Get a Second Opinion: Seek, Listen, Learn

If you’ve been diagnosed with cancer, seeking a second opinion will allow you to learn more about your cancer type and make truly informed decisions about treatment.

By Charles H Weaver, MD

Getting a second opinion is an important part of becoming educated about a cancer diag­nosis and treatment options, and all cancer patients should consider seeing at least one additional expert after an initial diagnosis. Getting a second opinion will also give you the opportunity to find a physician you are comfortable with—someone you respect and who you believe is paying attention to your needs.

Advances in cancer care are currently occurring at an unprec­edented rate due to advances in genomics and technology and the development of precision targeted therapies. In 2015 alone there were 32 new drug approvals by the US Food and Drug Administration for the treatment of cancer. Advances in sur­gery through the use of robotics and the delivery of radiation using newer technology that more precisely targets the cancer and spares normal tissues are occur­ring on an ongoing basis, and doc­tors are increasingly using available therapies in new ways to stimulate the immune system to fight cancer.

If you are facing a cancer diagno­sis, you need to know which ther­apy will give you the best chance of a cure and will prolong your life with the fewest side effects. Getting a second opinion will help you un­derstand the treatment options and help you make an informed deci­sion.

While many patients I have in­teracted with over the years have expressed concern that seeking a second opinion might offend their doctor or delay treatment, this is simply not the case. Second opin­ions are routine, will not offend competent physicians, and do not delay therapy. Second opinions will, however, provide reassurance to you and your family and potentially ex­pose you to other treatment options that will ultimately allow you to re­ceive the most appropriate therapy.

What Is a Second Opinion?

A second opinion is a review of the primary physician’s cancer diagno­sis and treatment recommendations by another, independent physician or cancer center. The most valuable second opinions are by physicians who have a dedicated research and clinical interest in your type of can­cer at a major cancer center. Either you, as 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 team of experts, called a multidisciplinary team, in a cancer center. This doctor or team of doc­tors will review the following:

  • The pathology report (how the cancer looks under a microscope) To confirm the diagnosis
  • To see if appropriate testing for specific treatment targets was performed, and whether additional testing is necessary
  • The stage or extent of spread of the cancer
  • The patient’s physical condition
  • The proposed treatment plan and other recommendations

The doctor(s) then communicate their opinion regarding treatment to you and, if you desire, to 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 subspecialist oncologists.

Why Do I Need a Second Opinion?

A second opinion is part of the crit­ical patient-education process. Can­cer treatment 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. To receive appropriate treatment, you must understand the type of cancer you have and the treatment options that are available.

There are also many more options for treatment, however, and these alternatives are more complicat­ed than in the past. For these rea­sons and others, it is helpful to seek more than one opinion about how the cancer can be treated. A second opinion also provides the opportu­nity to get information from some­one other than the physician who will be directing treatment, who 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 standard part of cancer management, and they should not be concerned about offending of the primary physician. If you decide to get an independent second opin­ion, it is important to communicate openly with the primary physician to obtain needed information for review and to keep the primary phy­sician informed. Most physicians welcome the opportunity to have a consultant review and approve their care decisions—or perhaps suggest another treatment that may be a better option. There are instances in which a patient may disagree with the primary physician and will need to seek care elsewhere, 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 problem you may encounter in seeking a second opinion is that in­surers may not cover the expense. Many insurance and healthcare companies, however, do pay for second opinions and acknowledge their importance. In some situa­tions insurers will even insist on a second opinion, as is often the case when the primary physician recom­mends an expensive treatment. Be­fore you seek a second opinion, you will need to review your insurance plan to understand what it covers.

Where Should I Get a Second Opinion?

If possible, the best place to get a second opinion is from a physician at a cancer center that has expertise in your cancer type. This will usu­ally, but not always, be at a major cancer center. That said, there are certainly community-based oncol­ogists (general cancer doctors) who have specific treatment and research interests; the point is, get the opinion from someone who spe­cializes in your cancer type.

Your primary oncologist should be able to refer you to another ex­pert for a second opinion. In ad­dition to your primary physician, social media can be quite helpful in seeking appropriate experts. On­line communities of cancer patients are good resources, as you can con­nect with others who have already done the research and are often quite eager to help others facing a diagnosis. One of the leading social communities is CancerConnect; many patients learn of new treat­ment options and doctors with spe­cific interests from others in these communities.

Who Should Get a Second Opinion?

There are situations in which a sec­ond opinion can be especially help­ful and provide the most benefit, including the following.

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 he or she 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. Patients not treated by specialists in cancer treatment, how­ever, 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 another doctor is more knowledgeable. Other times they are just too busy to consult with 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 kinds of specialists. For example, prostate cancer may be treated by urologists who are surgeons, radiation oncolo­gists, or medical oncologists who use drug treatment. Each specialist may think that his or her treatment is the best option for the patient. An exam­ple of this is in the management of localized prostate cancer:

  • Surgeons almost invariably advise surgery (radical prostatectomy).
  • Radiation oncologists invariably advise some form of radiation therapy.

For this reason patients with cancers who are treated by subspecialists may want to consult an oncologist or a 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, cause confusion about treatment options. The best way to resolve this confusion is to gather and use all the available information and make an informed decision.

Apparent lack of treatment op­tions. A second opinion can be use­ful for 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 spe­cific type of cancer and that 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.

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 ensure that 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 that specific 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 the cancer isn’t rare, you may benefit from find­ing someone with a special interest in that specific type. 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 from 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 it 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 receive 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 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 a higher volume of patients.

Specialized treatment. Not all medical centers offer the specialized treatments that may yield 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.

Specialized treatment may also be required for cancer involving the liv­er, a common site for metastases. 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 certain cancers. Not all centers have the capability of delivering this type of treatment, however. Patients with cancers that can be treated by such methods require second opinions from specialized institutions.

The Second-Opinion Appointment

You should consider your sec­ond-opinion appointment a consul­tation that will either confirm the initial treatment recommendation or allow you to discover other treat­ment options. For this consultation you should come prepared with an understanding of your primary phy­sician’s treatment recommendations. Consider the following tips for your appointment:

  • Write down your questions ahead of time and make sure that they are all answered.
  • Bring your caregiver or someone else to the appointment to listen.
  • Bring a tape recorder to the appointment. This way you can listen carefully to the consultant, don’t have to take notes, and can listen to the recording when you go home. (Be sure to inform those in the room that you are recording the conversation.)
  • Make sure you understand your diagnosis and stage and the goal of the treatment being offered.

Charles Weaver, MD, is uniquely qualified to help patients navigate their cancer. As a pioneer of Internet-based cancer information, he has been educating and empowering cancer patients since 1997 when he founded CancerConnect.com, one of the first patient-focused cancer web portals. He founded and serves as Executive Editor of Women, and he developed and moderates the social media applications used by Harvard, Memorial Sloan Kettering and other leading cancer centers to support and engage thousands of cancer patients. Dr. Weaver trained at the University of Washington, the University of Pennsylvania, National Institutes of Health, and Fred Hutchinson Cancer Research Center. His clinical research interests included stem cell therapy, breast cancer, lymphomas, and medical decision making. He has authored more than 75 articles in major medical journals including the Journal of Clinical Oncology, Blood, Cancer, Bone Marrow Transplantation and the New England Journal of Medicine.

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