Second Opinions

by Wendy Bachhuber

Jean Weber and her young family had recently moved from New York City to a small town in northern Illinois when Jean found a large lump under her arm while shaving. Her primary care physician referred her to a general surgeon who diagnosed breast cancer. Jean soon underwent a lumpectomy and axillary node dissection. The surgeon then referred her to a local oncologist for additional treatment, but even before she saw the oncologist, Jean decided to get a second opinion in Chicago, fifty-five miles away. She talked to friends, did some research, identified a breast cancer expert, and made an appointment. To her surprise, the local oncologist was supportive when she told him about the second opinion. He smiled and asked her to “say hello for me” to the doctor she’d be seeing – he had trained with that expert. The two physicians collaborated, and Jean felt secure getting chemotherapy and radiation treatment at the small but highly regarded hospital near her new home.

In contrast to Jean, Pamela Polashenski, MD, was well connected to the local medical community when she was first diagnosed with breast cancer in 2016. As Chief Medical Officer at Clifton Springs (NY) Hospital & Clinic, Pam knew and respected the oncologist on staff, and completed her initial treatment at Clifton Springs Cancer Center, which is part of the Lipson Cancer Institute of Rochester Regional Health (RRH). After Pam’s breast cancer metastasized in 2018, she decided, with the support of her oncologist, to seek a second opinion at a major cancer center. She used professional contacts to identify a breast cancer specialist, Rachel Freedman, MD, MPH, at Dana-Farber Cancer Institute in Boston, Massachusetts. Getting an appointment was quick—within a week—and her records were transferred through the electronic records system used by both RRH and Dana-Farber. Pam and her husband drove to Boston for the first of two in-person appointments. Dr. Freedman confirmed that Pam was getting optimal therapy for her type and stage of cancer. When Pam’s cancer continued to progress, Dr. Freedman identified a clinical study in Syracuse for which Pam qualified. Pam received treatment there, just an hour from her Wayne County home, while her local oncologist and her Dana-Farber oncologist coordinated her care. Pam now keeps Dr. Freedman in the loop via email updates and virtual visits while she continues treatment in Clifton Springs.

Seeking a second opinion for a cancer diagnosis or treatment is a common practice that is supported by almost all physicians, says Alissa Huston, MD, a medical oncologist in the Comprehensive Breast Care program at Pluta Cancer Center in Rochester, New York. Dr. Huston gives second opinions and has patients who consult other providers for second opinions, locally and out-of-state, and fully embraces both situations. She encourages people not to be shy about suggesting a second opinion to their provider, and says a second opinion works best when the two doctors have an interchange. Dr. Huston might even suggest to a patient who is struggling with a treatment decision that getting a second opinion would be beneficial. If a patient asks her for a recommendation, she is happy give them the names of specialists for their particular diagnosis or help them choose from a list of physicians they have discovered in their own research.

According to Dr. Huston, academic centers like the ones in Rochester have a “built-in” system for second opinions: they conduct weekly multidisciplinary tumor board meetings for breast cancer. A case report for each patient who has had a diagnosis of breast cancer in the preceding week is presented to specialists in breast cancer imaging, pathology, genetics, surgery, oncology, and radiology. As many as twelve physicians attend these “tumor boards,” including up to four medical oncologists. Unusual diagnoses and complex cases get a comprehensive review, and relevant clinical studies are identified.

A small retrospective study from South Carolina indicated that multidisciplinary breast tumor boards can provide a valuable diagnostic second opinion, especially for patients whose primary care is in rural areas.1 As a result of tumor board review, additional cancers were identified or the pathologic interpretation was changed for thirty of the seventy patients in this study. In Dr. Huston’s experience, though, the treatment plan she recommends is usually the same or similar to the one recommended at another major academic center. Sometimes, she says, there is a minor refinement in how the treatment is given or there is a regional difference in treatment recommendations that she then discusses with the patient to help them decide what makes the most sense for them.

