Curious Dr. George | Plumbing the Core and Nibbling at the Margins of Cancer

The Autopsy is Essential in Proper Cancer Care

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David S. Priemer, M.D., Resident Physician in Anatomic Pathology and Neuropathology, Indiana University School of Medicine Department of Pathology and Laboratory Medicine, Indianapolis, IN; priemerd@iu.edu

Q: The numbers show that American physicians are ready to cast the medical/hospital autopsy into some relic or trash bin. Yet some physicians believe that the low tech autopsy still has much to contribute. Do you believe that the autopsy still can be useful in cancer deaths? And, if so, in what ways?

A: As an aspiring autopsy pathologist, it has been disappointing to learn of the decreasing role of autopsy in medicine. Many in pathology do not care for autopsies because they are dirty, time-consuming, and not reimbursed. Issues also exist amongst clinicians who trust that modern diagnostic modalities provide equivalent value, fear exposing mistakes, fear litigation, and are growing increasingly uncomfortable with approaching patient families. This medical environment which has largely forgotten the autopsy is also that in which trainees are developing habits as future practitioners. As a result, we may be facing further decline in the use of autopsies in the years to come.
Despite diminishing emphasis on the autopsy, data suggests that it has retained its value. This is as true for cancer patients as it is for any. Below I have highlighted what I think are the most important ways in which autopsies are useful for cancer patients:

  1. Establishing cause of death. This reason for performing autopsies does not change because an individual has cancer. According to recent studies, major discrepancies (missed major diagnoses relating to the death that would have had a positive or equivocal impact on survival) between pre-and post-mortem findings occur in approximately one quarter of critically ill cancer patients. This rate is within the range of those observed in recent studies that used generalized patients. Therefore, it does not appear that deaths in critically ill cancer patients are any less likely to involve discrepant diagnoses than deaths in other settings. In addition to confirming the events that led to a death from cancer, the autopsy may also be the only way to discover that a patient died independently of their cancer. In other words, autopsy may be the only way to truly confirm a cancer death at all.
  2. Assessing diagnostic accuracy. Autopsy is the gold-standard for assessing the accuracy of medical imaging. In the cancer setting, autopsy can confirm or deny imaging results and may discover lesions that were not clinically noted. In addition, autopsy allows for histopathologic confirmation of the malignancy; this may be particularly important in patients who had limited tissue sampling prior to death.
  3. Evaluating effectiveness and potential adverse effects of treatment. The autopsy allows access to the entirety of a patient’s tissues, and therefore can serve as the ultimate tool for the determination of treatment effect and harmful side effects in the sickest of cancer patients, those who die. This should be especially considered in patients undergoing chemotherapeutic trials, which is where these outcomes are being studied. However, it is not required that research protocols in the United States include autopsies for patients who die while on trial therapies.
  4. Research. Perhaps the most notable modern example of the use of autopsy in research is actually in cancer research. Tumor molecular biology has been of growing research interest as we move toward targeted cancer therapies. However, tumor harvested for these purposes from living patients is often suboptimal for the purposes of comprehensive molecular analysis. Because of this, autopsy has emerged as a method to collect large amounts of tumor from deceased patients, and the field of “rapid autopsy” has been born. Rapid autopsies, which are performed within 6 hours of death to sample viable tumor, are now being performed in a handful of American institutions. The number is expected to grow in the coming years.

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