The Importance of a Second Opinion Following a Diagnosis of Cancer

A diagnosis of cancer is usually a critical event in a person's life because it carries with it the threat of premature death, pain and disability. Today, however, many cancers can be cured or palliated for extended periods of time if initial treatment involves the appropriate therapy. In order to receive appropriate treatment, patients must understand the type of cancer they have and the treatment options that are available. As the curative potential for cancer treatments has increased over the past several decades, so has the complexity of information needed to make appropriate treatment decisions. Since very few cancers require emergency treatment, it is important for patients, relatives and friends to allow themselves ample time to learn exactly what their diagnosis means.
Two of the most important things a patient can do following a diagnosis of cancer are to become educated about treatment options and to seek a second opinion. Historically, patients often relied upon a single physician recommendation or out-of-date print materials to make their treatment decisions. Now, the Internet has become a unique resource because it provides a vehicle for real-time distribution of information directly to cancer patients and their families. Currently, there are several Internet resources designed to educate patients. CancerConsultants.com, oncolink.com and the National Cancer Institute web site (www.cancer.gov) are all designed to educate patients and provide current, comprehensive, disease-specific information from screening to treatment.
Each individual involved needs to gather information on the nature of the cancer and how it can be treated (surgery, radiation or chemotherapy). This information educates patients and enables them to ask their physicians the right questions about their cancer treatment so that they can understand the options presented by the physician. However, the main source of information about treatment options comes from the physician who will be directing treatment. For a variety of reasons, it is frequently advantageous for patients with cancer to seek more than one opinion about how their cancer can be treated. Second opinions are a common practice in any area of medicine that is complex and that has multiple treatment options available. Getting a second opinion allows patients to become more informed about their cancer and their treatment options and also provides reassurance.

What is a Second Opinion?
Getting a second opinion involves obtaining a review of the cancer diagnosis and the treatment recommendations of the physician who is treating the cancer. Either the patient or the primary physician can initiate the process of getting a second opinion. Usually, patients can obtain a second opinion by getting a referral to a second physician or to a multidisciplinary team of experts in a cancer center. This doctor or team of doctors will review the pathology (how the cancer looks under the microscope), the extent of cancer, the physical condition of the patient and the proposed treatment. The doctor(s) then communicate their opinion regarding treatment to both the patient and the primary physician. The only problem with referral by the treating physician is that there may be a tendency to refer to physicians with the same treatment philosophies, thereby ensuring a concurrent opinion.
A second opinion should be independent and may be best performed by a physician or team of physicians who do not have a close relationship with the treating physician. More and more cancer patients are being evaluated in larger centers where multidisciplinary teams involving surgeons, oncologists, radiation therapists and sub-specialist oncologists have a role in determining treatment recommendations. In this multidisciplinary setting, second opinions are more likely to be comprehensive.

Who Should Get a Second Opinion?
Although no one has precisely defined the specific situations that merit a second opinion, there are clearly situations where a second opinion would be helpful and most patients would benefit. Patients who feel that they may not fully understand the consequences of the diagnosis and the treatment options should consider a second opinion. The basic complexity of the diagnosis and treatment options, as well as failure of the physician to communicate with the patient, can interfere with the understanding of the situation. In some instances, a patient may experience denial, which can be overcome if a second physician or team of physicians offers similar advice.
Patients, relatives and friends need to keep in mind that second opinions are a normal part of cancer management and they should not be concerned about hurting the feelings of the primary physician. If a patient decides to obtain an independent second opinion, it is important to communicate with the primary physician not only to obtain needed information for review, but also to keep the treating physician informed. Most physicians welcome the opportunity to have another consultant review and approve their care decisions, or perhaps suggest another treatment that may be better. There are instances when a patient will have a basic disagreement with their physician and will need to change physicians, but this is not the main purpose of a second opinion. Most of the time, patients simply need to make sure they are getting the best advice.

