This just in: Dr. Epstein, Hopkins second opinion and pathology guru, on an indefinite leave

Plus an interview with Dr. Epstein

By Howard Wolinsky

Dr. Jonathan Epstein has gone on a leave of absence from Johns Hopkins Hospital, where served as Director of Surgical Pathology. The reason for his leave has not been disclosed.

I asked Epstein Wednesday, but he has not responded.

I first heard about his leave on Tuesday from a patient who was referred to another pathologist in the Hopkins practice for a second opinion on his biopsy slides. The patient said he was satisfied with the visit.

Epstein rendered thousands of second opinions yearly for patients with prostate cancer.

Suzanne Hoffman, Epstein's assistant at Hopkins provided this update:

“Dr. Epstein is indeed out on a leave of absence, and we don’t know when he’ll return.

“In the meantime, however, you can suggest that tl(patients) continue to contact Johns Hopkins if they’d like a second opinion.  Drs. Andres Matoso, Tamara Lotan, and Ezra Baraban, the three other GU pathologists on staff, have been trained by him, worked with him for years, and will be assigned his cases fto review, so they’ll be in good hands.

You can send Dr. Epstein best wishes in the comment bubble above. He is a a reader of TheActiveSurveillor.com.

Epstein is recognized as a leader in the field of urological pathology. He reviewed slides from about 12,000 patients or more per year.

Epstein has been a fixture on the prostate cancer scene for more than three decades. In fact, he provided me with a second opinion when I was diagnosed in 2010.

In the 1990s, he did the foundational work that led to the classification of very low-risk prostate cancer vs. low-risk. The National Comprehensive Cancer Network still uses this classification, while the American Urological Association dropped it last year. For more on this debate: https://www.medpagetoday.com/special-reports/apatientsjourney/104586

He has spearheaded reforms of the Gleason scoring system. Most recently, he created the Grade Group system in which patients at the lowest risk are classified as Grade Group 1. Previously, such patients were classified as Gleason 3+3=6, which concerned some patients who misinterpreted a “Gleason 6” as being aggressive cancer based on the relatively high number. Epstein came u[p with the idea opf changing the scale to put patients’ minds at ease.

Epstein also has challenged the proposal to rename Gleason 6 lesions as non-cancers out of concern that patients won’t continue surveillance if they are told they have a noncancer. See: https://ascopubs.org/doi/full/10.1200/JCO.22.00926

Epstein has been generous with his time in speaking to patient groups. Most recently, he appeared in the Active Surveillance 101 program on second opinions and biopsies: https://aspatients.org/a-s-101/ He also appeared in a Q&A in April: https://aspatients.org/meeting/as-101-episode-5-second-opinions-and-biopsies/

He also spoke to AnCan: https://ancan.org/webinar-active-surveillance-and-beyond-4-dr-jonathan-epstein-grading-prostate-cancer-for-as/

Q&A with Dr. E.

By Howard Wolinsky

I had an email exchange with Dr. Epstein back in 2021 that I thought I’d share.

Dr. Epstein is famous for speaking with patients. Most pathologists don’t.

Pathologists typically consider themselves doctor’s doctors and rely on the referring doctor to share their results with patients. Epstein broke that pattern long ago and speaks directly to patients about their pathology results and whether he thinks they may be candidates for Active Surveillance or other treatment. (He explains why below.)

I have spent a lot of time in my freelance work with pathologists. In fact, I wrote a book about the future of pathology for the College of American Pathologists. (If you want a copy, let me know.)

I heard many jokes about pathologists: Pathologists are considered introverts.

How can you tell an introverted pathologist from an extroverted pathologist?

The answer: The introverted pathologist stares at his own shoes. The extroverted pathologist stares at the patient’s shoes.

One of the points I made in the book was pathologists will be having more patient contact in the future. Epstein has been a trailblazer

Dr. Epstein explains why he does this in the Q&A below.

Howard Wolinsky--How frequently do discrepancies occur when pathologists read slides?

Dr. Jonathan Epstein: Every day, I see discrepancies in terms of grading and missing small foci of cancer and less commonly overdiagnosing cancer.

HW: Why do these occur? Is pathology more of an art than a science?

JE: It is both an art and a science. The science aspect is that some pathologists do not have the same training or are not as skilled. Like any field, there is a range of both expertise and skill level.

Most pathologists are good at what they do, but there is a minority that is not. Pathology is a visual field, and some pathologists are not as visually adept at picking up subtle features as others. Some may not be as careful to find very focal areas of abnormality. Some are not as logical and approach cases incorrectly.

HW: How often are there upgrades vs. downgrades?

JE: I would say it depends. Gleason pattern 5 (4+5=9, 5+4=9, 5+5=10) are routinely undergraded and the pattern 5 not reported. We did two studies on this topic. In terms of Gleason pattern 4, it is both undergraded and overgraded about the same.

HW: How often are you wrong?

JE: Don’t know. I am aware of a handful of cases (12,000-15,000 per year) over the 30+ years I have practiced, where I have made mistakes and learned from them.

HW: I know someone who has had four biopsies. You and Ming Zhou (pathologist-in-chief at Tufts Medical Center) ruled the cores Gleason 3+3 but Mayo twice said 3+4. How can a patient decide what’s right?

I know another patients with this quandary at Northwestern where a urologist recommended surgery based on a single 3+4 which you say is a 3+3. Patients have to make serious decisions but don't know who to believe.

JE: Patients must decide whether they trust a recognized world leader in the field or an institution. For example, in the situation you cite above, when consults are sent to Mayo, they do not specifically go to genitourinary pathology experts but to a general consult service.

HW: Another patient told me the pathologist only sent for a second opinion six of 13 slides. Is this a common practice? Or should all slides be sent?

JE: The vast majority of time sending the key slides suffices, but occasionally I will find something important on slides that were called totally benign at the outside institution. It does not cost more to send the whole case, so it’s best to do so.

………..

Dr. Epstein, always eager to share information, sent me a follow-up note:

“One of the greatest difficulties is to distinguish between poorly formed glands of Gleason pattern 4 vs. tangentially sectioned small glands of Gleason pattern 3 (i.e., 3+3=6 vs 3+4=7). If I am uncertain, I call 3+3=6 so as to not result in overtreatment of the patient, which is irreversible.

“I think by my frequently talking to patients and getting a better sense of their fears of morbidity associated with treatment, along with my medicolegal work as an expert witness where I have seen some of the severe morbidity of treatment, helps me to be more conservative. Also, I see a lot of radical prostatectomy specimens where I have seen cases where after 3+4=7 is called on biopsy, it is hard to find pattern 4 in the radical prostatectomy, which also sensitizes me not to call pattern 4 on the biopsy unless definitive.”

---