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Second Opinions

Posted 8/4/2014

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  The question about second opinions comes up frequently. Should I get one? Do I need one? Where would I go? Certainly there are many answers to those and related questions, but I think there is one common truth: If you are wondering whether you should get a second opinion, you probably should do so. One of the few rules in Cancer World is that it is important to do everything possible to minimize future regrets. In this case, this means that you don't want to look back and wish that you had met with a second doctor for another consultation.

  For women who have a new breast cancer diagnosis, the truth is (at least here in Boston), it is usually not necessary to seek a second opinion. Breast cancer is usually pretty straight forward; there are standard guidelines, and you are likely to have exactly the same recommendations from two or three different doctors. Of course there are some exceptions and gray areas. Women sometimes want to talk with a second surgeon about the choice of wide excision vs a mastectomy or bilateral mastectomies. If you are planning breast reconstruction, it is probably wise to speak with two plastic surgeons. In my experience, plastic surgeons do often have different perspectives and recommendations, and you want the best possible advice for your situation.

  Regarding the need for chemotherapy, women sometimes want to speak with more than one medical oncologist. The use of the Oncotype DX for women with node negative ER positive breast cancer is pretty standard, but scores in the intermediate risk area may be challenging to incorporate into the best treatment plan. Women with advanced or metastatic breast cancer not infrequently want another opinion at the time of initial recurrence or later progression. There is no single best way to treat advanced breast cancer, and different medical oncologists may well have different recommendations.

  Of course, having two consultations can sometimes create even more uncertainty. What if you receive two very different suggestions? Do you then need a tie breaker meeting with yet another doctor? And how many consultations will your insurance cover? The answer to that last question is variable and probably worth a call to your insurance carrier.

  This is a good essay from the Huffington Post about this issue. I give you the start and a link:

Why Variability in Cancer Care Recommendations Means You
Should Consider Second Opinions

In America, the 41 best cancer centers have been named, by the National Cancer Institute, as Comprehensive Cancer Centers. From that list, 25 centers have formed the National Comprehensive Cancer Network (NCCN). Each cancer patient's care has been helped by the NCCN organization. NCCN has developed guidelines for the diagnosis, evaluation, treatment and of every type of cancer. You can see these guidelines on their website.
In most situations with individual patients, these NCCN guidelines can be used to develop the treatment plan that surgeons, radiation oncologists and medical oncologists follow so that every patient receives care that makes use of the most recent advances. Meticulously, NCCN committees review important new advances and rapidly update the guidelines. Like almost all oncologists, every time I see a new patient I refer back to the guidelines to be certain nothing new has been overlooked in the care of the patient. Nationally, when patients are discussed at hospital tumor board discussions, physicians often refer to the guidelines. Beyond cancer, guidelines also exist for nearly every disease, many developed by specialty physician
But how well do oncologists follow these NCCN cancer care guidelines? A recent study looked at variability in our best cancer centers' compliance with published guidelines for cancer care. Over 25,000 patient records from NCCN institutions were evaluated for deviations from their own published NCCN guidelines.


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