Second Opinions Should Be Inclusive, Not Voluntary

I submit that there is only one reason why any newly diagnosed cancer patient should not get a second opinion on both their diagnosis and the subsequent treatment recommendation:

The patient has factual and indisputable proof that their oncologist is God or somehow related to God (by blood; marriage doesn’t count).

Their oncologist may regard him or herself as God, but that's not the same thing.

Informal Case Study

There are dozens and dozens of hospitals that offer second opinion services. However, in hematology—and with all due respect to all other hard-working professionals at other hospitals—if you want a second opinion in lymphoma, you would be selling yourself short if you sought a second opinion from anywhere except from one of the centers in the National Comprehensive Cancer Network. Lymphomas are not easy to diagnose, and not all pathologists are equal in this respect.

I called Stanford University Hospital and talked to the lymphoma coordinator there about what is required for a second opinion.

First, the patient must ask their doctor for the following records:

• Pathology report
• Radiology report
• Treatment records (if any)
• Initial consultation and progress notes
• Initial bloodwork and most recent bloodwork

Then the patient faxes them to Stanford, where a hematology nurse and physician review the records. A consultation is then arranged for the patient.

Many people assume that the entire process--from faxing the records to going to the consultation--takes several weeks or even a month or more. This may sometimes be true, but for instance at Stanford I was told that the time frame can be as little as seven days.

If the patient has either Medicare or a PPO, there is no prior authorization needed for this consultation; patients can self-refer. If it's out-of-network or they have an HMO, the patient's primary care physician (PCP) has to contact the insurer for authorization. If it is not authorized, the patient has to pay for it.

The Most Important Decision

There is not one single good doctor who wouldn't be fully supportive of his or her patients seeking a second opinion. But the process itself has a few speedbumps:

• Many patients are timid about broaching the subject with their doctor for fear that they are insulting them by questioning their judgement.
• Some insurers don't pay for second opinions.
• Many hospitals that provide second opinion services require a referral from one's doctor.

Considering all the other things that a newly diagnosed patient is dealing with, and considering the extraordinary importance of a second opinion in the face of an estimated 150,000 misdiagnosed cancers in the United States every year, shouldn't the process be overhauled and simplified so that a second opinion from doctors who don't know the patient's doctor is not just recommended but required, and that the diagnosing physician assume the responsibility of initiating the process?

The National Comprehensive Cancer Network's patient-friendly treatment guidelines include a section on second opinions. It's the same in each one. I hope they don't mind me reproducing it here (click on it to see a larger version):

Did you catch the sentence in the third paragraph?

"This is one of the most important decisions you will ever make, and can have a significant impact on both the quality of your life going forward and the chances of a positive outcome."

Notice that it doesn't say it's "one of the most important decisions you will make in the course of dealing with your disease," it says flatly that it is one of the most important decisions, period. If it is that important—and no one thinks otherwise—then why isn't it built into the system and automatically made part of the process?

A Helping Hand

The medical community's passive role in second opinions strikes me as both irresponsible and arrogant. A cancer diagnosis demands the patient make so many decisions of lesser importance compared to this one. While we all must assume as much responsibility as we possibly can over our own care, this is one area where shell-shocked patients can really use a helping hand.