John Link is one of the premier breast cancer doctors in the U.S. and author of The Breast Cancer Survival Manual as well as Take Charge of Your Breast Cancer. He is a passionate campaigner for the importance of a second opinion and Optimal Care for women with breast cancer.
Take Your Time
With the crisis of a newly diagnosed breast cancer or even the knowledge of a suspicious finding on a mammogram, women often feel a tremendous urgency to have the lump or "lesion" immediately surgically removed immediately. The very act of doing something, anything, often alleviates the escalating anxiety.
It is extremely important to realize that you don't have to rush into treatment or a surgical procedure. If it is a cancer, it has been there for a minimum of two or three years. The majority of cancers can be diagnosed with a needle biopsy. With the results of this needle biopsy and the imaging studies, a treatment plan can be formulated for an optimum outcome.
Advantages of a 2nd Opinion
You may feel the need for a second opinion. By this I mean an independent review of your situation, an independent study of the images and the pathology from the biopsy followed by recommended treatment plan by a doctor or a team that specializes in breast cancer treatment. The number of women seeking second opinions for newly diagnosed breast cancer has increased tremendously in the last few years. I believe this is due to several factors. The first is that women are becoming much more comfortable and self-confident in seeking information and becoming involved in their own treatment. Secondly, the treatment for breast cancer has become much more complex, involving a number of different specialists, each of whom needs to communicate with the other in order to develop a coordinated and comprehensive treatment plan. When specialists do not communicate and work in isolation, women get conflicting opinions which then require some sorting out of treatment plans for optimal results.
Requesting a second opinion was once felt to be offensive or to represent a lack of confidence in their primary doctors. I believe this is much less the case today, and most busy, well-intentioned doctors are comfortable with a woman requesting a second opinion. In fact, it is cause for concern if the doctor or institution rendering the first opinion is defensive or non-cooperative as you pursue a second opinion. Most facilities and doctors will assist you in recommending a facility/physician for a second opinion and organizing your material so that it is convenient for you.
The Process
If you do decide to seek a second opinion, it is exceptionally important that you go to an institution or physician who does this routinely and has a system in place that will insure a thorough and detailed review. At Breastlink we see hundreds of women each year seeking second opinions. We believe that, to do this correctly and to serve the women optimally we must have the imaging and pathologic material reviewed before we meet with each patient.
When a woman calls, she will talk with one of our trained medical personnel (who will ask about all the important demographic and historic health information) and arrange for her to obtain breast images and pathology slides for us to review. Women in our geographic area will often hand deliver these to us so that we can review them in advance. Women from out of the area will have them sent to us by registered mail. This process usually takes one or two days. Once we have been able to review this material, we will do everything possible to see her promptly. It is critically important to have the prior imaging and any biopsy slides and pathology reports ahead of time to give a more accurate and meaningful opinion.
Many women, once they have had a second opinion, will return to their primary team of doctors for actual treatment. It is important that we create an open dialogue with these physicians what we believe is an optimal treatment plan.
What are the common situations when we at Breastlink differ with the primary opinion? What distinguishes a second opinion from Breastlink's breast dedicated team?
Pathology Report
We insist on expert pathology review to verify/confirm that the abnormality diagnosed is in fact a cancer and, most importantly if a cancer, the type of breast cancer that is present. Occasionally it is not cancer. This is very rare, but can happen. Much more common is a difference in the extent or the degree of malignancy. Under the microscope, the pathologist studies three major areas which affect prognosis and treatment planning: (1) the size and extent of the cancer (2) the degree of malignancy, also referred to as the grade of the tumor and (3) involvement of the lymph system. There are also a number of special tests that can be done on a genetic and molecular level that aid in treatment planning. For further information about the importance of an expert pathology report, click here.
