As a physician, the most important things I can do for all my patients is to provide them with the best possible care. For most of my patients, I am the captain of the ship and I have a whole team of specialized physicians (surgical oncologist, radiation oncologist, interventional radiologist, pathologist, gastroenterologist, nuclear med etc), extenders, nurses, nutritionist, pharmacist, navigators, research coordinators, managers, fellows, residents, and students. For some new patients, I will only see them as a second opinion as they drive a distance from a local oncology provider. I want to share with you two patient cases that demonstrated just how valuable second opinions can be for patients and their families.
The first patient I want to tell you about was a young woman who had been misdiagnosed with a stage IV “metastatic” cancer at another major institution. This assessment was based on a liver biopsy that apparently showed “cancer cells” on frozen section at the time of original operation but had not been confirmed on the final pathologic assessment. As a result of this finding during her attempt for a curative intent surgical resection of the primary tumor, the procedure was aborted and she was placed on palliative chemotherapy for about 7-8 months. When she came to see me for a second opinion, I took a closer look at her scans and surprisingly I did not see any evidence of metastatic disease in the liver. Sometimes this can happen where there is a pathologic proven disease seen in surgery and/or under the microscope but that is not overtly evident on radiographic scans. Perhaps she was doing well on the chemotherapy she was taking for the last several months, so I had thought?
I immediately ordered updated scans, requested old records and pathology slides from the other institution. At a tumor board conference, our pathologist surprisingly found no evidence of cancer in the original liver biopsy, which our pathologist was able to confirm after he called over to the other institution’s pathologist to make sure there were no other biopsies or pathology tissue we had missed or did not receive. As a medical oncologist, I also made a courtesy call to the other institution to determine if there was any other information that we were missing. The deep implication of this finding would mean that the patient could undergo a curative intent albeit delayed surgical resection of the primary tumor?
Most second opinions are usually confirmatory of the general treatment plan given by the primary providers. This gives peace of mind to patients and their families that they are receiving appropriate standard of care treatments as can be found in the NCCN guidelines. Second opinions can also open the doors for newer treatments not offered at every cancer center or novel experimental treatments given under a clinical trial. Certainly there may be nuances or slight providers differences in opinions regarding which drugs may be giving or the type of surgical approach or sequence of therapies but generally speaking the “big picture” treatment-intents are usually consistent either curative or palliative intent therapies.
However, in this situation it was a clear divergent opinion from the other institution which led to the correct diagnosis and an opportunity for the patient to undergo a curative intent surgical resection of the primary tumor as opposed to just continuing palliative chemotherapy waiting for resistance or metastatic spread to occur. It is a genuine pleasure for me to tell you that this patient had a complete resection of the primary tumor and can now undergo routine surveillance imaging every 3-4 months in the hopes of maintaining long-term remission… off all chemotherapy.
The second patient I saw today was a patient with stage IV pancreas cancer who had prior standard of care chemotherapy and had all the appropriate workup and evaluations. Unfortunately, her nutrition and physical status had declined to the point of being in a chair most days with oral intake of teas and soups. She had progressive peritoneal disease and a recent hospitalization for bowel obstruction requiring a bypass surgery to alleviate her abdominal pain and constant throwing up. Her local oncologist recommended home hospice care and upon my review and personal assessment of the patient, I had agreed with home hospice. This was clearly not what the patient or family wanted to hear, but this was a honest opinion that provided closure and peace of mind for the patient and family to transition to comfort care measures at her home.
Second opinions can provide confirmation of a diagnosis and treatment plan, new perspective and insight, new treatments not offered at every center and/or novel therapies under a clinical trial. They can also provide closure and peace of mind for the patient and their families where the treatment intentions are clearly palliative or comfort care alone.
As a physician, I cannot stress enough the importance of second opinions. They can provide patients and their families the confidence and reassurance that they are receiving the best possible care. I also state this to my own patients where I feel perhaps there may be a better treatment option or clinical trial at another institution or when dealing with rare cancer types. If you or a loved one is dealing with cancer, I strongly encourage you to consider getting a second opinions at a major institution with a disease specific oncologist and/or disease specific multi-disciplinary team. It could make all the difference in the outcome of your treatment.
About the author
Dr. Sajeve Thomas is a distinguished medical professional and a compassionate guide in the field of oncology. With over a decade of dedicated experience as a board-certified medical oncologist/internal medicine specialist, Dr. Thomas has become a trusted expert in the treatment of melanoma, sarcoma, and gastrointestinal conditions. Currently practicing at the renowned Orlando Health Cancer Institute, he brings a wealth of expertise to the complex and challenging world of oncology.