Second Opinions: Who, What, Where, When, Why, and How?

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Second Opinions: Who, What, Where, When, Why, and How?

http://blog.lungevity.org/2011/11/21/second-opinions/

November 21st, 2011 - by Dr. Jared Weiss

Why should you get a second opinion?

My father once told me that the hardest part of getting what you want is knowing what you want. Though in truth he was really giving me advice on my (then) terrible choices in dating, I believe the same idea applies to second opinions, and a lot of other things in life. What do you want from the second opinion?

What should you be looking for in a second opinion? At the most specific end, I’ve had a few patients that have arrived with a consult question of, “I’d like to get on your clinical trial of X.” At the most nebulous end, I’ve had patients visit saying, “Well, my daughter doesn’t trust my local oncologist and looked you up online.” Both of these kinds of patients are welcome, as well as the full spectrum between them, but having some idea of realistic goals for the visit can be helpful to achieving them.

Many patients seek a second opinion to evaluate if their current choice of treatment is correct and to ensure that nothing is being missed. Self-assured, nerdy, ivory-tower academic docs (yes, I’m making fun of myself and my friends here) love to criticize local oncologists to make ourselves feel smarter. But the truth is that there are many incredibly talented, brilliant community oncologists who somehow manage to know all the details of care in not just one or two cancers, but a wide range of them! Very frequently, I have the great pleasure of assuring a patient and their loved ones that they are receiving sterling care and that they should continue on with the current plan. In such cases, the second opinion provides reassurance. Further, the academic doctor can educate you about your cancer from a different perspective. Finally, in such a consult, you can establish a relationship with the second opinion doctor in the event that you want additional input later on.

Regardless, most patients are seeking some kind of advice about treatment options. In particular, one of the most popular reasons to seek consultation with an academic physician is to seek clinical trial options. As our scientific understanding of cancer explodes, these advances in understanding are being translated into improvements in clinical care. While altruism is certainly one legitimate reason to enter a clinical trial, it’s far from the only one. If the trial really is successful, the participants are the first to benefit. Assuming that your second opinion doctor has chosen his trials well, you may be able to achieve 2015-level care in the year 2011.

Who should I get a second opinion from?

My perspective is that you should see an academic doctor with specialty expertise in lung cancer at an academic center and not another private practice oncologist. Most community oncologists are knowledgeable about a very wide range of cancers and blood disorders. I greatly admire their ability to keep track of so many different cancers and wonder if I could ever do that. At the same time, I believe that someone who specializes very narrowly in one or two cancers will know these cancers inside and out, from the details of standard care to the most promising trials available. You may have an excellent mechanic, but can he repair a rare part on your 1967 Camaro as well as mechanic who specializes in old Camaros? Will your local mechanic know, for example, that the solenoid on 1967 Camaros was designed too narrowly, and can wear into the middle oscillator creating a certain high-pitched noise? And, does this lung cancer specialist actually know anything about old Camaros? Sorry, folks, but I made up the car stuff. Still, I hope that it makes my point. Going to another local oncologist with the same level of knowledge is less likely to result in a higher level of expertise or greater clinical trial options. If a family member of mine had cancer, I would seek consultation from someone who specialized in that particular cancer at a major academic center, with a good portfolio of carefully chosen clinical trials.

Location is a final factor worth considering. You may love the idea of my 2nd line trial for patients with EGFR mutation, but are you really willing to travel from WA to NC every six weeks to see me? For some patients, any degree of travel is acceptable to get on the best trial or get a good opinion. But for most patients, time and financial resources impose restraints on distance.

When to get a second opinion

The best time to get a second opinion is at a major decision point, typically before ever starting therapy or at progression before starting a new kind of treatment. The very least productive time is right after starting a new line of treatment. Why? Unless the chosen regimen is truly terrible, a good consult oncologist will not recommend changing it until it has failed. Further, once the first drop of a regimen has been started for a given line of therapy, the patient becomes ineligible for clinical trials for that line. This last point is truly important. Too often, patients see me a day or two after starting a new treatment, with the idea that if I have a good trial for them, they’ll switch. No clinical trial allows this. They can’t, because they would have no way of knowing if a response was due to the trial regimen or to whatever was given before it.

