Getting a Second Opinion

A crucial step for learning more

At Virginia Cancer Institute, we recognize there are circumstances where a second opinion is useful. After all, a second opinion can help you become even more educated about your cancer and your treatment options. The more you can learn about your diagnosis and your treatment options, the better chance you have of receiving the most appropriate treatment.

There are many resources here in Central Virginia for getting a second opinion. And remember, second opinions will not offend competent physicians. Second opinions will, however, provide reassurance to you and your family and ultimately allow you to receive the most appropriate therapy.

What is a second opinion?

A second opinion is a review of the cancer diagnosis and the treatment recommendations of the physician who is treating the cancer by another, independent physician. Either the patient or the primary physician can initiate the process of getting a second opinion. Usually, patients obtain a second opinion after being referred to a second physician or to a special team of experts in a cancer center, called a multidisciplinary team. This doctor or team of doctors will review the following:

• Pathology report (how the cancer looks under the microscope)

• The extent of cancer

• The physical condition of the patient

• The proposed treatment

The doctor(s) then communicate their opinion regarding treatment to both the patient and the primary physician.

Second opinions are more likely to be comprehensive, or inclusive of every possible perspective, when performed in a cancer center with a multidisciplinary team, which usually includes surgeons, oncologists, radiation therapists and sub-specialist oncologists.

Why do I need a second opinion?

A second opinion is part of the education process that is critical for cancer patients. The treatment of cancer has evolved tremendously in the recent past. As a result, many cancers are now more treatable than they once were, especially if the appropriate initial treatment is selected. In order to receive appropriate treatment, patients must understand the type of cancer they have and the treatment options that are available. However, there are also many more options for treatment, and these options are more complicated than in the past. For these reasons and others, it is advantageous to seek more than one opinion about how your cancer can be treated. Also, a second opinion provides the opportunity to get information from someone other than the physician who will be directing treatment, which is usually the main source of information for most patients. Second opinions are a common practice in any area of medicine that is complex and that has multiple treatment options available.

Is getting a second opinion considered “bad etiquette”?

Patients, relatives and friends need to keep in mind that second opinions are a normal part of cancer management, and they should not be concerned about hurting the feelings of the primary physician. If you decide to obtain an independent second opinion, it is important to communicate with the primary physician not only to obtain needed information for review, but also to keep the treating physician informed. Most physicians welcome the opportunity to have another consultant review and approve their care decisions or suggest another treatment that may be better. There are instances when a patient may disagree with the physician and will need to change physicians, but this is not the main purpose of a second opinion. Most of the time, you simply need to make sure you are getting the best advice.

Who pays for a second opinion?

One of the problems with second opinions is that insurers may not cover the expense. However, many insurance and healthcare companies do pay for such opinions and acknowledge the importance of second opinions. In some situations, insurers will even insist on a second opinion. This is often the case when the primary physician advises an expensive treatment.

The best protection for cancer patients who are health maintenance organization (HMO) members is to seek a second opinion even if they have to pay for it. HMOs usually try to diagnose and treat patients within their system, because the more money the HMO spends on second opinions and treatment outside the HMO, the less money there is available for operation costs and profits. This may cause a conflict of interest between the patient and the HMO, especially if very expensive treatment is available only outside the HMO system. HMO members may also be discouraged from trying expensive treatments that have only a small chance of success, even if that chance is real. For these reasons, it is a good idea for HMO members to get a second opinion and make sure they are informed about clinical trials or other promising new treatments. Most reputable HMOs can, however, deliver state-of-the-art treatment for most cancers. If you are considering undergoing a specialized treatment, such as cancer surgery, within your HMO, it is important to inquire about the number of such procedures performed each year by the HMO and the results.

Who should get a second opinion?

Although the specific situations in which a second opinion is most useful have not been defined, there are clearly situations where a second opinion would be helpful and most patients would benefit. These may include:

• A poorly understood or communicated diagnosis

• An initial diagnosis by a non-cancer specialist

• A diagnosis by a cancer sub-specialist

• Apparent lack of treatment options

• A treatment plan that involves a clinical trial

• Rare cancers

• A treatment plan that involves surgery as primary treatment

• A diagnosis that has been made at a small or rural hospital

• A treatment plan that involves aggressive treatment

• A treatment plan that involves specialized treatment


Poorly understood diagnosis: Patients who feel that they may not fully understand the diagnosis and their treatment options should consider a second opinion. Another physician may communicate in a way that the patient can better understand, or simply hearing the diagnosis a second time may help the patient overcome any denial they may have.

Initial diagnosis by a non-cancer specialist: Patients who have been diagnosed by a non-cancer specialist benefit from a second opinion. In the United States, doctors other than oncologists often diagnose and treat patients with cancer. Cancers are diagnosed and treated by family doctors, internists, pediatricians, gynecologists, urologists, ear-nose-and-throat doctors and other non-cancer specialists. In most instances, appropriate therapy is administered. However, patients not treated by specialists in cancer treatment should consider seeking a second opinion. In some situations, physicians will not refer patients for a second opinion because they may lose control and revenue from treatment, they may feel threatened by a more knowledgeable doctor, or they are just too busy to consult other physicians. The patients of these types of physicians are the most in need of a second opinion.