Patients who come to Dr. Huston for second opinions often travel from outlying areas, including rural communities, and their questions to her are, “Is my local doctor giving me the same treatment recommendation that the academic doctor would? Can I get the best available treatment and receive that treatment close to home?” Sometimes a person needs a second opinion about their diagnosis as well as advice on treatment. Rochester native Stephanie Tubman was living in the Upper Peninsula of Michigan when she noticed one of her nipples was slightly inverted. As Stephanie discussed in October 2020 on the WXXI News show, Connections with Evan Dawson,2 she was a healthy thirty-three-year-old at the time, and was vigilant in her own healthcare because her mother had experienced a cancer diagnosis. Stephanie’s physician assistant ordered a mammogram, which the local radiologist judged to be normal. Stephanie was relieved and tried to put her worries out of her mind. But a few months later, she realized the changes in her breast were getting more pronounced. Stephanie decided to get a diagnostic second opinion and researched her options online. The nearest specialty breast cancer center was the Breast Clinic at the Mayo Clinic in Rochester, Minnesota; a seven-hour drive from her home. She called Mayo’s new patient phone number and set up an appointment. Stephanie requested her patient records from her local doctor and hand carried them to her appointment, as required by Mayo. The doctors there determined immediately that Stephanie had breast cancer. She and her husband were able to move temporarily to Minnesota and work remotely for the nine months of her treatment, which included neoadjuvant chemotherapy as part of a clinical trial, surgery, and radiation. Stephanie finished treatment in fall 2020. She is back in Michigan and doing well.

Rachel Freedman, Pam Polashenski’s oncologist at Dana-Farber, says there are several ways patients come to her center for second opinions: some are referred by their own providers, others may call or fill out an online form on their own, or sometimes a friend or family member will urge them to contact Dana-Farber. Getting an appointment does not usually delay treatment. “We are committed to getting patients into our clinics quickly, as we know this is a stressful time. Most patients are offered an appointment within a few days,” she says. Before the appointment, Dana-Farber will collect medical record information and request imaging and pathology slides and reports. The new patient office then creates a packet for her to review in preparation for the patient’s visit. After the visit, she closes the loop with the patient’s other providers.

Dr. Freedman says that before the Covid-19 pandemic, patients wanting second opinions came to her from all over the country and the world. Travel restrictions and the dangers of traveling for those with impaired immunity have decreased the number of people she sees from outside the northeastern United States. However, new consultations can now happen virtually for patients in some states. The process for making an appointment and gathering medical records is the same. Dr. Huston agrees that travel limits imposed by the pandemic have increased the number of second opinions given virtually. A review of data and a discussion of treatment recommendations can be done remotely, but talking to a patient in person is still preferred. For a surgical second opinion or a discussion of reconstruction options, examining the patient is much more important, she says.

Shortly after finishing her treatment in Illinois, Jean Weber moved to Rochester, NY, and established relationships with oncologists in the Rochester Regional Health system. Unfortunately, her breast cancer recurred, and Jean had a lumpectomy. When the surgical margin was found to be to narrow for comfort, her surgeon, Robert Tripp, MD, and oncologists Julia Smith, MD (now retired) and Jeffrey Haynes, MD, recommended further surgery. Jean had questions about this approach, and her cousin, a surgical Physician’s Assistant, arranged a phone consultation with a surgeon at Memorial Sloan Kettering (MSK) Cancer Center in New York City. The MSK physician agreed with her Rochester doctors, and Jean had the additional surgery. She has this suggestion for those considering a second opinion: “If it will ease your mind, get a second opinion. You are doing your due diligence—because this is your life.”

References
1. Garcia D, Spruill LS, Irshad A, et al. The value of a second opinion for breast cancer patients referred to a National Cancer Institute (NCI)-designated cancer center with a multidisciplinary breast tumor board. Ann Surg Oncol 2018;25:2953-2957.
2. “Understanding the latest in breast cancer screening, research, and treatment.” Connections with Evan Dawson. WXXI News, Rochester NY. 23 Oct 2020. Radio.