Referrals for second opinion in surgical pathology: implications for management of cancer patients in the UK

Abstract

Objective: To compare patterns of outgoing referral practice from one large district general hospital histopathology (cellular pathology) laboratory to other pathology laboratories.

Design: Referral cases for the relevant years were identified via hand searching of consultant referral files and from a central laboratory referral file. A comparison was made of the number and nature of pathology case referrals made to other laboratories in year 1990 with those made in year 1998.

Setting: Large district general hospital pathology laboratory in the UK.

Results: A statistically significant increase in the number of cases referred for a second opinion to an outside pathologist was noted, from 60 to 128 cases, representing an increase from 0.35 to 0.56% of total laboratory specimen workload (P=0.0034). In 36 (31.0%) of 116 cases from 1998 the diagnosis was altered, or a confident diagnosis was made where previously there was no definite diagnosis. Five cases with a benign in-house diagnosis had a malignant second opinion diagnosis and five cases with a malignant in-house diagnosis had a benign second opinion diagnosis. The largest single category of referred cases was for classification/grading of malignant lymphoma, comprising 27 (23%) of cases. The mean time delay between receipt of a specimen in the laboratory and issuing of the final report was 22 days (range 7-60 days). Only 25% of the referred cases were reported within 14 days.

Conclusions: Referrals are an important component of pathology practice. In the UK much of this activity is performed on a 'grace and favour' basis between laboratories despite the fact that referral cases are often complex and time consuming for the recipient pathologist and laboratory. Histopathology referrals do not seem to be adequately costed and accounted for in interinstitutional service level agreements within the UK National Health Service.