What's taking so long?

You had a biopsy and now you're waiting. Maybe your doctor has even warned you that it is "probably" cancer or they are "concerned about" cancer. You want an answer and you've been waiting....maybe a few days....maybe a week or more. What is going on behind the scenes? More importantly, why is this taking so long?

Sometimes it must feel like visiting the doctor is like going to see an elaborate play. The actors are chosen, the scenes set and painted, the lines written and memorized, the movements choreographed, and the production delivered by the actors. Before they go out on stage, however, a writer has been toiling at his or her computer choosing the right words. Not just any words will do -- they must be the right ones. If a line is written poorly, it could throw off the whole message of the play.

The surgeons, chemo and radiation doctors -- these are the players. These are the ones you see delivering the lines and conveying the message to the audience. They have different styles, different tones, different passions. But before the lines are delivered -- your pathology results -- a doctor has been (hopefully meticulously) pouring over the information and carefully generating a report that will guide all the decisions to come (no pressure).

This is what happens behind the scenes:

A piece of your body (tissue) is removed and placed in a container. That container then goes to an administrative person in the laboratory. The tissue is carefully logged in (accessioned) and a case number is assigned. It is critical that all the information be logged in correctly. The right result getting to the wrong patient could be catastrophic. Depending on when the tissue gets to the lab, this may take a few hours or even overnight. The tissue then needs to be "fixed" -- which can take 2-24 hours depending on the size of the sample. This preserves the cells and the architecture, basically freezing them in time so they no longer break down and die (and turn into a pile of mush).

After it is fixed, a pathologist or a well trained pathology assistant puts the tissue specimen on a bench and looks at it thoroughly. They describe the size, weight, appearance, and any concerning features into a microphone (because their hands are pretty dirty at this point). This is called the "gross description." They cut it into pieces to get a really good look and decide what needs to be examined under a microscope. The process is called "grossing." The tissue selected for microscopic examination must be further processed before it is put on the slide. A machine makes sure the tissue is further rendered preserved in a complex process that is kind of like mummification. What you are striving for is a snapshot of what the organ or tumor looked like in your body when it was still alive.

The processed tissue is then embedded in clear, melted wax and cut to less than half the thickness of a sheet of common plastic wrap. It is placed on a glass slide and dipped into a battery of basic stains. Grossing, processing, slide-making, and staining takes at least 8 hours, but some specimens can take up to 2 weeks. Why so long? Some tissues like bone need special processing (decalcification, in this case) that just take longer by virtue of the chemical process utilized. The average time this takes in the United States is about 24 hours.

Here's the part that you really don't want screwed up. A pathologist looks looks at the tissue under the microscope. What, exactly, is a pathologist? A pathologist is a doctor who went to medical school just like me. After graduation, I did an Internal Medicine Residency and they did a Pathology Residency. Correction: most of them did two residencies -- Anatomic Pathology and Clinical Pathology (looking at tissue and troubleshooting and explaining laboratory tests run on machines, respectively). I took an Internal Medicine Board Exam, and they took 1-2 board exams. Like me, some of them went on to more specialized training called "fellowship."

It may seem like looking at cancer under a microscope is like looking at a picture of a dog and saying, "yes, that's a dog." But no, it is more like looking at a picture of a 4 legged animal that might be a dog and then justifying why it is or isn't a dog. Not only that, in modern medicine, you need to state exactly what breed it is. This requires more stains which can take additional tests on the tissue. These tests -- especially if they need to be sent to specialized laboratories, can take anywhere from 1 day to 2 weeks. If it is a rare diagnosis, it may even be sent to an expert who did a fellowship in that type of biopsy or tissue, which is even more time.

Here is my advice:

1. Be patient. You want a diagnosis, but it needs to be right.

2. Quality takes time.

3. If it has been a few weeks, ask your oncologist/surgeon to check up and see where your biopsy is in the process. They might have done this already.

This blog was inspired by another blog I read about misdiagnosis. Yes, it happens. Why? Honestly, the times I've seen it is when the pathologist rushes through their work or they give a "preliminary" diagnosis over the phone (what they think it is going to turn out to be) before they have all the information and the treating doctor runs with it. I NEVER prescribe treatment on a preliminary diagnosis. Most of the time, I don't even tell the patient. I get my plan ready so when the final report is signed out and all done, I can get treatment started as soon as possible. That said, if the diagnosis we suspect is one of the fast-growing cancers (acute leukemia, race-car lymphomas, or small cell cancer of any organ), we can work with the pathologists on our team to rush a specimen. Still, what we want -- no, what we NEED -- is quality, not speed.

And in my case, it doesn't hurt that I am married to a pathologist (who helped me write this post).

Thanks for reading.

-Dr. G