The patient is a 77-year-old woman with a history of myocardial infarction, diabetes, and hypertension who presents with newly diagnosed breast cancer. She has a hearing impairment and mild cognitive dysfunction, and has several well-educated children involved in health care. She has a 5.1 cm hormone receptor-positive tumor but no lymph node involvement (i.e., a stage III breast cancer). After surgery, she was referred to an oncologist.
A diagnosis of cancer is an overwhelming experience for patients and their family members; therefore choosing the “right” oncologist is often the most important decision they make. The oncologist has many roles, being involved in diagnosis, counseling, treatment, administration, support, and coordination of care. Often a patient is limited in his or her choice by location or insurance plan. Even within these limitations, there are still many decisions to make: tumor-specific versus general oncologist, oncologists associated with teaching hospitals versus those in the community, as well as a variety of personal characteristics. Ultimately, the patient and family will select an oncologist they feel comfortable with for a balance of reasons. Frequently, making such a decision requires meeting several doctors (first through third opinions) or whatever else is required until they find a doctor with the personality and clinical characteristics with which they are content.
The first step in choosing the right oncologist is finding one who has experience treating the type of cancer with which a patient has been diagnosed. The comparison of outcomes among general medical oncologists and tumor-specific oncologists remains a matter of considerable debate. In the oncology literature, there is little literature comparing outcomes between general versus tumor-specific oncologists. Who delivers the “best” care is more likely to be based on a number of factors such as patient volume, personal preferences, and differences
The patient’s daughter, who is a PhD immunologist, drives her mother 60 miles for their first consultation to see a breast cancer specialist at the closest academic center. It takes 2 hours with traffic to make the trip.
between academic and community setting. Oncologists who specialize in a particular tumor are more likely to be affiliated with large hospitals or academic teaching hospitals that may not be located in proximity to the patient’s home and which can make receiving treatment involve considerable logistics and travel time. In a recent survey, specialist oncologists who practiced in a university setting were more likely to be aware of clinical trials and to enroll patients into them than oncologists who practiced alone or in private groups in the community by a ratio of 56:1. In addition, academic oncologists were simultaneously more likely than community oncologists to report providing off-protocol therapy. On the other hand, general medical oncologists can provide excellent care and achieve excellent outcomes. An advantage to community oncologists may be their increased availability to patients. Studies that show a benefit of one over the other usually use intermediate outcomes and there are many confounding factors, including referral biases, shared care, and illness burden.
Academic versus Community Setting
Teaching hospitals are responsible for training medical residents and fellows in the United States. There are many studies that examine outcomes in teaching hospitals versus those in a community setting. Superior outcomes have been reported in some studies, but others claim the opposite. A systematic review of the literature demonstrated a great deal of variability, but overall there was no major difference in the effectiveness of treatment provided by teaching hospitals or nonteaching hospitals. The most convincing arguments in favor of outcomes in teaching hospitals pertain to cancer patients undergoing complex surgical procedures who benefit from board-certified specialty surgeons, multidisciplinary teams, availability and use of sophisticated clinical amenities, and highly trained personnel. A study of over 24,000 cases of breast cancer, comparing outcomes, suggests that patients with infiltrating ductal carcinoma treated at teaching hospitals had significantly better survival than those treated at high-volume centers or community hospitals, particularly in the setting of advanced disease. A study in Great Britain of nearly 3000 women also suggests this trend, demonstrating that breast cancer patients treated in specialist units had 57% lower local recurrence rate and 20% lower risk of death. However, the literature also highlights some less optimal aspects of receiving care in teaching hospitals. Often teaching or academic centers are not in proximity to the cancer patient’s home, and travel may be a burden; this may be more significant as the condition deteriorates or if the treatment plan is quite intense. In addition, if patients do not live near the treating hospital, it is likely that in an emergency they will be hospitalized close to home, where their records may not be available and they will not be under the care of their primary oncologist or team. In addition, physicians in academic centers have additional responsibilities other than patient care that may make them less “available.” There are many reasons why obtaining care in the community setting may be preferable. For instance, a community hospital is more likely to be close to a patient’s home and convenient for emergencies. The doctor treating the patient’s cancer is most likely going to be the one treating him or her on inpatient admissions and returning phone calls and answering questions. The doctors, nurses, and office staff are generally more available and have more flexible hours than those provided in a teaching hospital setting.
