Second opinions and cancer
People who suspect they might have cancer — or who were just tested, diagnosed or started treatment — often have questions. Sometimes patients want another doctor's point of view or a second opinion about the tests, diagnosis or treatment.
Physicians have their own methods for getting second opinions within their profession. If a surgeon says a cancer is inoperable, for example, an oncologist may look for another surgeon who disagrees with the first surgeon and takes a more aggressive approach.
A patient needs to feel comfortable with the decision to have surgery and that all options were explored, said Dr. Colin Birch, an obstetrician and gynecologist in Calgary.
The patient's trust and confidence in the doctor is key, Birch told CBC Radio's White Coat, Black Art.
Sometimes a patient wants to explore other options that weren't discussed the first time, or there is a personality conflict with the first surgeon, or the patient may feel their questions were not answered fully enough, added Dr. Gail Darling, a thoracic surgeon in Toronto.
Darling is a top doctor on Best Doctors Canada's list. Since 1998, the private medical consultation and advocacy service has connected patients with medical experts who give second opinions for a price. The patient or patient's health insurance provider buys a policy with the service. For example, it may be covered through an employer's extended health coverage.
When the patient needs a second opinion, Best Doctors does the legwork of getting the patient's medical files and sending them to their world renowned specialists, who pore over the file, perhaps ordering more tests, and then come back with an opinion on whether the first doctor is on the right track.
Pathology report reviews
The list of top doctors is based on a survey asking doctors one question: if you or a loved one were ill with this condition, which specialist would you want to be evaluated by? The doctor's credentials based on professional reputation, experience, training, publications and presentation record are considered, Darling said.
A similar U.S. service, Cancer Second Opinion Consultation Service, checks pathology test findings alone. The fee is $150 US to review a pathology report and slides or $175 US to review a pathology report and request the slides with a shipping fee.
Cancer Second Opinion cites published studies suggesting a major discrepancy is found in 5.3 per cent to 6 per cent of reports reviewed by a second pathologist worldwide that affected patient care.
Likewise, Best Doctors said that based on its experience in more than 30 countries and tens of thousands of reviews over 20 years, the initial diagnosis is incorrect 22 per cent of the time on average. The rate of misdiagnosis was not unique to Canada, with a similar trend found around the world, regardless of how the health care system was funded, the group said.
To be sure, in 1990, a review by researchers at Harvard University and the RAND Corporation published in the Journal of Health Politics, Policy and Law concluded that studies on second surgical opinion programs fell short on having an appropriate control group and a comprehensive definition of cost and outcomes, or were too short in duration or small in scale to measure changes at a population level.
The authors of that review concluded the value of surgical second opinion programs for saving money and improving health outcomes "remains an open question."
Asking for a second opinion
When patients do seek a second opinion on their own, they don't want it to be a difficult conversation, said Donna Czukar, director of cancer information and support for the Canadian Cancer Society's Ontario division.
It answers up to 250 calls a day from patients and their families across Canada. Nurses, nutritionists and people who have worked in radiology and other parts of the health care system answer the calls.
To obtain a second opinion, a patient needs to be referred by a doctor. If the person is uncomfortable asking the specialist, the society suggests asking the family doctor. Callers are reassured that it's OK to ask for a second opinion and that care won't be compromised by the request.
"People sometimes seek reassurance that it's OK to ask for a second opinion because of concerns they may have of offending their doctor," said Dr. Carol Sawka, vice-president of clinical programs and quality initiatives at Cancer Care Ontario.
"We reassure patients that they can ask for a second opinion and that in fact it is not uncommon for a doctor to seek a second opinion in cases where there is uncertainty about the best approach."
Patients who've had a misdiagnosis caught through a second opinion advise others to:
- Be informed about the options.
- Keep all medical records.
- Track tests for all serious diagnoses.
Still, some patients, particularly those in rural areas, may feel they can't wait for an opinion from another specialist.
"If you've got a fast-acting disease, you're going to want to accept that treatment plan even while you're seeking other options," said Kyle Buott, provincial co-ordinator for the Nova Scotia Citizens' Health Care Network in Halifax.
People in small towns may also be more reluctant to branch out than those in large cities, but they should keep in mind that doctors in Canada are well trained, and that not all good surgeons are concentrated in university centres, Birch said.
When opinions differ widely, Darling said, she tells patients that Dr. Y may be more aggressive in terms of offering surgery, but what Dr. X said is not wrong, it is just a different approach. Darling suggests talking to family and the family physician and consulting reputable internet sites to help decide.
Doctors' case conferences
Cancer patients can also be reassured that groups of medical experts may review cases to ensure the most up-to-date evidence and treatment options are considered. These teams, known as multi-disciplinary case conferences, are recommended in Canada, the United Kingdom, the United States, Australia and Belgium, according to Cancer Care Ontario.
In Canada, multidisciplinary case conferences were traditionally part of academic centres. Cancer Care Ontario now recommends and supports the approach in community hospitals as well. The goal is for the attending physician to meet with colleagues to discuss a new case and all treatment options before all parties agree on a course of treatment.
"We discuss cases — and discuss them with all the appropriate players, not just one physician giving an opinion in isolation from other opinions," said Dr. Anne Doig, president of the Canadian Medical Association and a family physician in Saskatoon.
While the conferences are not a complete substitute for a second opinion, the meetings do allow oncologists dealing with complex cases and surgeons working in community hospitals who may not have a radiation oncologist on staff to discuss radiation treatment options by video conference. For rare diseases, a doctor may still seek a second opinion, and the patient always has the option.
The Canadian Medical Association's code of ethics tells doctors: "Respect your patient's reasonable request for a second opinion from a physician of the patient's choice."
Most colleges of physicians and surgeons also support a patient's option to seek a second opinion.