Type of Surgery Recommended
Surgical recommendations can vary widely. After thorough review, our breast-dedicated surgeons will give an opinion if we feel the whole breast needs to be removed (mastectomy). Whenever possible, we want to offer women breast conservation. Always the prime consideration is cure, and under no circumstances would we compromise a woman's ability to survive this disease. It is often the case, however, that breast preservation can be achieved with no increase in the risk of recurrence. We can often do this with innovative surgical techniques (tissue flap advancement). The reason for preserving the breast is always for cosmesis. There are situations when the cosmetic result, however, will be inferior to mastectomy and reconstruction. We believe that women should have an honest assessment of what their chances are of getting a good cosmetic result with breast preservation. For further information, see breast cancer surgery.
Sequence of Treatment
Younger women with palpable invasive breast cancers are often now receiving systemic therapy (chemotherapy and hormone therapy) prior to surgery. Giving systemic treatment first has a number of advantages that may include the provision of prognostic information (the response from chemotherapy of the primary cancer may allow one to predict ultimate cure rates) and may shrink the tumor and permit a more limited surgical procedure that allows for better clearance with free margins of normal tissue around the removed cancer. The sequence of radiation, surgery and chemotherapy has changed dramatically in the last few years and depends on a number of factors, which can be discussed at the second opinion consultation.
Radiation or Not?
The purpose of radiation therapy added to surgery is to prevent local recurrence. Often with well-planned surgery with adequate margins, radiation is not necessary. The standard of care in the past has always been to include radiation following lumpectomy or wide local excision. However, we are now learning that there are certain situations where radiation may not be necessary or adds very little benefit and has potential downsides.
Types of Radiation
There are various ways to give radiation as an adjunct to breast cancer surgery. One is to give whole-breast radiation, another is to give limited breast radiation using a number of techniques, and in fact we are beginning to use a single dose of intraoperative radiation which would appear in some circumstances to be as good as the seven weeks of radiation that has been the traditional way of administering it. The various methods and types of radiation should be addressed at the second opinion. For more information, see Breast Cancer Radiation Therapy.
Types of Chemotherapy and Systemic Therapy
A major concern for many women is whether or not they need chemotherapy. The risk-benefit of systemic therapy including hormonal therapy and chemotherapy should be discussed thoroughly with each woman. A number of prognostic tests allow us to predict the risk of systemic spread. Unfortunately, we are lacking a perfect test that allows us to assess this risk. However, after going through the factors that have been identified to prognosticate or predict cells having escaped into the system, one can then discuss the benefit by undergoing systemic therapy. There are a number of different chemotherapies and investigational regimens that are being studied. In a second opinion the risk-benefit of these various therapies should be presented.
Genetic Testing
By taking a thorough family history, one can assess the risk of a woman having a genetic defect or hereditary abnormality that has been passed down from her mother or father. The presence of such a gene defect may affect the primary treatment, the type of surgery and the type of treatment recommendations made. This is why it is important to assess the genetic risk of hereditary breast cancer early on when treatment decision-making is being performed.
The 2nd Opinion Report
Once your case has been reviewed you should receive a written summary of the findings of the treatment team that have undertaken the review. You may want a copy of this sent directly to your primary doctors, but this should be your choice. This document should consist of a review of the pathology from previous biopsies or surgery, a review of any imaging studies that have been submitted, a summary of the history and pertinent facts pertaining to your situation, and then a summary of treatment recommendations. With the treatment recommendations there should be a discussion of risks versus benefit for each treatment option and, when appropriate, any investigation or research protocols available. Once you have reviewed the document, you may want to discuss the results with a member of the treatment team. At Breastlink our Patient Services Director arranges a follow-up phone call when she sends you a copy of the report.
It often requires courage and bravery to seek a second opinion, and to instruct your doctor to send the necessary information to another medical professional. Remember that it is not about your doctor, it is about you! To achieve Optimal Care you need to become informed and become your own advocate. You need to be presented with options, not just recommendations. You must consider the opinions presented to you and choose the treatment plan that you feel is right for you. Demand the very best. These are the cornerstones of healing.
For more information or to contact Breastlink about a second opinion, click here.
To read more about the importance of a second opinion in Dr Link's books, click here.
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