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Second opinions in oncology: Reducing frustration
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At a regular cancer service-line meeting last week, we reviewed our experience with pathology over-reads.
Like many other centers, we at Huntsman Cancer Institute have a policy that all patients who are referred to us from another center will have their pathology reviewed in-house before any cancer treatment is given.
Multiple publications have demonstrated the value of expert pathology review, particularly in disciplines such as hematopathology. Extensive literature shows the referring diagnosis is frequently modified after expert review — in up to 30% of cases in some reports — and that, in a variable proportion, this can result in a change in treatment recommendations.
Although hematologic malignancies are a common source of diagnostic uncertainty, reports show diagnostic changes in almost all diseases, sometimes in the range of 40% to 50%. However, how often these lead to substantial changes in treatment is less well-documented.
I totally agree with the intention of the over-read policy, but believe that in a well-functioning institution, the rate of over-reads will never reach 100%.
Some patients require emergent therapy and it is not feasible — and can be potentially life-threatening — to withhold treatment while reviewing a diagnosis. Some patients have already had review of their pathology at other institutions by acknowledged experts and, in these cases, further review seems redundant.
A more frequent problem, however, is the delay in obtaining diagnostic material or imaging studies from an outside center, which can sometimes be measurable in weeks. In these cases, the correct approach is a matter of judgment.
Value, challenges of second opinions
This issue reminded me of a commentary by Andrew C. Neuschatz, MD, a community-based radiation oncologist, on the use of second opinions in oncology. The article elegantly outlines some of the understandable frustrations of the second-opinion process from the perspective of a private practice-based oncologist.
Included among these are minor changes in pathology interpretation or in treatment recommendations that have marginal, if any, benefit for the patient, but can undermine the patient’s confidence in and relationship with their primary oncologist.
Referring oncologists have an expectation that a second-opinion encounter at an academic cancer center will take place with a relatively senior physician, whereas Neuschatz’s experience has been that these evaluations are often performed by relatively junior faculty.
In addition to these challenges, there is interesting literature on physician attitudes to second opinions and how these can be driven by the doctor’s emotional commitment and attachment to his/her patients, as well as to the recommendations they have given.
Other challenges mentioned in the commentary include a lack of understanding of the social, insurance and geographic limitations that many patients face, which are beyond the scope of some “ivory-tower” academic clinicians.
Indeed, perhaps the biggest challenge for our second-opinion services relates to accessibility and protection against the potential for another disparity in cancer care.
Although I have no literature to support my impression, it seems likely that the cost of second-opinion consults that involve extensive review of pathology or imaging is prohibitive for many. One of the most common concerns I hear from patients is the copays they have for over-reads, which can sometimes be substantial and certainly beyond the financial means of many.
I also suspect that travel to an academic center from a long distance is a problem for patients in rural areas and another potential source of disparity.
The true effectiveness of second-opinion consults is very difficult to evaluate, outside of individual patient anecdotes — most oncologists reading this article can probably think of occasions when a second opinion resulted in a change that had a major positive impact on a patient’s outcome, and others where the opinion was unhelpful, resulted in a bad clinical outcome or damaged a physician-patient relationship because of a loss of trust and confidence.
There is no doubt that the traditional second-opinion consult process has challenges for the physician.
From personal experience, perhaps the most frustrating situation is when — getting to the point of the opening paragraphs — there is some urgency to decide upon and start a treatment plan, but original diagnostic material (pathology, lab data and imaging) are not all available at the time of the consult because of administrative delays. Particularly for diseases such as lymphoid malignancy, it is difficult to live up to the expectations of a patient or referring physician when the primary material is not fully available.
Poaching patients
Another problem Neuschatz mentions in the commentary is the tendency to attempt to “poach” patients from the referring physician.
This is clearly a major concern for many referring physicians, although it can be difficult to get to the truth of what happens during a second-opinion visit.
I don’t think I am alone in stating that I never try to poach patients who come for second opinions. There are several reasons for this.
Firstly, in the vast majority of cases, my opinion coincides exactly or very closely with that of the referring clinician.
Secondly, in a center that serves a vast geographic area, where patients can have a 500-mile or longer roundtrip to get to the facility, it can be impractical or potentially unsafe for patients to be so far from their primary cancer care team.
Thirdly, as I outlined in my May 10, 2016, editorial, there are very real, measurable advantages to having care at or close to home.
There are two situations in which transfer of the patient’s care is appropriate. One of those is when the complexity of the therapy is such that it can only be delivered at a major center.
The other, more contentious situation is when the patient expresses, without prompting, a desire to transfer care. This can be a sensitive discussion.
My own approach is to recommend they return to their primary oncologist, especially if they live a long distance from our center. If, however, the patient expresses a strong desire to transfer care, I will typically agree to do so — ultimately, it’s their call.
I can understand how this can be viewed as poaching from a referring provider, but I am trying to respect the wishes of the patient and family and will only do so if it does not put the patient at extra risk for major additional inconvenience.
‘Dr. Google’
I am sure that many, if not most, second-opinion consults have value for the patient and for the referring provider.
That said, this process creates tensions between patients and physicians, and between providers, emphasizing that there is substantial scope for improvement.
Novel approaches to traditional second opinions have been emerging. Some centers now offer an “e-consult” — an online second-opinion service where patients can interact directly with a physician, transfer relevant pathology and imaging, and obtain an opinion without the inconvenience of a face-to-face visit.
This system can work well for decisions that are not very time-sensitive; but, having provided some opinions in this setting at a former institution, something is missing when there is no direct patient encounter.
Organizations such as ASH provide a “consult a colleague” service for members, who can electronically “curbside” an expert about the care of a specific patient and seek guidance on options or trial availability. Again, this is no substitute for a face-to-face consult, but it gives a referring provider the opportunity to reassure patients that he or she has consulted with an appropriate expert.
Hopefully, more of these innovations will develop in coming years.
At a time when an increasing number of patients with cancer are using “Dr. Google” for their information — according to a January article in TheNew York Times — it’s important to extend the accessibility of second opinions more widely though electronic means to provide individualized information, especially considering that information derived from the internet can often be inaccurate, conflicted and dangerous.
The demand for second opinions is likely to increase as public awareness of cancer-related issues grows.
Accessible online platforms for individualized second opinions will be an important source of information to complement the growing number of informational/educational websites providing excellent, but typically not personalized, advice.
References:
Brody JE. There’s a good chance Dr. Google doesn’t know best. The New York Times. Jan. 22, 2019; page D5.
Neuschatz AC. How a cancer doctor really feels about second opinions. Medscape. Dec. 31, 2018. Available at: www.medscape.com/viewarticle/907021. Accessed on Jan. 23, 2019.
For more information:
John Sweetenham, MD, FRCP, FACP, is HemOnc Today’s Chief Medical Editor for Hematology. He also is senior director of clinical affairs and executive medical director of Huntsman Cancer Institute at The University of Utah. He can be reached at john.sweetenham@hci.utah.edu.
Disclosure: Sweetenham reports no relevant financial disclosures