“Please see this patient for an urgent second opinion,” pleaded the letter on my desk.
But when I read the referral, it became clear that the patient was not looking for a second opinion as much as confirmation that she did not have cancer. Her diagnosis, however, was evident – and curable. What she needed was good communication and a way forward.
The aftermath of a cancer diagnosis is so overwhelming that patients often find themselves adrift. The abundance of gratuitous advice – about everything from genetics and lifestyle to mood and food – adds more pressure, making it understandable when patients crave simplicity.
Some patients walk away from a diagnosis, preferring to ignore it, while others are reluctant to seek a second opinion over fear of alienating their specialist. But many more are not sure whether or how to ask important questions to gain confidence in their care. In an era of remarkable medical advances, a second opinion can play an important role in guiding choices, shaping the future, and importantly, sparing time toxicity.
A doctor with cancer recently illustrated the disconnect between how she and her oncologists viewed her treatment. The “universal” medical attitude that she was “handling this treatment well”, she lamented, minimised her suffering through tremendous fatigue, nausea, explosive diarrhoea, hair loss, joint and muscle discomfort, loss of salary, inability to drive due to brain fog, and loss of mobility, just to name a few. Her powerful words underlined the importance of listening to the patient as closely as the literature.
Given the consequential impact of cancer treatment on virtually every aspect of life, there are good reasons to seek a second opinion.
Doctors typically regard a second opinion as the assessment of a diagnosis or treatment plan proposed by a fellow specialist. Indeed, oncologists routinely utilise second opinions when we discuss cases at a tumour board, refer patients to tertiary centres, or ask international experts.
Patient-initiated second opinions are instigated for some of the same reasons – seeking reassurance and certainty – but also other reasons such as distrust, dissatisfaction and the need for more personalised information.
Evidence of the clinical value of second opinions in cancer is limited. In one review, a second opinion most frequently confirmed the outside diagnosis and treatment plan, lending valuable reassurance to patients.
The most important message was this: the value of high-quality second opinions was most frequently derived from de-escalating or modifying treatment in ways that reduced morbidity rather than improved prognosis.
In other words, a second opinion rarely offers a wholesale change; rather, it can lend nuance to complex decisions, which is no small thing for patients.
If a second opinion can be empowering, it can also waste critical time, cause harm, increase cost and reduce access for others. Patients may also end up feeling emotionally worse and more confused, as happened to 39% of the parents of paediatric cancer patients in one study.
If you are a cancer patient at any stage of the illness, here are three things to know about a second opinion.
Don’t worry about causing offence
A patient of mine disappeared from my clinic for some weeks before resurfacing. Her son volunteered renewed confidence in me after seeing a veteran oncologist who had endorsed my approach and graciously added that as my one-time boss, he believed she was in good hands.
I told the family that, had I known, I would have spared them the effort of mustering the paperwork and even helped expedite a second opinion. Surprised by my openness, they replied they had not wanted to hurt my feelings. But good doctors are not so brittle of ego and generally curious in nature. We want what’s best for our patients. No patient should avoid a second opinion for fear of offending a doctor.
Know what questions to ask
Patients who get the most out of a second opinion take time to digest the first opinion and formulate questions.
Is my diagnosis accurate? How reliable are my pathology and radiology reports? Is this approach right for my individual circumstances? Is there a clinical trial suitable for me? What side-effects are pertinent to me? These are vital questions that can add information and shift the direction of care.
Many patients don’t doubt the professionalism of their doctors, but rather find them wanting in communication. Rapport matters. Frequently, second opinions are less about reasserting the medical facts than discovering confidence. Excellent cancer care means connecting every cancer patient with nurses, allied health and mental health providers to fill the gaps left by (even the best) doctors. If a second opinion achieves this, it has succeeded.
It’s never too late to get a second opinion
Some patients regret having foregone a second opinion and then feel it’s too late to do so. Patients who have started or even finished treatment may benefit from a fresh perspective, reassessment and recommendations for monitoring and remaining healthy.
The estimated doubling time of medical knowledge in 1950 was 50 years; in 2010 it was 3.5 years; today, it is just 73 days.
Most oncologists are humbled by how little they know about the unfolding universe of cancer. Therefore, their patients should know that second opinions need not have an expiry date – and where access to such an opinion is an issue, expect their treating doctors to help. It is inadvisable to keep seeking advice without making a decision, but doctor-shopping is not the same as seeking to be fully informed. Every patient has a right to a second opinion.
When faced with a life-threatening condition, it’s common for patients to ask who is the “best” doctor. Sometimes, the best treatment may lie behind a comprehensive second opinion.
Ranjana Srivastava is an Australian oncologist, award-winning author and Fulbright scholar. Her latest book is called A Better Death
