The Benefit of Second Opinions – Who Needs Them the Most

July 2020 Vol 11, No 7

Categories:

Lung Cancer
Jacques Fontaine, MD
Director, Mesothelioma Research and Treatment Center
Moffitt Cancer Center, Tampa, FL

When a patient first receives a cancer diagnosis, their initial thoughts likely turn to a storm of questions without answers.

Such news easily puts anyone in a dazed and frantic search for more information, but that initial visit can quickly become a flood of details that are difficult to process. It is at this point that a patient needs to know about one of the most important steps in their fight against cancer: a second opinion.

A patient may not have the confidence or capacity to consider seeking a second physician’s advice right away, especially after such devastating news. They may be inclined to follow directions exactly and do everything as prescribed by their treating physician to avoid any “mistakes” in the course of their care. The truth is, a patient should be empowered with the knowledge that they have options for their future.

Misdiagnoses happen. Some treatments are not always presented. Anxiety and fear prohibit even the most organized person from comprehending, coping, and deciding care for themselves.

Exploring second opinions allows patients to become more informed and secure in their choice of which treatment to pursue. A second opinion may reveal multiple options for a specific type or stage of cancer. Due to a lack of expertise or available resources, a physician may not offer or discuss a certain treatment that could possibly result in a better prognosis with fewer complications and a faster recovery.

Why Referrals Matter

Cancer patients who are most in need of second opinions are at risk to receive the least support for getting one.

If a second opinion is not provided as an option by their oncologist, a patient will have a difficult time discovering whether they need one and how to obtain one on their own. The ideal scenario is a patient having access to a specialist for their cancer without having to navigate referrals and insurance coverage on their own. For example, peritoneal mesothelioma is notoriously difficult to treat, and a patient looking for an experienced oncologist may not know where to start.

A new diagnosis of cancer will drive someone to investigate cancer centers based on prominence and advertisement, but they should not have to refer themselves. Waiting for a referral or insurance approval to be sent from one office to another can feel like a death sentence to a patient who is newly diagnosed. There is an urgency to the diagnosis, and a patient will look for whatever resources are available, but the best support can come from the oncologist who already knows their history.

Patients should feel safe and encouraged to ask their oncologist for a referral to a specialist for a second opinion. The risk is too high that a patient becomes lost in the navigation of their care and wastes precious time searching for confirmation or alternatives. That time is better spent planning treatment and committing to a therapy or set of modalities.

A patient who has secured a strategy for fighting their cancer is a patient who can feel empowered and trust that they have explored the landscape of options and have arrived at the best one for them.

The benefits of a second opinion will vary from one patient to the next, depending on their priorities. However, the value of these options should not be understated. Some facilities may provide technology and techniques that are not well known but which represent the best science has to offer.

Advanced surgical techniques from physicians who are specialized in specific methods of cancer treatment can represent invaluable hope to someone with a rare diagnosis. In some cases, a patient may find that they can more easily form a relationship with a different doctor.

The nursing team and office staff could make all the difference in whether a patient feels like they are in good hands. If a patient is in search of diagnostic confirmation, a second opinion will confirm disease stage and type.

The Importance of Specialization

One in 8 cancer patients is misdiagnosed, and a rare cancer can greatly increase those odds. Mesothelioma is often misdiagnosed due its nonspecific presentation and rarity.

More complex cancers can appear as less serious conditions depending on where tumors form. As they grow and spread, cancers can mimic a myriad of illnesses.

Early symptoms of pleural mesothelioma, for example, present as shortness of breath and coughing, resembling signs of emphysema or pneumonia. Peritoneal mesothelioma, meanwhile, can imitate the presentation of other abdominal cancers, gallstones, or hernias. If an initial diagnosis is not definitive, referring a patient for a second opinion may be the only way to discover or confirm rare illnesses.

Specialized oncologists provide access to pathologists and radiologists familiar with rare types of cancer who are aware of more nuanced methods of detection and treatment. In addition to misdiagnosis, inaccurate staging is another possibility with unspecialized oncologists. The correct stage of cancer is crucial for prescribing the most effective treatment. Encouraging patients to find a doctor with years of specialized experience could make all the difference.

In my experience, the time it takes to definitively confirm a mesothelioma diagnosis can be several months. Pleural effusion and pleural inflammation commonly send up red flags that may indicate early mesothelioma, but in reality, these symptoms are easily attributed to benign disease seen after chest surgery or a viral infection.

There have been cases where patients have said to me, “I was exposed to asbestos at work a few months ago, and I have fluid around my lungs and heart. Do I have mesothelioma?” The answer is no, because it takes decades to develop mesothelioma after exposure.

On average, mesothelioma manifests 25 years after initial exposure to asbestos. However, a specialist knows not to ignore repeated episodes of pleural effusion with pain or tightness in the chest. Patients with these symptoms as well as a thin rind on the pleura, as identified on CT scan, may be showing signs of mesothelioma. This is especially true if they had a previous significant exposure to asbestos.

A specialized oncologist or pathologist is essential when confirming a diagnosis. An experienced pathologist can tell the difference between cancerous mesothelioma versus inflamed mesothelial cells or other forms of lung cancer. My team and I at the Moffitt Cancer Center in Tampa deal with a high volume of mesothelioma cases every year. Because of our specialization, we receive biopsy samples from patients across the country looking for a second opinion.

A cancer diagnosis is incomplete without staging and histological details. If a patient is given a diagnosis of pleural mesothelioma, that is not enough. Is it epithelial, sarcomatoid, or biphasic? That distinction will determine the aggressiveness of the cancer and the availability of a patient’s treatment and therapy options.

A patient with epithelial mesothelioma may be a candidate for surgery, whereas a patient with sarcomatoid type will likely not have that option. Referring patients to a specialist is important not only for confirming a diagnosis but also for making sure they have every available opportunity for treatment.

Encourage Second Opinions

All patients deserve the best treatment available, and they trust their doctors to provide it to them. Unless a physician is unequivocally an expert in a specific field of practice, they owe it to the patients to help them find experienced providers specific to their condition. In today’s discussion of cancer, it is more important than ever to admit when current strategies are failing.

Cancer research and emerging technology can provide hope to millions who need it but have been unable to find it. Instead of conviction in an initial diagnosis, physicians should help patients uncover the road to new and exciting alternatives. Patients should not be left to discover the resources they will need on their own.

Connecting patients with support groups, physician networks, and experienced medical teams are incredible ways to encourage the search for more options. Embracing the second opinion, especially for patients with new cancer diagnoses, may mean the difference in admitting defeat and finding a cure.

Sources

  • Axon A, Hassan M, Niv Y, et al. Ethical and legal implications in seeking and providing a second medical opinion. Dig Dis. 2008;26:11-17.
  • Czara R, Manfredi C, Price J. The determinants and consequences of information seeking among cancer patients. J Health Commun. 2003;8:529-562.
  • Moumjid N, Gafni A, Bremond A, Carrere MO. Seeking a second opinion: do patients need a second opinion when practice guidelines exist? Health Policy. 2007;80:43-50.
  • Selby K. Mesothelioma Misdiagnosis & the Importance of a Second Opinion. Asbestos.com, www.asbestos.com/mesothelioma/misdiagnosis. Updated March 6, 2020. Accessed March 17, 2020.

You can contact Dr Jacques Fontaine directly at www. floridachestsurgery.com.

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