September 30, 2023
September 30, 2023

Linking Northern and Central NJ, Bronx, Manhattan, Westchester and CT

Two friends recently contacted me regarding second opinions for close relatives with advanced cancer. Of course, I frequently see patients for second opinions, and my patients frequently go elsewhere to obtain second opinions—this is a common part of cancer medicine. But my experiences with these two cases made me realize that it was worth reviewing some of the issues involved in this practice.

Following a diagnosis of cancer, it is more than reasonable to seek a second opinion, no matter how good or friendly the initial physician. This is not and should not be seen as an insult—it is fair to want to corroborate the diagnosis, prognosis and treatment plans for you (or your loved one) going forward. In most circumstances, the second opinion will ratify the initial opinion, or suggest reasonable alternatives that the first doctor may not have mentioned or may not have emphasized as much.

You could then return to the first doctor and discuss the full set of options and consider the pros and cons of each. These do not necessarily reflect errors—they usually reflect attitudes and judgments that each physician may harbor regarding the management of a given condition or of cancer in general. Some physicians may be more conservative and some the opposite, but you have a right to review the entire spectrum of options available.

There are also certain biases in physician recommendation that are highly prevalent. Each practitioner likes to exercise the tools of his trade—a surgeon wants to operate, an oncologist likes to give chemotherapy, and so on. And the fee-for-service structure of our healthcare system encourages that in circumstances where an either/or situation is present, yeshiva tuition or a large mortgage will affect what recommendation is made. That does not mean a proactive recommendation is wrong or incorrect—it simply cannot be seen as unbiased. And a second opinion by a second practitioner can redress this bias and assure you that the recommendation is sound and appropriate.

In the two cases I mentioned above, both individuals were already scheduled to begin chemotherapy the next day. I recommended that the patients call and delay the initiation of chemotherapy until after the second opinion. I often see second opinions after they have started a chemotherapy regimen, and I find it relatively pointless—what can I say then? The die is cast. For both of these patients, I had to reassure them that there is almost no such thing as emergency chemotherapy—that a few days or even a week or two delay makes no difference in the world of cancer treatment, and it is better to be right with the choice of therapy than fast. In one of the cases, the husband decided, after contacting me on Wednesday, that his wife could not delay chemotherapy that was scheduled Thursday to be seen Friday, as I assured him that at worst the second opinion would confirm the correctness of the treatment decision, which could then proceed on Monday or Tuesday with no loss.

This is a common misconception. The reality is that cancer, even aggressive cancers, are relatively slow-moving, and days or weeks do not matter. What matters is to do things correctly. I should say that there are hematologic malignancies—certain leukemias or lymphomas—that are so fast-growing that rapid treatment is mandatory. But I am mostly referring to solid tumors—breast, colorectal, lung, prostate.

How often does a second opinion lead to a major change or improvement over the initial evaluation? Surveys show that a very large percentage do result in important education and clarifications for the patient and his/her family so that they learn important new information about their disease and its management that make a second opinion worthwhile. Probably 20-30% provide important alternative options for the patient that were not previously discussed, and whether the patient does or does not exercise these new alternatives, they should be weighed.

How often are outright errors found? This is a difficult question to answer as it depends on how one defines an error. It would not be uncommon to opine that a tumor is more or less aggressive than the initial evaluation found. For certain unusually complicated tumors, like sarcomas or brain tumors, it may be as common as 20-25% to get a different or modified diagnosis that leads to a distinctive approach to management.

The hope would be that most of the time the second opinion would come very close to confirming the first opinion and reassuring you that the plans in motion are sound and appropriate. As a rule, it is better to go to a different institution for the second opinion as colleagues within an institution are going to manage diseases in a similar fashion, and also be less likely to contradict each other.

It does take effort to find someone at another hospital, and then to gather the necessary documents, scans and pathology reports, but cancer is a bad disease, and it is best to do what is right from the get-go rather than start treatment and then wonder if you did the right thing.

And what do you do if the two opinions are directly opposed? How do you decide? Usually you can determine and weigh the pros and cons and considerations and what matters to you. But if you really cannot decide, a wise friend who recently requested referral for a second opinion raised this question with me, and then she laughed and suggested that we look at the 13th principle of Rebbe Yishmael: When two passages contradict each other, let a third passage come and resolve the contradiction.

Alfred I. Neugut, MD, PhD, is a medical oncologist and cancer epidemiologist at Columbia University Irving Medical Center/New York Presbyterian and Mailman School of Public Health in New York. Email: [email protected].

This article is for educational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment, and does not constitute medical or other professional advice. Always seek the advice of your qualified health provider with any questions you may have regarding a medical condition or treatment.

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