The optimal type of personality for an oncologist depends on who the patient is and what qualities are important to him or her. For the most part, it is agreed upon that “effective” care requires a match between health care provider skills and the needs and expectations of the patient. Table 5-l lists many of the characteristics that oncologists, ideally, should possess.
| Effective communicator |
| Trust |
| Compassionate |
| Patient |
| Experienced |
| Gender (if patient has a preference) |
| Same cultural/language background |
One of the most important characteristics of an oncologist is that he or she be an effective communicator (understandable, direct, and simple). When 100 patients at an Israeli cancer center were asked about doctor-patient communication, nearly 90% of patients felt strongly that eye contact was important. Trust is a central element in the patient-physician relationship. Patients base this trust on physician behaviors such as competence, compassion, dependability, confidentiality, and communication.
- •
Compassionate (“touchy-feely”) or more reserved (“hands off”)
- •
Experienced (young and with recent training, older and seasoned with more experience)
- •
Gender: Some patients feel that to have a physician of a specific gender will improve their ability to communicate.
- •
Culture: Just as with gender, a patient and his/her family concentrate their efforts on finding a physician with a similar cultural background, so that the diagnosis, prognosis, and treatment plan can be communicated in a culturally acceptable fashion.
Not only did it take 2 hours to drive to the initial consultation, but the physician was running behind, spoke abruptly, and strongly argued for an aggressive treatment plan with combined hormone and chemotherapy. The daughter was hoping for a more informative encounter that would allow more discussion and more involvement with decision making.
Not only did it take 2 hours to drive to the initial consultation, but the physician was running behind, spoke abruptly, and strongly argued for an aggressive treatment plan with combined hormone and chemotherapy. The daughter was hoping for a more informative encounter that would allow more discussion and more involvement with decision making.
Value of a Second Opinion
Second opinions in oncology are common. In 1992, 56% of 1500 cancer survivors in the United States reported to have obtained at least one second opinion. It has been shown that a process of second opinion is of great value for the staging of tumors, which is the foundation for individual treatment decisions. Second opinions are sought for many reasons. ( Table 5-2 .)
| Denial/Need for more information |
| Treatment is too aggressive or not aggressive enough |
| Interpersonal difficulties |
| Treatment failure |
Denial/ Need for More Information
Denial occurs relatively frequently in patients with cancer, because of the life-threatening character of the disease. As stated by Bayliss, “Often the patient or patient’s relatives are concerned at the diagnosis and potential prognosis that the first opinion is unacceptable or not fully comprehended until confirmed by another expert.” Most patients report the reason for seeking a second opinion is their need for more information. This does not necessarily mean that the first specialist did not provide the patient with enough information. A plethora of research has shown that recall of clinical information and treatment in the medical encounter is suboptimal. It has been hypothesized that the ability to recall this information predicts patient satisfaction. Many studies suggest there are many factors that influence this ability such as age, gender, educational status, and prognosis, among others.
Treatment
Cancer treatment is usually toxic and/or potentially disfiguring. The treatment offered by the first oncologist may be deemed too radical, or often, in the case of the older cancer patient, not radical enough, and some alternative treatment plans are hoped for in the second consultation. Another reason for seeking a second opinion is when interpersonal difficulties occur. Dissatisfaction with the first specialist was observed in one third of cancer patients questioned regarding their motives for seeking a second surgical opinion, in a study in the Netherlands. Treatment failure and clinical trial availability is a very common reason for a second opinion.
There are several important things to review in a second opinion. Patients usually have high expectations for this consultation. Asking at the outset of the visit for the patient’s specific agenda and questions they want answered can improve patient and physician satisfaction. The basis of the second opinion is a thorough reevaluation of the patient’s case, including a review of diagnostic material such as diagnostic history, sequence of events, surgical record, radiographic images, pathology report, and, at times, the tissue itself.
In oncology, perhaps more than in other fields of medicine, diagnostic and treatment guidelines and protocols are well defined for most tumor types. The variability of interpretation and weighing of older patients’ clinical and personal characteristics, however, leads to considerable variability in the advice they receive, and therefore a second opinion may be more important.
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