Doctors back new approach on 2nd opinion(ZT)

Reluctantto get a second opinion? Consider this: Over half of breast cancerpatients had their initial treatment changed when they sought a reviewat a specialty center. But the question remains whether everybody withcancer really needs to go shopping for a second opinion. And if thefirst two doctors disagree, do you need a tiebreaker?

Better than serial doc-shopping may be what Dr. Michael Sabel, aUniversity of Michigan breast cancer surgeon, calls the team approach.It's where specialists in different aspects of cancer care — theradiologist and pathologist, surgeon, medical oncologist and radiationoncologist — all get together, usually with the patient, to reread allthe tests and hash out the best treatment.

That, not run-of-the-mill second opinions, is what Sabel set out tostudy when he examined what happened to 149 breast cancer patients who,in one year alone, came to Michigan's Comprehensive Cancer Center afterbeing diagnosed, biopsied and getting a treatment recommended from adoctor elsewhere.

"This was very eye-opening," he says of the results. Now he wonders,"Is there a benefit to the multidisciplinary approach upfront, ratherthan seeing a surgeon, then going to the next doctor, then to the nextdoctor?"

The study examined just recommendations for initial surgical treatment,not later chemotherapy or radiation — yet 52 percent of the women hadone or more changes urged by the specialty tumor board, Sabel reportedin the journal Cancer.

Sometimes it was because the original doctor didn't follow nationaltreatment guidelines. Five patients, for example, had been told to geta mastectomy when they were good candidates for breast-conservinglumpectomy instead.

Sometimes the original advice didn't take into account newertechniques, such as using chemotherapy to shrink the tumor beforeoperating so the breast could be saved.

Sometimes surgeons thought women were good lumpectomy candidates —only to have an oncologist determine they couldn't tolerate theradiation that's required afterward, and these surgeons ended uprecommending a mastectomy instead.

And in 29 percent of the patients, the Michigan pathologistsinterpreted biopsy results differently than the original doctors,leading to a change in diagnosis — cancer instead of benign breastdisease for one — and a change in the aggressiveness of treatment.

Doctors have long known the value of a second set of eyes examiningmammograms, biopsies and other types of cancer tests. At many cancercenters, an in-house recheck is routine.

The new study provides a broader look at other areas where doctors canlegitimately disagree on the best treatment, or may have missedsomething, says Dr. Ted Gansler of the American Cancer Society.

It was that team approach that gave Carol Pitz the confidence that hermother should follow the more aggressive treatment recommended byMichigan's tumor board, rather than what her hometown doctor severalhours away had recommended.

Pitz was worried by a remark in one of her mother's many medicalrecords suggesting that her 1999 lumpectomy may not have been bigenough to get all the cancerous cells. So Pitz insisted on a secondopinion.

"The experience was amazing," Pitz, of Minneapolis, recalls of the tumor board meeting.

The recommendation: more aggressive chemotherapy to shrink anyremaining tumor, followed by another cut at the original incision siteto remove any lingering traces of cancer. Seven years later, Pitz'smom, now 66, remains healthy.

"We really have spread the word to everybody we know about the importance of getting a second opinion," Pitz says.

Still, "the question is whether everybody needs a second opinion,"Gansler notes — especially if they originally sought care at one ofthe many hospitals officially designated by the National Cancer Institute or the American College of Surgeons as comprehensive cancer centers and that use the team approach.

The cancer society has no official recommendation on that, althoughmany patient advocacy groups do suggest a routine second opinion.

But anytime there's uncertainty about a diagnosis or best treatment, orif you have a more rare form of cancer, it's probably a good idea, hesays.

Another reason: If your doctor or hospital hasn't cared for lots ofother patients with your type and stage of tumor. The cancer society'sWeb site — http://www.cancer.org/asp/search/ftc/ftc_global.asp— provides a searchable database of just how many cases of, say, Stage3 pancreatic cancer, that hospitals in different areas treat in a year.

It's "always a good idea just to say, 'Have you treated many patientsin a situation similar to mine? Is my case unusual in any way? Is thereany reason you think I might benefit from a second opinion?'" Gansleradvises.

A good doctor won't be offended by a patient seeking a second opinion,Sabel stresses, saying they're used to it. Nor will it hurt to postponetreatment a few weeks to get that review. "A few weeks is veryreasonable. Patients shouldn't feel pressured."

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EDITOR'S NOTE — Lauran Neergaard covers health and medical issues for The Associated Press in Washington.