It is reasonable to want to start treatment right away. I agree that effective therapy should be instituted as soon as possible after diagnosis. But please note that the key word here is “effective.” Rapid administration of less effective therapy is less helpful than slightly delayed administration of truly optimal therapy. So, if you truly want to consider options from a second opinion, don’t start a new line of therapy before seeing the expert!

Some patients (and their doctors) wait to seek another opinion until they have exhausted standard options. While the academic doctor may have clinical trials that can offer treatment when no good FDA-approved options are left, but some of the very best clinical trials are restricted to patients in early lines of therapy and it would be a shame to miss out on even considering these. Therefore, I recommend seeing at least one second opinion at a major academic center as soon as possible after diagnosis.

Empowering the doctor to help you: the value of data

The consult physician will give you advice based on the information you provide him. This data includes: doctors notes, laboratory reports, pathology reports (and actual tissue or slides for further testing), radiology reports, and CDs of the actual images. The better the information you provide, the better the opinion he can give you. Many academic centers have patient coordinators that will help you to transfer this information. I’m blessed with a very good coordinator—she’s an incredibly valuable partner in enabling me to serve my consult patients. However, even with the best coordinator, you can improve the quality of your second opinion by advocating for yourself or your loved one by ensuring that all of the data is there before the time of consultation. Often, patients ask their local doctor to send “everything”, and very little of value is sent. The consultation is then frustrating for both patient and doctor. Cancer is frustrating and the cancer family shouldn’t have to deal with getting information transferred. But, as reality stands, you can improve the quality of the advice you receive by making sure the relevant data is available. Some of my patients even bring binders with them that contain a copy of these records, along with medication lists, lists of medication allergies, and CDs of all of the images. While this is certainly not expected, this practice can facilitate an optimal consult.

At the consult—What to expect, and how to maximize your time

If you’ve done the prep work described above, you’ve already done the most important things. You know what you want, and you’ve brought copies of your records. What else should you bring with you? I recommend starting with loved ones who you want to support you. Loved ones can provide both emotional support and intellectual support. They may ask useful questions. They mayalso remember things that you don’t, so the more ears, the better. If there are important people that can’t be there at the visit, consider creative ways to bring them in. The most common modality my patients have used is a cellphone with speaker mode. I’m working on a project at UNC to use video-conferencing to bring distant children and other loved ones into the consult room. You can replicate this idea yourself with a computer with skype or facetime (or even one of the new phones that can do this!)

What else should you bring? Consider bringing a notepad or, if you’re not good at taking notes, a tape recorder. Some patients are shy about tape recorders in our medico-legal era, fearing that this will make the doctor uncomfortable and disrupt the doctor-patient relationship. Of course, you should ask for permission before recording, but most docs will be comfortable and won’t mind; if anything, a tape recording protects good doctors. Bring your questions, ideally written down so that you don’t forget them. On the Internet, you can easily find lists that others have written of questions to ask your doctor. I recommend against these lists. If you have a good doctor, he will cover the key points on these “standard” lists. You should, however, ask anything that’s on your mind, even if you think it’s silly or trivial.

Finally, bring a book (or ipad, computer, or other choice of entertainment device). Doctors who take a lot of time to talk to patients often run behind. This is particularly common in academic offices, where doctors have little profit incentive to see more patients. I don’t mean to excuse doctors who run behind (myself included). Rather, since it happens frequently, why not prepare for it to make the wait less miserable? Allot a few hours for a one-hour appointment, and account for this in your driving time and parking arrangements.

The consult will often begin with a nurse, nurse practitioner, physician’s assistant (PA), or medical trainee. This person will get a lot of basic information from you, and, if it’s a high level person, even provide some education. Such a person is not a replacement for the doctor, but a supplement to him or her. Some of these people may become longitudinally invested in your care and may be very useful to you. Don’t be surprised or put off by them: they’re part of the consult and may become important allies in your care.

