Second Opinions
Getting the best information
Obligatory—This is not medical advice
There are various reasons why patients might benefit from seeing a second opinion on their condition, such as differences in communication style, familiarity with a specific area of practice in the field, or the use of specialized or novel therapeutics. Both patients and their doctors have the best of intentions and approach clinical encounters in good faith, but different perspectives can lend new insights and a fresh set of eyes. This truth extends beyond medicine as well. There is reassurance in hearing that multiple experts agree on a recommended plan.
What is the role of a second opinion?
To ensure clarity in our discussion, let's establish a common understanding of the term "second opinion." In this context, a second opinion refers to the act of seeking a review of a medical case or therapeutic recommendation from a physician who specializes in the same subspecialty. For example, if a patient has sarcoma and is already under the care of a medical oncologist, it is often recommended by professional society guidelines to seek a second opinion from another medical oncologist, preferably one affiliated with a sarcoma center of excellence.1 When considering my role and preparing for new patient visits, particularly those seeking second or third opinions, I approach the process in several steps. Before the actual visit, there are a few key thoughts that occupy my mind.
Do I agree with the diagnosis and staging?
Has the pathology been reviewed by an expert? Do the histology, immunohistochemistry, and genetics line up with the clinical picture?
Has imaging been performed, as able, to appropriately stage this patient (this might be contingent upon histology and include CTs, MRIs, etc)?
Prior treatment
What local therapies (surgery, rt, cryoablation, etc) have been done and why?
What systemic treatments have been given (doses, frequencies, timeline, etc)?
If multiple lines have been received, why was each discontinued?
Therapeutic considerations
What trials might they be eligible for (our center, or others)
What data might be required prior to next steps
What are standard of care options
What is the anticipated level of tolerance, interactions with medications, or comorbidities
The Visit
In order to streamline the process and avoid the time-consuming history collection phase during routine visits, I review all the patient's information beforehand. Unfortunately, despite the presence of an electronic medical record (EMR), there have been limited efforts to create a user-friendly format that can be easily interpreted by both patients and physicians. Consequently, it often requires a significant amount of time to sift through outside records. Typically, I receive around 100 pages of information for most new patients, which I condense into succinct bullet points with around 200 words.
Setting aside these challenges, during my visits, I prioritize engaging the patient in a conversation about their perspective on the sequence of events in their medical care. This not only helps validate the history I have collected but also allows me to address their specific concerns and questions effectively. Once we have established this shared understanding, I make it a priority to provide answers to all of their inquiries regarding their diagnosis and potential treatment options. Since individuals have varying levels of knowledge and different priorities, I aim for a highly conversational approach in order to address their needs comprehensively.
Here is a list of questions that could be useful to guide discussion:
Based on the information available, would it be reasonable to agree with the pathologic diagnosis?
If not, what other analyses should be performed?
If this remains difficult to characterize, please describe how this might impact treatment planning
Do you agree that the imaging performed allowed for staging?
In what instances might other forms of imaging be used?
What imaging intervals are reasonable?
Sometimes it’s important to point out that the data for frequency of imaging can be lacking
Given the information available, what treatment recommendations would you or your team make?
If additional information is required, what is necessary and why?
If treatment was started, was this reasonable?
How might treatment affect prognosis?
Are there clearly established survival or symptom benefits?
What types of clinical trials might be available for a patient at this time in their treatment?
Would you enroll a family member on these trials?
If I were your family member is there anything that you would have done differently?
How many second opinions?
As a general recommendation, I advise patients who are interested to consider obtaining at least one second opinion around the time of their diagnosis, before initiating any treatment. Beyond that, the timing becomes crucial. The most valuable time to seek a second opinion is when making a treatment decision. In essence, these consultants play a role in addressing a specific but significant question: what is the best next step?
If a patient's treatment is going well, a second opinion will likely concur with the continuation of the current therapy. However, I caution patients against placing excessive weight on minor variations in opinions, especially when based on incomplete information. It is important to recognize that in medicine, similar to life, there isn't always an absolute truth. Instead, there exists a range of acceptable or reasonable approaches for a given condition. Cancer, in particular, is a complex and unpredictable disease, which makes it challenging for physicians to predict best future treatment directions. Instead of offering specific actions, doctors are more likely to present a range of options. While these aspects of second opinions can provide some context, they may also vary due to the inherent uncertainty.
Final Thoughts
Second opinions can be valuable for patients who are seeking specialized expertise based on the specific histology of their condition. For patients not being followed at a sarcoma center of excellence, they can be particularly vital. In general, physicians who have extensive experience in diagnosing and treating a particular disease are likely to have a deeper understanding of its nuances and complexities. However, it is important to note that this is not always the case, as there are exceptions and outliers. Careful deliberation and discussion with the treating oncologist is necessary. The most useful second opinions involve direct communication with the patient and their primary oncologist.
When seeking second opinions or consultations, attempt to frame them with a clear and specific question in mind, such as determining the best next step in the treatment journey. Sometimes a lack of focus can lead to further confusion or conflicting recommendations. Nevertheless, second opinions are generally a useful source of additional information and insights for patients to consider in their healthcare decision-making process.
https://www.annalsofoncology.org/article/S0923-7534(21)02184-0/fulltext