Diagnosis by a cancer sub-specialist: Many types of cancers are treated by several different types of cancer specialists. For example, prostate cancer may be treated by urologists who are surgeons, radiation oncologists and/or medical oncologists who use drug treatment. Each specialist may think that his or her treatment is the best treatment for the patient. An example of this is in the localized prostate cancer, where surgeons invariably advise surgery and radiation oncologists invariably advise radiation.

For this reason, a patient may want to consult an oncologist (general cancer doctor) or multidisciplinary team to obtain a thorough understanding of treatment options. Seeking a second opinion from a different type of specialist can be informative, but it can also, unavoidably, create confusion about treatment options. The best way to resolve this confusion is to gather and use all the available information to make an informed decision.

Apparent lack of treatment options: A second opinion can be useful for some patients who are told that there is no appropriate treatment for their cancer and that there is no hope of survival or relief of symptoms from the cancer. Such patients have nothing to lose by seeking a second opinion. In this situation, patients should seek out physicians and institutions that specialize in treating their type of cancer and performing clinical trials.  Here again, information available on the Internet can help locate such physicians and institutions.

A treatment plan that involves a clinical trial: When the treating physician recommends participation in a clinical trial, a second opinion should be obtained to make sure this is the appropriate treatment. There are many types of clinical trials, some of which may benefit a patient with a specific cancer and some of which may not.

While a clinical trial may be your best treatment option, you should consider all possible clinical trials before selecting the one your treating physician recommends. Two sources of ongoing information regarding clinical trials include comprehensive, easy-to-use listing services provided by the National Cancer Institute and

Rare cancers: When dealing with a rare cancer, it is usually best to seek a second opinion, unless the diagnosis is made at a center that specializes in the treatment of this cancer. If a local expert is available, treatment should be switched to that doctor. If the expert is far away, which is likely, the home physician can usually coordinate treatment by phone or email. Even if your cancer isn’t rare, you may benefit from finding someone with a special interest in your specific type of cancer. For instance, kidney cancer is not really rare, but it’s not common, either. Usually patients with kidney cancer are treated in clinical trials carried out in one of several large institutions. This is because the clinical trial may require specialized treatment, and there are not enough patients with kidney cancer at one institution to make the research meaningful.

Surgery as primary treatment: If there is any doubt about the operability or inoperability of a cancer, a second opinion is in order. In this situation, patients are urged to seek second opinions in institutions where large numbers of patients are treated. For instance, esophageal cancer may be considered inoperable in a hospital that performs one such procedure a month, but may be considered operable in an institution that performs several per day. Just as important can be the determination that a cancer deemed operable is, in fact, inoperable and that surgery would be harmful.

Small hospitals and rural practices: Patients who live in rural areas and are treated at small hospitals should get a second opinion from a larger medical center before treatment is initiated. Although smaller and rural hospitals are usually fully capable of and typically deliver excellent treatment, they may not see a large volume of cancer patients. It is prudent to seek a second opinion to help determine the appropriate course of action and if the recommended treatment can be safely administered. Sometimes, the recommended treatment will determine whether a patient should be treated locally or at a larger medical center. For example, most small hospitals can effectively deliver chemotherapy, whereas patients requiring a complicated procedure, such as a stem cell transplant, may need to travel to a larger institution that treats a higher volume of patients.

Aggressive treatment: Most of the cancers that can be cured with chemotherapy (acute leukemias, some lymphomas, testicular cancers) require intensive treatment, such as high doses of chemotherapy or radiation therapy. A second opinion is useful for ensuring that the proper intensity will be used to achieve a cure and not just a temporary remission. Also, intensive treatment requires rigid adherence to prescribed doses of drugs to ensure the delivery of optimal treatment, careful monitoring for complications, and aggressive supportive care to manage side effects. In many instances, intensive treatment can be administered locally, but such patients are usually best treated in centers that use state-of-the-art protocols (clinical trials) and treat large numbers of patients. If you are considering an aggressive treatment, you should determine how many patients are treated per year at your local treatment center and what the results are. Ask your treating physicians for their own results and not results from patients treated in other institutions.

Specialized treatment: Not all medical centers offer the specialized treatments that may offer the best results for some patients. In these cases, a second opinion may be in order.

For example, bone marrow or blood stem cell transplants may offer the best chance for cure or control of blood and lymphoid cancers such as leukemia, lymphoma and multiple myeloma and other cancers such as breast, ovarian and testicular. Specialized treatment may also be required for liver cancer. Recent clinical trials have suggested that sophisticated treatment techniques such as intra-arterial chemotherapy, chemoembolization, radiofrequency ablation, radioactive isotopes and conformal radiation therapy can be of major benefit for liver cancer treatment.

However, not all centers have the capability of delivering these types of treatments. Patients with liver cancer and other cancers that can be treated by specialized methods require second opinions at specialized institutions.