Inside a laboratory room surrounded by books and tools, female pathologist holds up a slide before inserting it into the microscope.

The Crucial Role of Pathology

Patients are often advised to get a second opinion after receiving a bladder cancer diagnosis. But did you know you can not only get a urology, radiation, or medical oncologist second opinion but also a pathology second opinion?

You don’t hear much about pathology when you hear about bladder or any other cancer. But the information that a pathologist provides to a urologist is crucial in determining the recommended course of treatment.

What do pathologists do?

Per the National Cancer Institute (NCI), a pathologist is “a doctor who has special training in identifying diseases by studying cells and tissues under a microscope.”

When the urologist first suspects that you have bladder cancer, a biopsy is taken. The biopsy is a sample of the suspicious cells. They are sent to a pathologist.

What the pathologist reports on the biopsied cells determines the entire course of your treatment. So, getting the pathology right is crucial. I know more than one patient whose diagnosis (and treatment plans) were revised after a second opinion on the pathology.

What does the pathology tell us?

The pathology gives a patient key information about his or her bladder cancer that is used to determine a course of treatment. The pathology is the diagnosis. It tells us three crucial things: tumor type, grade, and stage.

Tumor types

The pathology report identifies the type of tumor: papillary, sessile or carcinoma in situ (CIS).

Papillary tumors tend to grow into the bladder cavity rather than into the deeper layers of the bladder wall. Sessile tumors lie flat and are more likely to grow deeper into the bladder wall.

CIS is a flat type of tumor (that may appear as an inflamed patch). It is non-muscle invasive but tends to be higher grade and, therefore, puts the patient at a higher risk of progression and/or recurrence.

Knowing which kind of tumor is essential for deciding how aggressively to treat.

Tumor grade

Bladder cancer tumors can be classified as high grade or low grade. Grading is a measure of how normal or abnormal the cells appear under the microscope. The more abnormal they appear, the higher the grade of the tumor. Higher grade tumors tend to be more aggressive.

Cancer stage

Accurate staging of bladder cancer is also crucial for determining the treatment course. The stage can range from Ta to T4. The stage identifies the location of the tumor relative to its original site in the bladder. The stage is higher the further the tumor has grown away from the original site. The highest stage is T4 or Stage IV, known as metastasis, in which the bladder cancer has spread beyond the bladder to other organs.

If you seek a second opinion from a urologist at a large academic cancer center, there is a good chance that a second opinion on your pathology will come along with that. But it is worth asking about and requesting if it’s not automatic.

Request a second opinion on pathology

It's also possible to seek out a second opinion just on the pathology. You don’t need to travel to do it, and you don’t need to have another biopsy. Your slides can be sent to the institution giving the second opinion. You might need your doctor to help you request it. Any doctor should be glad to do that. Do not feel intimidated to ask.

You might have to pay out of pocket for it if your insurance won’t cover it. If you can manage to afford that, do it.

The pathology is the crucial information that will determine everything that happens next. Even if you are being treated by a community urologist, you will feel much peace of mind when your pathology results (and thus your diagnosis) have been reconfirmed by a large center with extensive expertise such as Johns Hopkins or MD Anderson.

Read your pathology report and do the work you must to understand it

I encourage you to read your pathology report – first and second opinions – in detail. It will seem like gibberish. It will seem incomprehensible. But work through it. All the details of your cancer are included there. You can find information online and you can ask your doctor about what it means. I wish I had done this more diligently when my husband was first ill with bladder cancer – and especially when it came back metastatic.

If you want the Ph.D. level course on understanding your pathology, I recommend this excellent and highly detailed webinar put together by the Bladder Cancer Advocacy Network.

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