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Second Opinions: A Valuable Part of Supportive Care
Malin Dollinger, MD

None of us are prepared to be told we have cancer. It's like a membership in a new club, one we didn't know existed, didn't apply for, and don't want to belong to. Everyone seems to treat us differently. All of our old priorities and life suddenly change. We need to know RIGHT NOW what is going on, how bad the cancer is, where it is, where it has spread. What are the choices for treatment? How successful is each one? What are the risks and side effects of each treatment? Is one better than another? Why? What should I do? How much time do I have to decide? For that matter, how much time do I have?

Thank God you have never had to ask and answer these questions before. Somewhere in the back of your mind, you were worried about an auto accident or breaking a bone, or needing an operation, but you have absolutely no training or experience in having cancer. How do you make decisions about what to do? You find a physician you trust. Usually a cancer specialist (Oncologist) is involved in your care. This makes sense. Oncologists know about cancer. However, there is so much information about cancer. Some of it is really valid and reliable, in books and medical literature, and from your doctors. Some of it may not be reliable: what your friends or the Internet tells you. How do you tell the difference?

First, believe what your doctor tells you. She or he has spent years training, learning, and understanding this process we call cancer. Second, read all you can. However, making these vital and critical decisions about your cancer care is different from most decisions we have made in our lives. Almost always we choose between two things we like: steak or chicken? A Ford or a Chevy? Buy this house or that one? Fact is it wouldn't be the end of the world no matter which of these decisions we made. Both choices, then, are in a sense positive.

When making a decision about cancer treatment, our choices are things we don't want, instead of things we do want. I don't want an operation (no matter which one you suggest). I also don't want radiation therapy. I don't want chemotherapy. I don't even want a biopsy!! Much less the blood tests and CAT scans and all the doctor visits. So we are not used to making choices about things we don't want. It feels strange, and it is strange.

That's why it is so important to be able to talk to a health care professional about these choices. Best is someone who knows what the choices mean good and bad. Often your main-MD - perhaps your oncologist can explain all these choices to you. You may be quite happy and satisfied with these discussions. However, you have no prior experience with making these choices, or making this kind of choice, about things you don't want.

So a second opinion is one way of exploring the choices. It's an important one, to help you be very sure that you understand what the choices mean. Some choices in life are very clear: it does not require a second opinion to know the significance of pulling a parachute ripcord or not pulling a ripcord. However, before you go up in an airplane, to do skydiving, would it be important to know which brand of parachute (and parachute packer) is reliable. Of course!! You do this before the plane takes off.

In cancer treatment, even though there is a great emotional need to get going - I want the treatment yesterday, there is rarely an emergency medically. Most of the time, nothing bad will happen if a few weeks go by while you make sure you understand the difficult decisions that you need to make. If you have a need for additional discussion (and maybe you aren't even sure if you do), a second opinion is one way of being sure you understand the choices.

This should not be a threat to your regular doctor. You should be partners in your care, and you can simply explain that, "Yes, I am really pleased with your care, and I want you to continue to take care of me and I would also love to have some additional input from someone who maybe has a different perspective or angle."

After all, who is the one that is most important to please and be satisfied? You are! Do not worry about hurting the doctor's feelings. He/she is a professional, and this is not the first time another physician has looked over her/his care. It begins in early training, and happens every day, in some way. As a matter of fact, your physician should welcome the opportunity to have another consultant review and approve your care decisions, or perhaps suggest a new, clever, or novel idea that might be to your benefit. Either way, you win. Yes, there are some instances when you have some basic disagreement with your physician, or there isn't the fit that there should be. Sometimes you do need to change physicians. But that isn't the usual reason for a second opinion. Most of the time you simply want to be sure that there is no stone left unturned in your care. Few people change oncologists-he or she becomes a really important person in your life.

What does the second opinion consultant do? He or she wants to know everything about your previous diagnosis and treatment. You usually bring copies of all your x-ray films, and all your records. It's a good idea to have a copy of all your records anyway, in case you travel and are away somewhere and become ill. Often the consultant will wish to look at the pathology slides to verify the type of cancer that is present. You need to have copies of your previous consultations and opinions, hospital records and discharge summaries, and especially the pathology reports (that give the cancer diagnosis) and the operative reports of any surgery you have had for the cancer. The consultant reviews all this material and examines you. Often you will bring your spouse, significant other, family members, or a close friend with you, to share in the discussion and to help you remember the discussion and make decisions. It may be helpful to bring a pad to take notes, and a tape recorder to keep a record. The consultant will then go over all of the findings with you and especially discuss and emphasize the current and future decisions to be made. It would be especially helpful if you bring questions of your own; to be sure you have no unanswered questions or problems when you are done. The consultant will then prepare a written report, which will be sent to your physicians, and often to you as well. She may call your doctor on the phone to have an immediate discussion of your findings, especially important if you are about to have surgery or begin a new treatment program, and are waiting for agreement.

Should you tell your present physician about the second opinion? Yes!! It is in your best interest that all of your doctors know all the facts and opinions. Your health is at stake, and unless you have had a major disagreement with your physician, and are using the second opinion as a pathway toward changing doctors, it is to your advantage to share all the information. Your physician is your partner in the pathway toward success.

Specialists usually make cancer treatment decisions, and their training is relatively uniform and sophisticated. There are seldom any major differences in the standard ways of treating various cancers, and cancer specialists generally know what the choices are and what the risks and complications are. There may be advantages and disadvantages of each treatment choice. What a consultant may help with is:

- 1. Deciding for you which choice makes the most sense

- 2. Reassuring you that your own doctor has made the best choice for you at this time.

- 3. Outlining some of the future choices that need to be made later, should there be a need for other or different treatment.

4. Defining a new treatment or pathway that may not be generally known or available, such as a center or physician with special research in your cancer, or with a special program, protocol, or clinical trial or promising new treatment.

Many insurance and health care companies, who will pay for such opinions, have acknowledged the importance of second opinions. It is becoming the normal and appropriate thing to do. My experience is that second-opinion consultants are very respectful of the hard work and dedication of your principal doctor, and are careful to be entirely professional and to give appropriate credit and validity to those decisions already made. After all, their patients have obtained second opinions, too!!

The Cancer Answer

Following are points of view about second opinions as a part of the supportive care process.

Does Everyone Need a Second Opinion?
Multidisciplinary Second Opinion Fundamentals
Cancer Second Opinions Upon Recurrence

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