Specific Situations Where A Second Opinion is Useful
Non-Cancer Specialist Treatment Recommendations: In the United States , doctors other than oncologists often diagnose and treat patients with cancer. Cancers are diagnosed and treated by family doctors, internists, pediatricians, gynecologists, urologists, ear-nose-and-throat doctors and other non-cancer specialists. In most instances, appropriate therapy is administered. However, patients not treated by specialists in cancer treatment should consider seeking a second opinion. In some situations, physicians will not refer patients for a second opinion because they may lose control and revenue from treatment, they may be threatened by having their patient believe some other doctor is more knowledgeable or often they are just too busy to bother with consulting other physicians. The patients of these types of physicians are probably the most in need of a second opinion.
Cancer Sub-specialists: Many types of cancers are treated by several different types of cancer specialists. For example, prostate cancer may be appropriately treated by urologists who are surgeons, radiation oncologists and/or medical oncologists who use drug treatment. Each specialist may think that the treatment they advise and are involved with is the best treatment for the patient. This is dramatically shown in recommendations for the primary treatment of localized prostate cancer. For localized prostate cancer, surgeons almost invariably advise surgery (radical prostatectomy) as the primary treatment and radiation oncologists invariably advise radiation therapy (either external beam or brachytherapy). A patient with early prostate cancer may want to consult an oncologist or multidisciplinary team who would not be treating this stage of prostate cancer as well as a surgeon and a radiation oncologist to obtain a thorough understanding of treatment options. Seeking a second opinion from a different type of specialist can be informative but it can also, unavoidably, create confusion about treatment options that will need to be resolved by having all of the available information and making an informed decision.
Apparent Lack of Treatment Options: A second opinion can be useful in some patients who are told that there is no appropriate treatment for their cancer and that there is no hope of survival or palliation. Such patients have nothing to lose by seeking a second opinion. In this situation, patients should seek out physicians and institutions that specialize in treating their type of cancer and perform clinical trials. Often, this is accomplished by finding out who is performing clinical trials of novel treatments for the type of cancer in question. Here again, information available on the Internet can help locate such physicians and institutions.
Clinical Trials: Progress in cancer treatment has come predominantly from participation in clinical trials. There are many types of clinical trials, some of which may benefit a patient with a specific cancer and some of which may not. Doctors who participate in clinical trials, whether from a single center or as part of a multi-center trial, need to put patients on these trials and often have trouble finding patients to participate. Unconsciously, such doctors may suggest a trial that may not represent the best treatment for a patient with cancer. When participation in a clinical trial is recommended by the treating physician, a second opinion should probably be obtained to make sure this is the appropriate treatment. The patient should also be aware of all the clinical trials that are available for his or her cancer before selecting the one the treating physician recommends. Two sources of ongoing information regarding clinical trials include comprehensive, easy-to-use listing services provided by the National Cancer Institute (cancer.gov) and eCancerTrials.com. eCancerTrials.com also provides personalized clinical trial searches on behalf of patients.
Rare cancers: If a patient has a rare cancer, it is usually best to seek a second opinion unless the diagnosis is made at a center that specializes in the treatment of this cancer. If a local expert is available, treatment should probably be switched to that doctor. If the expert is far away, which is likely, the treating physician can usually coordinate treatment by phone or e-mail communication. Even if your cancer isn't all that rare, there may be benefit from finding someone with a special interest in the specific type of cancer being treated. For instance, kidney cancer is not really rare, but it's not common either. Usually patients with kidney cancer are treated on multi-center protocols carried out in large institutions. This is because the newer treatment protocols require specialized treatment and clinical trial accrual has to be pooled from several institutions to be meaningful.
Surgery as Primary Treatment: If there is any doubt about the operability or inoperability of a cancer, a second opinion is in order. In this situation, patients are urged to seek second opinions in institutions where large numbers of patients are treated. For instance, esophageal cancer may be considered inoperable in a hospital that performs one such procedure a month, but may be considered operable in an institution that performs several per day. Just as important can be the determination that a cancer deemed operable is in fact inoperable and surgery would be harmful.
Small and Rural Hospitals: Patients who live in a rural area and get treatment at a small hospital probably should get a second opinion from a larger medical center before treatment is initiated. Although smaller hospitals typically deliver excellent treatment, it is prudent to ensure that the recommended treatment is appropriate and can be safely administered. Small and rural hospitals may not see a large volume of cancer patients, and while they are usually fully capable of delivering treatment, it is best to seek a second opinion to help determine what the appropriate treatment is. Sometimes, the recommended treatment will determine whether a patient should receive their treatment at their local hospital or travel to a larger medical center. For example, most small hospitals can effectively deliver chemotherapy; whereas patients requiring a complicated procedure, such as a stem cell transplant, may need to travel to a larger institution that treats a higher volume of patients.
Aggressive Treatment: Most of the cancers that can be cured with chemotherapy (acute leukemias, lymphomas, testicular cancers) require intensive treatment. Intensive treatment may consist of high doses of chemotherapy or radiation therapy and requires rigid adherence to prescribed doses of drugs to ensure that optimal treatment is delivered. Intensive treatment also requires careful monitoring for complications and aggressive supportive care. In many instances, intensive treatment can be administered locally, but such patients are usually best treated in centers that use state of the art protocols (clinical trials) and treat large numbers of patients. All too often, oncologists treat patients with curable cancer with lower doses of chemotherapy in order to decrease side effects. This practice can seriously compromise the chance for cure. Patients should determine how many patients are treated per year and what the results of local treatment are at the treating institution. Treating physicians should present patients with their own results and not results from patients treated in other institutions.
Specialized Treatment: In many instances, specialized treatment is required to achieve optimal cure or control rates. One example of this is stem cell transplantation. Allogeneic or autologous bone marrow or blood stem cell transplants can often offer the best result for patients with blood and lymphoid cancers such as leukemia, lymphoma and multiple myeloma and other cancers such as breast, ovarian and testicular. However, not all medical centers offer this type of therapy. If the treating center does not offer stem cell transplant, a second opinion may be in order. Another example of specialized treatment is treatment for liver cancer. Recent clinical trials have suggested that sophisticated treatment techniques such as intra-arterial chemotherapy, chemo-embolization, radiofrequency ablation, radioactive isotopes and conformal radiation therapy can be of major benefit for the treatment of liver cancers. However, not all centers have the capability of delivering this type of treatment. Patients with liver cancer and other cancers that can be treated by specialized methods require second opinions at specialized institutions.

