A second opinion is an important
part of becoming educated about your
cancer and your treatment options.
The more you can learn about your
diagnosis and your treatment
options, the better chance you have
of receiving the most appropriate
treatment. Cancers are now more
treatable than they once were, but
there are also many more treatment
options and more complicated
procedures. Getting a second opinion
will help you understand these
options and help you make an
informed decision about which is
best for you. Second opinions will
not offend competent physicians.
Second opinions will, however,
provide reassurance to you and your
family and ultimately allow you to
receive the most appropriate
therapy.
What is
a Second Opinion? A second
opinion is a review of the cancer
diagnosis and the treatment
recommendations of the physician who
is treating the cancer by another,
independent physician. Either the
patient or the primary physician can
initiate the process of getting a
second opinion. Usually, patients
obtain a second opinion after being
referred to a second physician or to
a special team of experts in a
cancer center, called a
multidisciplinary team. This doctor
or team of doctors will review the
following:
- Pathology report
(how the cancer looks under the
microscope), - The extent of
cancer - The physical condition
of the patient - The proposed
treatment
The doctor(s) then
communicate their opinion regarding
treatment to both the patient and
the primary physician. Second
opinions are more likely to be
comprehensive, or inclusive of every
possible perspective, when performed
in a cancer center with a
multidisciplinary team, which
usually includes surgeons,
oncologists, radiation therapists,
and sub-specialist oncologists.
Why
Do I Need a Second Opinion?
A second opinion is part of the
education process that is critical
for cancer patients. The treatment
of cancer has evolved tremendously
in the recent past. As a result,
many cancers are now more treatable
than they once were, especially if
the appropriate initial treatment is
selected. In order to receive
appropriate treatment, patients must
understand the type of cancer they
have and the treatment options that
are available. However, there are
also many more options for treatment
and these options are more
complicated than in the past. For
these reasons and others, it is
advantageous to seek more than one
opinion about how your cancer can be
treated. Also, a second opinion
provides the opportunity to get
information from someone other than
the physician who will be directing
treatment, which is usually the main
source of information for most
patients. Second opinions are a
common practice in any area of
medicine that is complex and that
has multiple treatment options
available.
Is
Getting a Second Opinion Considered
"Bad Etiquette"? 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 you decide 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 may disagree with their
physician and will need to change
physicians, but this is not the main
purpose of a second opinion. Most of
the time, you simply need to make
sure you are getting the best
advice.
Who
Pays for a Second Opinion?
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.
The best protection for cancer
patients who are Health Maintenance
Organization (HMO) members is to
seek a second opinion even if she or
he has to pay for it. HMOs usually
try to diagnose and treat patients
within their system because the more
money the HMO spends on second
opinions and treatment outside the
HMO, the less money there is
available for operation costs and
profits. 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.
HMO members may also be discouraged
from trying expensive treatments
that have only a small chance of
success, even if that chance is
real. For these reasons, it is a
good idea for HMO members to get a
second opinion and make sure they
are informed about clinical trials
or other promising new treatments.
Most reputable HMOs can, however,
deliver state of the art treatment
for most cancers. If you are
considering undergoing a specialized
treatment, such as cancer surgery,
within your HMO, it is important to
inquire about the number of such
procedures performed each year by
the HMO and the results.
Who
Should Get a Second Opinion?
Although the specific situations in
which a second opinion is most
useful have not been defined, there
are clearly situations where a
second opinion would be helpful and
most patients would benefit. These
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 diagnosis:
Patients who feel that they may not
fully understand the diagnosis and
their treatment options should
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. While a
clinical trial may be your best
treatment option, you should
consider all possible clinical
trials before selecting the one your
treating physician recommends.
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.
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