Take Time for a Second Opinion

Getting a second opinion about your diagnosis and treatment options is important. The more you learn, 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. Receiving a second opinion will help you understand these options and make an informed decision about which is best for you.

Don’t worry that your doctor will be unhappy with you if you review your diagnosis and treatment plan with another physician before proceeding. It’s normal to get a second opinion in cancer treatment, and a knowledgable doctor will not be offended. 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 your physician’s cancer diagnosis and treatment recommendations by another, independent physician. Either the patient or the primary physician can start 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 pathology report (how the cancer looks under the microscope) 
• The extent of the cancer 
• The physical condition of the patient 
• The proposed treatment 

The second doctor then offers his or her opinion on treatment to both the patient and the primary physician. 

Second opinions are more likely to be comprehensive and include every possible perspective when performed in a cancer center by a multidisciplinary team, which usually includes surgeons, oncologists, radiation therapists, and subspecialist oncologists. 

Why do I need a second opinion? 

A second opinion is a critical part of a cancer patient’s education. Patients must understand the type of cancer they have and the treatment options that are available. Those options are more numerous and more complicated than in the past. The treatment of cancer has evolved tremendously, and many cancers are now more treatable than they once were, especially with the appropriate initial treatment. For these reasons and others, it is to your advantage 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, the main source of information for most patients. Second opinions are a common practice in any complex area of medicine with multiple treatment options. 

Is getting a second opinion considered “bad etiquette”? 

Patients, relatives, and friends should keep in mind that second opinions are a normal part of cancer management and not worry about hurting the feelings of the primary physician. If you decide to obtain an independent second opinion, it is important to communicate with your primary physician—not only to get the information you need for review, but also to keep him or her informed. Most physicians welcome the opportunity to have another consultant review and approve their care decisions, or perhaps suggest another treatment that might be better. There are instances when a patient may disagree with his or her physician and need to find a replacement, 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 acknowledge the importance of such opinions and pay for them. 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 members of a health maintenance organization (HMO) is to seek a second opinion even if they have 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 available only 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 and promising new treatments. 

However, most reputable HMOs can 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 benefit most patients. These may include: 

• A poorly understood or communicated diagnosis 
• An initial diagnosis by a noncancer specialist 
• A diagnosis by a cancer subspecialist 
• Apparent lack of treatment options 
• A treatment plan that involves a clinical trial 
• Rare cancers 
• A treatment plan 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 the patient can better understand, or simply hearing the diagnosis a second time may help the patient overcome denial. 

Initial diagnosis by a noncancer specialist -  Patients who have been diagnosed by a noncancer specialist benefit from a second opinion. In the United States, doctors other than oncologists often diagnose and treat patients with cancer: family doctors, internists, pediatricians, gynecologists, urologists, ear-nose-and-throat doctors, and other noncancer 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. They may fear losing control and revenue from treatment, they may be threatened by the patient’s perception that another doctor is more knowledgeable, or, often, they may be 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 subspecialist -  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 oncologists who use drug treatment. Each specialist may think his or her treatment is the best for the patient. For example, in localized prostate cancer, surgeons almost invariably advise surgery (radical prostatectomy), while radiation oncologists invariably advise some form of radiation therapy. 

For this reason, a patient with cancers that are treated by subspecialists 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 unavoidably creates confusion about treatment options. The best way to resolve this confusion is to gather and use all of the available information to make 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. 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. 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 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. 

Although a clinical trial may be your best treatment option, you should consider all possible clinical trials before selecting the one your treating physician recommends. A source of ongoing information regarding clinical trials includes a comprehensive, easy-to-use listing service provided by the National Cancer Institute. 

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 that 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 in 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 one that performs several per day. Just as important can be the determination that a cancer deemed operable is in fact inoperable and that 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 begins. 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 many 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 recommendation will determine whether a patient should receive treatment locally or travel to a larger medical center. For example, most small hospitals can effectively deliver chemotherapy, but patients requiring a complicated procedure, such as a stem cell transplant, may need to travel to a larger institution that treats more patients. 

Aggressive treatment -  Most of the cancers that can be cured with chemotherapy (acute leukemias, some lymphomas, and testicular cancer) require intensive treatment, such as high doses of chemotherapy or radiation therapy, and a second opinion is useful to ensure that the proper intensity will be used to achieve a cure, not just a temporary remission. Occasionally, oncologists treat patients with curable cancer with lower doses of chemotherapy 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, 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, chemoembolization, radiofrequency ablation, radioactive isotopes, and conformal radiation therapy can be of major benefit for the treatment of liver cancers. However, not all centers can deliver this type of treatment. Patients with liver cancer and other cancers that can be treated by specialized methods require second opinions at specialized institutions.