The Cancer Navigator (@navigator) published a blog post · February 28th, 2013
When Should Patients Consider a Second Opinion
Although most individuals benefit from a second opinion, there are specific situations in which a second opinion is very useful. These situtaitons may include:
• A poorly understood or communicated diagnosis
• An initial diagnosis by a non-cancer specialist
• A diagnosis by a cancer sub-specialist
• Apparent lack of treatment options
• A treatment plan that involves a clinical trial
• Rare cancers
• A treatment plant that involves surgery as primary treatment
• A diagnosis that has been made at a small or rural hospital
• A treatment plan that involves aggressive treatment
• A treatment plan that involves specialized treatment
Poorly Understood or Communicated Diagnosis: Patients who feel that they may not fully understand the diagnosis and their treatment options should also consider a second opinion. Another physician may communicate in a way that the patient can better understand, or simply hearing the diagnosis a second time may help the patient overcome any denial they may have.
Initial diagnosis by a non-cancer specialist: Patients who have been diagnosed by a non-cancer specialist benefit from a second opinion. 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 consult other physicians. The patients of these types of physicians are probably the most in need of a second opinion.
Diagnosis by a cancer sub-specialist: Many types of cancers are treated by several different types of cancer specialists. For example, prostate cancer may be treated by urologists who are surgeons, radiation oncologists, and/or medical oncologists who use drug treatment. Each specialist may think that their treatment is the best treatment for the patient. An example of this is in the localized prostate cancer, where:
• Surgeons almost invariably advise surgery (radical prostatectomy)
• Radiation oncologists invariably advise some form of radiation therapy.
For this reason, a patient with cancers that are treated by sub-specialists may want to consult an oncologist (general cancer doctor) or multidisciplinary team 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. The best way to resolve this confusion is to gather and use all of the available information to 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 relief of symptoms from the cancer. 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.
A treatment plan that involves a clinical trial: 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. 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 participate in cancer research by enrolling their patients in clinical trials; however, they often have trouble finding patients to participate. Unconsciously, such doctors may suggest a trial that may not represent the best treatment for a particular patient.
Rare cancers: When dealing with 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 home physician can usually coordinate treatment by phone or e-mail. Even if your cancer isn't rare, you may benefit from finding someone with a special interest in your specific type of cancer. For instance, kidney cancer is not really rare, but it's not common either. Usually patients with kidney cancer are treated on clinical trials carried out in one of several large institutions. This is because the clinical trial may require specialized treatment and there are not enough patients with kidney cancer at one institution to make the research 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 hospitals and rural practices: 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 locally 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, some lymphomas, testicular cancers) require intensive treatment, such as high doses of chemotherapy or radiation therapy, and a second opinion is useful for ensuring that the proper intensity will be used to achieve a cure, and not just a temporary remission. Occasionally, 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. Also, intensive treatment requires rigid adherence to prescribed doses of drugs to ensure that optimal treatment is delivered, careful monitoring for complications, and aggressive supportive care to manage side effects. 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. If you are considering an aggressive treatment, you should determine how many patients are treated per year at your local treatment center and what the results are. Ask your treating physicians for their own results and not results from patients treated in other institutions.
Specialized treatment: Not all medical centers offer the specialized treatments that may offer the best results for some patients. In these cases, a second opinion may be in order. For example, bone marrow or blood stem cell transplants may offer the best chance for cure or control of the cancer for patients with blood and lymphoid cancers such as leukemia, lymphoma, and multiple myeloma and other cancers such as breast, ovarian, and testicular. Specialized treatment may also be required 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.