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Few women with early-stage breast cancer seek second opinion
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Very few women with early-stage breast cancer pursue a second opinion when considering cancer treatments, according to survey data recently published in JAMA Oncology.
“Second opinions can facilitate treatment decision-making and should be encouraged when patients are uncertain about their options or lack confidence in the treatment decision process,” Allison W. Kurian, MD, MSc, associate professor of medicine and of health research and policy at Stanford University, and colleagues wrote. “However, little is known about how patients are referred to a medical oncologist after diagnosis, and, surprisingly, virtually nothing is known about the patterns and correlates of second opinions in community practice or the implications for quality of care.”
Researchers used two Surveillance, Epidemiology, and End Results registries in Georgia and Los Angeles County, California to identify 1,901 women (mean age, 61.6 years) who had been diagnosed with breast cancer between July 2013 and Sept. 2014. All women were between stage 0 and stage II.
One thousand seventy-one patients (56.3%) were white, 17.3% were Hispanic, 16.1% were black and 7.4% were Asian. Sixty-one percent had a high school-level education or lower. Most (62.8%) had stage I disease.
A weighted data analysis showed that 168 women (9.8%) received a second opinion, 54 (3.2%) of whom underwent chemotherapy with their second oncologist.
Satisfaction with treatment did not significantly differ between those who did and did not get a second opinion (4.3 vs. 4.4 on a 5-point scale).
The use of internet support groups (OR = 2.15; 95% CI, 1.12-4.11), a college education compared with less education (OR = 1.85; 95% CI, 1.24-2.75), intermediate 21-gene recurrence score assay results (OR = 1.85; 95% CI, 1.11-3.09) and uncertain significance on hereditary cancer genetic testing (OR = 3.24; 95% CI, 1.09-9.59) were all predictive of a patient seeking second opinion.
“Our results indicate that a patient’s preference for greater engagement is one factor contributing to second opinion use, and uncertain results of diagnostic testing are another,” the researchers wrote. “As treatment options proliferate and molecular diagnostic tests expand, physicians may face increasing pressure to enable patients’ preferences about treatment decision-making and to navigate the increasingly murky landscape of genomic testing. These tasks demand effective physician–patient communication, and developing interventions to enhance the quality of such communication is a high priority.” – by Andy Polhamus
Disclosure: The researchers report no relevant financial disclosures.Perspective
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Advances in breast cancer treatment provide physicians and patients with an array of potential therapies, yet the heterogeneity of breast cancer requires a close physician–-patient relationship that respects the patient’s autonomy and desired level of engagement. Standard and effective adjuvant treatment recommendations exist for many presentations of early stage breast cancer; choosing the most suitable and effective adjuvant treatment is often a shared decision between patient and oncologist. Accordingly, women who want greater confidence in the chosen treatment may seek second opinions. It is unclear what factors lead to this decision, and whether second opinions, ultimately, affect treatment.
In the accompanying article, Kurian and colleagues surveyed 1,901 stage I and stage II breast cancer patients to investigate the patterns and correlates of second opinion use. It was noted that only a minority of patients (9.8%) sought a second opinion; those who did, had a higher level of education, frequently used internet-based support groups and preferred self-directed decision-making. Overall, use of second opinions did not appear to be associated with a higher or lower rate of receiving chemotherapy, and patients reported a high level of satisfaction with the chemotherapy decision-making process and with oncologists’ respect of patient autonomy.
Intriguingly, equivocal molecular or genetic test results (e.g. variants of uncertain clinical significance on germline testing or an intermediate risk on the 21-gene recurrence score) that currently lack clear-cut and specific treatment recommendations were associated with a much higher likelihood of seeking a second opinion. As the practice of oncology moves toward a more personalized treatment approach, use of genomic and molecular assays in routine clinical practice is anticipated to increase over the coming years. This important observation suggests the need for continued education of oncologists in understanding the complexity and clinical utility of new assays.
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