quicker deployment of EMR interfaces.
From an academic standpoint, Cockerell Dermatopathology hosts numerous Internet-based continuing education events and has a 14-headed microscope for in-person training sessions. Cockerell Dermatopathology serves hundreds of clinicians from across Texas, the United States, and abroad. With an accessible team of board-certified dermatopathologists and a highly trained support staff, Cockerell Dermatopathology’s vision is to treat every specimen as if it came from one of our own family members.