Oncologist Asks for Your Second Opinion

Kathy D. Miller, MD


July 20, 2015

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Hi. This is Dr Kathy Miller from Indiana University. I want to try something different today: a game of role reversal. I am going to tell you about a patient of mine, and I want you to be the oncologist who is seeing her for a second opinion.

The Case

In a nutshell, this is a 63-year-old woman. I assumed her care from one of my colleagues. She had presented years earlier with locally advanced breast cancer that was treated with neoadjuvant chemotherapy followed by a mastectomy and radiation that included extended nodal fields. Her initial tumor was estrogen receptor (ER) negative, progesterone receptor (PR) negative, and human epidermal growth factor receptor 2 (HER2) positive. She has been well and without evidence of recurrence.

At my very first visit with her, her voice was quite hoarse, consistent clinically with a vocal cord paralysis. On examination, she had bilateral supraclavicular adenopathy that had not been previously noted. A fine-needle biopsy of those nodes confirmed that this was her breast cancer disease with the same phenotype: ER negative, HER2 positive. Imaging revealed additional, more extensive mediastinal adenopathy, two very small pulmonary nodules that had not been seen on imaging at the time of her initial diagnosis, and limited asymptomatic bone metastasis.

We discovered her metastatic disease shortly after trastuzumab and pertuzumab with docetaxel was approved for HER2-positive metastatic breast cancer on the basis of the CLEOPATRA trial.[1] She began that regimen. She had a very gratifying, prompt, clinically complete response; her voice returned to normal, the palpable adenopathy completely disappeared, and after six cycles of therapy, her mediastinal nodes returned to normal size, her pulmonary nodules were no longer seen, and her bone metastasis had become sclerotic. We stopped her chemotherapy and continued the trastuzumab and pertuzumab.

Around that time, she had seen some extended family members and they asked whether a second opinion would be helpful. I did not think we needed to change her therapy at that point but agreed that a second opinion could be very helpful.

What would you do if she came to you for a second opinion? Take a minute to think about it. Press pause if you need to. Consider what evaluation you would do as part of that second opinion.

I assume you have your evaluation in mind, so let me tell you the evaluation this woman had.

The Second Opinion

This patient was seen first by an internist who referred her to a medical oncologist, a radiation oncologist, and a palliative care pain specialist. She also was seen by a nutritionist and a mind-body expert psychologist.

She underwent full laboratory studies, including a complete blood count, a chemistry panel, lactate dehydrogenase level, a human cancer antigen (CA 27-29) test, a carcinoembryonic antigen (CEA) test, and tests for CA 15-3, and circulating tumor cells. They repeated the imaging studies, including CT scans of the head, chest, abdomen, and pelvis, a bone scan, a positron emission tomography-CT scan, brain MRI, and cardiac function studies. They reviewed her previous pathology results, including her initial diagnosis of locally advanced disease. They also reviewed the fine-needle aspiration specimen that identified her metastatic disease. They examined that pathology and repeated the receptor stains on tumor blocks or unstained slides that were sent to them.

She returned to the facility a week later to review the results of all of those evaluations. Her laboratory studies were completely normal. Her circulating tumor cells were completely negative; they found no circulating tumor cells. Levels of all three tumor markers were less than normal. Cardiac function was also normal. And her scans found absolutely no evidence of progressive disease.

During her pain assessment, she noted that she occasionally has a little back discomfort for which she takes a dose of acetaminophen or ibuprofen about once a week, but the pain consultant suggested a variety of other interventions that they could try to minimize her pain. She has not lost weight. She does not have any nausea or gastrointestinal symptoms, but the nutritionist gave her a thorough evaluation, including measures of prealbumin, vitamin B12, folate, and iron, all of which were normal.

At the end of the day, the consultants suggested that she continue exactly the same therapy.

To be clear, I believe that second opinions can be very helpful. Occasionally they result in a change of treatment or uncover symptoms that had not been adequately palliated. Sometimes the clinician gives patients additional explanations or analogies that can improve their comfort with their disease. But think a bit about the evaluation you had in mind for this patient, what she actually underwent, and whether this was good value for her care, for our healthcare system, and for us as a society.


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