This past weekend I received a call from a woman, whom I’ll name Norma, audibly unnerved by events that transpired after her 74-year-old father was diagnosed with Stage IV liver cancer. The seed of her despair was that her father’s doctors discharged him immediately after diagnosis to receive palliative care from hospice in his home. No alternatives were offered. Although a photo of her father leaving the hospital shows him smiling alongside her brother, within three days he was in a vegetative state, responding only to rationed drops of water squeezed from a sponge to his lips. Norma chokingly described him as a “fish gasping for life”.
Her father was on continuous morphine and denied nourishment and hydration of any substance, as the hospice nurse informed her his body “would reject water and food”. Norma told me her father was dying before her eyes and speculated that, perhaps, the starvation and/or morphine was killing him faster than the cancer. She was very doubtful of this being the right course of action. Again and again Norma mentioned that she wished they had obtained a second opinion from another qualified doctor.
Perhaps there is no more compelling reason for a cancer patient to get a second opinion than to eliminate the regret of having hastily followed the treatment plan presented by the original doctor. No patient wants to be in the fourth week of debilitating radiation and doubting the merits of their treatment plan. Such skepticism creates tremendous anxiety for a patient and is suffered by family and friends as well. A second opinion helps patients make treatment decisions with lasting confidence.
A second opinion is a review of the original pathology report, diagnosis and treatment plan by an independent, qualified physician. Its importance for cancer patients and their families cannot be overstated. The journal Cancer reported in 2005 that more than 12% of cancer patients in the U.S. are initially misdiagnosed. Second opinions are a common and well-advised practice, especially in areas of healthcare that involve complex disease and multiple treatment options.
Cancer is highly complex. It is a single term that encompasses over one hundred distinct diseases, each with unique and constantly evolving treatment protocols. No doctor can be sufficiently informed in every moment of the latest and best treatment for every type of cancer. Therefore, initial treatment recommendations may not be grounded in complete and current data, making it paramount to get a second opinion from a specialist with the requisite experience and up-to-date knowledge of a patient’s particular cancer. This process will also help a patient decide if changing to a new treatment team should be a first step. Research shows that assertive patients get better health results.
After diagnosis, unless medical urgency dictates, getting a second opinion enables cancer patients to slow the process down, properly digest life-changing information and take charge of their healthcare. It is an explicit acknowledgement that cancer diagnosis is a serious matter, involving prolonged, aggressive treatments that often result in significant side effects. Denial prevents a patient from being in the right mindset to confront the difficult decisions that must be made to fight cancer. Simply hearing an independent, qualified confirmation that the original diagnosis is accurate helps a patient to sidestep denial.
The merits of a cancer treatment plan depend largely on an accurate pathology report and diagnosis, which are both prone to human error. Numerous cases have come to light of patients who endured severe treatments they did not need, or were not prescribed treatments they desperately needed. Research has shown that a second exam by a specialist may change treatment options for up to 20% of breast cancer patients. Furthermore, a treatment plan is appropriate to the extent it is tailored to the individual patient, which depends on the patient articulating personal values and preferences and becoming informed about the pros and cons of treatment options. Doctors adhere to different treatment philosophies, some more conservative, others more aggressive. The best treatment plan is a delicate balance between personal preferences and a strict adherence to the best possible health outcome. A second opinion helps a cancer patient to substantiate and refine what may be the most important decision of his or her life- the treatment plan.
Adding more ambiguity to cancer diagnosis and treatment is the fact that the economic interests of a doctor, hospital or healthcare plan may not be entirely aligned with the best health interest of a cancer patient. In some cases they may be in direct conflict. First of all, healthcare providers are incentivized to keep a patient “in-network” as their salaries are not paid by referring patients to a more qualified clinic or specialist elsewhere. Physicians are also known to recommend a course of action within their own practice- surgeons advise surgery, oncologists prescribe chemotherapy, etc. Thirdly, healthcare providers have an economic incentive to provide less expensive care, which may result in a patient not being informed of clinical trials or expensive treatments with a minimal chance of success. In the 1990s, HMOs were hit with heavy criticism for “gag rules” found in contracts between them and their doctors, which prevented these doctors from “fully informing patients about options not included in their coverage”. This practice is in clear conflict with the Hippocratic Oath. Some states have since outlawed “gag rules”, but, in essence, a doctor’s recommended plan may not entirely embody a cancer patient’s path to the best possible health outcome.
Federal laws support patients with a legal right to a second opinion. This right combined with the aforementioned reasons and the fact that some insurance plans reduce or eliminate benefits if a second opinion is not secured, make it clear that pursuing a second opinion is the wise choice. In fact, most physicians, if diagnosed with cancer, would do the same.
Nevertheless, many patients do not get a second opinion. Why?
- They are unaware that a second opinion is an option.
- They are not informed of the compelling reasons for getting a second opinion.
- They do not want to “upset” or “insult” the doctor who will be treating them. This perspective may be rooted in the cultural or generational belief that one should not question a doctor’s authority.
- They want the path of least resistance. Because of emotional distress and lower stamina it may seem “easier” to simply follow the original doctor’s recommendations.
- They want to remain less certain about the diagnosis, reinforcing denial.
- They feel that resources and/or time are not available to pursue a second opinion.
If a doctor is threatened or irritated by a patient who wants a second opinion, it is a red flag, a strong signal that the patient should definitely seek additional counsel. Competent, confident physicians are not offended by second opinions.
Grant Achatz, the acclaimed chef of Alinea in Chicago, was diagnosed with stage IV tongue cancer in 2007. Mr. Achatz’s first doctor and three subsequent specialists favored a treatment plan to remove the middle of his tongue, a jaw section and lymph nodes in his neck. For a man whose passion resides in appreciating the subtleties of culinary delights, this was unthinkable. It was his fifth specialist who proposed to put off surgery until after chemotherapy and radiation. Today Mr. Achatz is cancer-free and his tongue prevails as the discerning instrument of his profession and passion. Clearly his quality of life has been preserved as a result, at least partly, of seeking additional expert opinions.
A cancer patient will be confronted by many developments beyond his or her control, yet a patient can control the act of making informed decisions. Getting a second opinion is the first and vital step to becoming duly informed and minimizing future regret. I have never heard about a patient who regrets getting a second opinion. Unfortunately, the window for getting a second opinion is short and may come only once.
 Cancer (online issue), October 10th, 2005.
 Sherrie Kaplan, PhD, Primary Care Outcomes Research Institute.
 U.S. News & World Report (online issue), October 31, 2004.
 Oncology Times, May 1996.
 Everyday Health, Vincent De Vita, former Director of the National Cancer Institute and Chairman of the Yale University Medical School, “I’ve never taken care of one physician who didn’t get a second opinion.”