Cost of Second Opinions
One of the problems with second opinions is that insurers may not cover the expense. However, many insurance and health care companies do pay for such opinions and acknowledge the importance of second opinions. In some situations, insurers will even insist on a second opinion. This is often the case when the primary physician advises an expensive treatment.
Health Maintenance Organizations (HMOs) have a vested interest in keeping patients within the system. This may cause a conflict of interest between the patient and the HMO, especially if very expensive treatment is only available outside the HMO system. The more money the HMO spends on second opinions and treatments outside the HMO system, the less money there is available to treat patients within the system and the less the HMO makes in profit. However, most reputable HMOs can deliver state of the art treatment for most cancers. It is a good idea, however, for HMO members with cancer to make sure they are informed about clinical trials or other promising new treatments. HMO members may also be discouraged from trying expensive treatments that have only a small chance of success, even if that chance is real. It is also important for HMO members undergoing cancer surgery to inquire about the number of such procedures performed each year by the HMO and the results. The best protection for an HMO member is to seek a second opinion even if she or he has to pay for it.
In summary, patients should become their own advocates and become as knowledgeable about their treatment options as possible. When there is any doubt about the diagnosis or treatment plan, patients should obtain a second opinion. Second opinions will not offend competent physicians. Second opinions will, however, provide reassurance to patients and family members and ultimately allow patients to receive the most appropriate therapy.