On playing nicely together—the value of academic/community cooperation

Congratulations! You’ve completed the consult. The doctor has taken your history, examined you, and reviewed all of your laboratory results, pathology results, and imaging. You now have a real opinion. Hopefully, you’ve actually had everything explained to you in plain English and had your questions answered. Now what?

Well, if you have a good local oncologist, you have just added another member to your team. Many patients fear that their local oncologist will be jealous or that the academic doc will only be interested in them if they can take over care. That’s very far from the truth. For a variety of reasons, academic and local docs often love to cooperate to provide optimal care for a patient; in quick summary, it naturally aligns with the interests of what each enjoys doing. Success in providing best care as a team involves communication. Doctors primarily communicate via notes. While phone calls and emails are a part of care at some decision points, notes are especially powerful because they convey a great deal of detail. You can facilitate this exchange of notes by bringing each of the doctors each other’s cards. This is worth doing even if one of the doctors referred you to the other.

When the teamwork approach is chosen, there are two basic ways that work for when to see the academic doc again. Often, patients will return at the time of progression. At this visit, the academic doc will review images (sometimes with his radiologist too) to confirm that progression really happened. Next, he will review treatment options including both clinical trials (which would usually have to be administered at the academic center) and standard options (which can usually be administered locally). The one key point here is to not start a new line of therapy until you’ve had this consultation—its administration would make you ineligible for trials until you progress again! The second approach is chosen by patients who want closer contact with the academic doc and want things checked on a bit closer. This approach would be to see the consult doc each time that scans are obtained. The advantage of this approach is more constant involvement of the consult doc in your care—she reviews each scan, has the opportunity to provide more supportive care (help a bit more with day to day stuff like side effects from chemo) and is more up to date with everything going in with you when key decisions are needed.

The danger of multiple opinions

If getting one second opinion is good, getting two must be better. Right? Although it’s OK to get more than one second opinion, there are certain dangers in multiple opinions. The most obvious problem is fishing until you hear what you wanted to hear. If your cancer is incurable, do you really want to doctor shop until you find a surgeon who is willing to do a futile surgery? What if his approach, destined to fail, causes you harm including side effects, complications, and even shorter life?

This latter concern was exemplified for me in dramatic fashion a year ago. I had a challenging case that I wanted advice on and happened to be attending a lung cancer conference. In one session, participants had the opportunity to ask a panel of experts for advice on difficult cases. In front of me sat a panel if the world’s most famous thoracic oncologists—the perfect opportunity to get a dozen high level opinions for my patient. I presented the case. Then, one by one, the panel members rendered opinions. As the discussion moved from panelist to panelist, the advice got progressively more aggressive. Gentle chemo became aggressive chemo became small surgery plus chemo became chemoradiation became chemoradiation followed by massive surgery! Academic doctors often have big egos. They feel a need to “one up” the opinion given before them. The problem is that the more aggressive advice isn’t necessarily the advice that will result in the longest life with the highest quality. Patients will be prone to privilege the last opinion, not only because it is given last, but because the most aggressive option often sounds the most hopeful. The problem is that if the hope is false, the patient will be more likely to be harmed than helped.

Final Thoughts

I hope that I haven’t offended any of the audience members in the LUNGevity community here, as I’ve included some rather frank comments, all with the goal of giving you the best knowledge of how to seek a second opinion.

My strong personal opinion is that the best care available to most patients is on clinical trials. I’ve cut my income into a third by becoming an academic doc for the privilege of designing clinical trials to try to improve the standard of care. I passionately believe that many of our trials regimens are very promising to be better than existing standard of care, which, frankly, is not good enough. I have no doubt that if my father were to develop lung cancer, that I would seek the best available clinic trial for him. In my opinion, seeking good clinical trials is the most important reason to seek out a second opinion. Clinical trials are not the best choice for every patient at every time point, but I feel strongly that optimal care should at least consider them at every major decision point.