The value of second opinions, and who one gets them from

An interesting new paper published this morning in Cancer has shown that while lots of men have been getting second opinions from urologists on what to do about a diagnosis of prostate cancer, those second opinions don’t seem to have had much impact on their care.

Radhakrishnan et al. surveyed men diagnosed with prostate cancer as part of the Philadelphia Area Prostate Cancer Access Study (P2 Access). Here are some of the key data from their study:

  • 4,676 men were eligible for inclusion in the study and were sent survey documents.
  • Responses to the survey were received from 2,386 men (51.0 percent) who were newly diagnosed with localized prostate cancer in the greater Philadelphia area between 2012 and 2014.
  • 40.2 percent of respondents had obtained second opinions from urologists.
    • 51.2 percent of the men who got second opinions gave two or more reasons for seeking a second opinion.
    • The reasons given for seeking a second pinion were
      • They wanted more information about their cancer (50.8 percent).
      • They wanted to be seen by the best doctor they could get to in the area (46.3 percent).
      • They were encouraged to seek a second opinion by a friend or family member (31.0 percent).
      • They wanted to find out about a treatment not offered by their first doctor (25.0 percent).
      • They were dissatisfied with their first urologist (15,5 percent).
  • Men who obtained second opinions because they wanted more information, were seeking the best doctor, or had been encouraged to by family or friends were more likely to ultimately receive surgery as first-line treatment for their cancer.
  • Men who sought second opinions because they were dissatisfied with their initial urologist were 51 percent less likely to receive definitive treatment.
  • Men who wanted more information about treatment were 30 percent less likely to report excellent quality of cancer care compared with men who did not receive a second opinion.
  • Overall, obtaining second opinions was not linked with receiving definitive treatment or with perceived quality of cancer care.
  • The study did not find that second opinions affected treatment among low-risk men — the most likely candidates for active surveillance — casting doubt on whether second opinions are sufficient to reduce over-treatment among this group.

Radhakrishnan et al. suggest the possibility that, at least for some men, second opinions represent a way to pursue the treatment they already plan on receiving, rather than to explore other treatment options. Dr. Radhakrishnan is quoted as stating that:

Patients often report getting second opinions for prostate cancer. Their impact on care that patients receive remains uncertain.

However, one of the more critical issues associated with a study like this is, from whom the second opinion is being sought. Every patient in this study was getting their second opinion from a second urologist.

Most men diagnosed with low-risk prostate cancer are not going to understand that (at least in the period from 2012 to 2014) there was still a high degree of skepticism among the urology community about the appropriateness of active surveillance. So, if one was diagnosed with Gleason 3 + 3 = 6 disease by a urologist in 2012, and that urologist recommended surgery, and one then went to see another respected urologist for a second opinion, it is highly likely that the second urologist would have concurred with the first urologist. On the other hand, if one had gone for a second opinion to a urologist who was committed to managing appropriate patients on active surveillance, there is a strong chance that one would have been told that active surveillance was an appropriate form of initial management. And if one had gone to a center that used a multi-specialty clinic system in assessing prostate cancer patients (like the one at Thomas Jefferson Hospital in Philadelphia, which was well established by 2012), one would probably have been given at least three options: active surveillance, surgery, and radiation therapy of some type.

The structure of this study therefore makes it hard to understand exactly what patients were or weren’t learning from a second opinion — or why, indeed, they were seeking one. There is one really very good reason for seeking a second opinion from a second urologist after initial diagnosis, and that is because one wants the very best surgeon to operate on you if you want to have surgery. In this case a second opinion from a second urologist makes perfect sense. But the survey questionnaire doesn’t appear to have been designed to elucidate detailed information of this type from the participants.

Editorial note: The Philadelphia Area Prostate Cancer Access Study (P2 Access) is a study focused on how access to care influences racial disparities in prostate cancer treatment for men living in the greater Philadelphia area — a large, racially and ethnically diverse area containing some 5.3 million residents. A prior report from this study, by Pollack et al., also published this year, has already shown that what are known as “mystery-caller” methods that reflect real-world patient referral processes from primary care offices to specialist offices can be used to measure access to specialized cancer care.

Pollack et al. reported significant differences in wait times and insurance acceptance between radiation oncology and urology practices. Specifically, they reported that, although they successfully obtained information on new patient appointments from 198/223 practices in the region (88.8 percent), radiation oncology practices were far more likely to accept Medicaid patients (91.3 percent) than were urology practices (36.4 percent) and had shorter mean wait times for new patient appointments (9.0 vs. 12.8 days). However, they did not observe any significant differences in wait times according to census tract characteristics, including neighborhood socioeconomic status and the proportion of male African-American residents.

9 Responses

  1. A second opinion is only half the story I found relavent in my being “forced” to go elsewhere to get not only a second opinion, but also to shop for everything from more interactive clinics; total radiographic abnormalities inventories, access to more modern treatment regimes; and younger more aggressive doctors/clinical researchers who think outside of the very limited Standard of model.

    You, or I, am having to stitch together three to four medical centers to assemble a “cancer team” to answer all possible connective questions that is an advanced stage cancer management portfolio.

  2. Might be more elucidating on second opinions from a cancer center of excellence, or major research or medical schools.

  3. In 2012 I was diagnosed with Gleason 3 + 3 = 6 disease. I chose brachytherapy as the first-line treatment. Nine months later I had a rising PSA and a metastasis to bone in L5. My urologist said I was now incurable and the only treatment was lifelong ADT. I went for a second opinion at M. D. Anderson and got a totally different treatment plan consisting of 6 months ADT followed by 36 Gy EBRT to the L5 vertebral body which happened in March of 2014. On my latest MRI the lesion in L5 was not discernable. I have been under no further treatment since March of 2014 and my PSA is steady at 0.1. I’m very glad I went for that second opinion.

  4. There is nothing wrong at all with second opinions. … But they need to be second opinions that are given on the basis of well-documented data and not just “opinion”.

    In the case that Allen describes above, not only did he get additional tests and a “good” second opinion. It also turned out the the proposed new form of treatment actually worked too.

  5. I left the Netherlands for Sweden for a second opinion for high-risk prostate cancer in December 2008. Having good reasons to distrust the privatised Dutch health system (lies to my wife about her places on waiting lists), I travelled in secret from Amsterdam to Uppsala. I was offered a more aggressive form of treatment than I was offered in Amsterdam. I moved 13 days later and shall not return. I found the Dutch guideline of 2007; the Uppsala treatment was not in it as an acceptable option and was in fact disadvised. I was 66 and the guideline was for men 65 or older. I figured this was an upper bound for adequate treatments for high-risk cases. I am glad to live where a single payer system is the preferred health coverage.

  6. In April 2004, my urologist made the diagnosis of Gleason 9 prostate cancer. With his full support, I sought a second, confirming opinion from an oncologist at a nearby Comprehensive Cancer Center. Given all the facts, he agreed totally with the diagnosis and the recommended treatment: IMRT plus ADT. I proceeded on that basis and, since I am still around 12 years later, I am obviously happy with the outcome.

    Manny Rosenbaum,
    Oak Park, MI

  7. Mike:

    Are the numbers reversed in order in “radiation oncology practices were far more likely to accept Medicaid patients (19.3 percent) than were urology practices (36.4 percent)”?

  8. Jim:

    No … but there was a typographic error that has now been corrected. Thank you for noticing.

  9. I was diagnosed in 2014 with Gleason 3 + 4 in one core (< 5%). The urologist recommended treatment. I saw a second urologist with the idea of him performing robotic surgery. However, he recommended active surveillance, which I am still on.

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