August - December 2005 Issue
Program Can Offer Fresh Options for Men
With Prostate Cancer
William A. See, MDMedical College of Wisconsin Urologist
Named one of the "Best Doctors in America®" 2004 by Best Doctors, Inc.
A diagnosis of cancer always warrants a second opinion. William See, MD, talks about a new program at Froedtert & Medical College of Wisconsin that helps men with prostate cancer explore all of their options.
Q. Why is it important for men with prostate cancer to get a second opinion?For men with prostate cancer, getting the opinion of the people who really are the experts in prostate cancer management is critical to making the best care decision. I personally think prostate cancer is a disease that does not mandate emergent treatment. Men and their partners should be aware they have time to engage in an information-gathering process and make an informed decision.
Q. What is the goal of the Prostate Cancer Second Opinion Program?The program is twofold in scope. One purpose is to heighten awareness among men with prostate cancer about the importance of getting a second opinion from experts in the field. The second is to provide men who have a prostate cancer diagnosis with the full spectrum of specialists who participate in the disease process. This would include urologic oncologists (surgeons who focus on prostate cancer care), radiation oncologists (who treat prostate cancer with various forms of radiation) and medical oncologists (who are important participants in the management of care for men with advanced prostate cancer).
I think it's important that the Prostate Cancer Second Opinion Program not be viewed as, first, implying that the treatment recommendations made by an initial diagnosing physician are incorrect or, second, suggesting that care cannot be delivered in those settings. What the program is really intended to do is critically review all the individual details of a patient's circumstances and make sure that all the treatment options have been explored and recommendations made up to that point are appropriate.
Q. Why is it important to see a urologic oncologist?A urologic oncologist is a urologist who cares only for patients with cancer, who predominantly cares for patients with prostate cancer, who sees more of that disease, reads more about that disease and thinks more about that disease, who does research in that disease and is consequently better able to make sure the right thing is being offered and the patient is aware of all choices.
Do we have the right diagnosis? Do we have the right assessment of disease extent? Are we doing the right thing to maximize the chance of cure? Do we have the right balance of risk versus benefit? You really want to tailor therapy to the circumstances of each individual patient and you want to make sure all the subtleties of the disease management process are being considered.
Q. Can you give some examples?Sure. Let's take a 78-year-old man who has a Prostate-Specific Antigen (PSA) reading of 5 or 6 and a biopsy that shows a small amount of well differentiated cancer. That man might get a recommendation to get some type of curative therapy-for example, radioactive seed implantation or external beam radiation or even, on occasion, surgery. It would be very important for that man to recognize that although he has prostate cancer, the likelihood that the cancer will result in his death is very, very low. Given that low risk of death and the risks associated with any treatment, simply monitoring his cancer (what we would call "expectant management") would be a very appropriate option. It would be important for the patient to hear that he doesn't necessarily need treatment, that it may be very safe and appropriate simply to follow his disease.
As another example, there might be a patient with locally advanced disease who has been given a recommendation for surgery but for whom surgery is probably unlikely to get rid of all his local disease. That patient would want to know that external beam radiation therapy would be a better option, perhaps in combination with hormone therapy.
It's not uncommon for men with poorly differentiated cancer, cancer that under the microscope looks more aggressive, to get a recommendation to have a seed implantation. Based upon the literature, we know seed implantation does not work as well as external beam radiation therapy or surgery for patients with poorly differentiated cancers. Again, it's not that the patient couldn't choose to have a seed implantation. It's just that he should clearly understand the implications of that choice relative to the likelihood that it will cure his cancer.
Q. How do you tell your doctor you want a second opinion?I just encourage patients to be up front about it. I think physicians in general are quite understanding of patients’ desire to get a second opinion.
Most physicians want their patients to make a good decision and to be comfortable with the choice they have made. Part of that process is to offer patients a second opinion on a routine basis. I think a second opinion has value irrespective of where that patient ultimately chooses to have his care delivered. In many cases, the patient will go back to the primary diagnosing physician and have his care delivered there.
Again, just speak openly and honestly about it. I think it really strengthens the relationship between the patient and the individual physician.
Q. Does health insurance cover second opinions?I think insurance for a diagnosis of cancer typically does cover a second opinion. The caveat to that is that I’m no insurance expert.
Q. Nationwide, are there many second opinion programs for prostate cancer?I think one needs to separate what exists informally in most academic medical centers (“If you want a second opinion, we’re happy to see you”) from those programs that have been formalized and thought about and put together in a rational and patient-friendly design.
There are some things that distinguish our program. We’ve really tried to structure it so that it’s accessible, it’s patient-friendly, it gets you to see the experts you need to see in a timely fashion, and it encompasses all the important physician medical specialists who are involved in prostate cancer disease management.
At Froedtert & Medical College of Wisconsin, all of the various specialists are under one roof, so you can come here and conceivably see all the partners in one day if you had to. The user-friendly part is that there is a single phone number to call and there is a care navigator who walks you through the process. We’ve really tried to structure this in such a way as to obviate some of the anxiety of (a) the diagnosis, (b) simply seeing the doctor and (c) coming to a new institution that you may not have been to.
Author: William A. See, MD
Source: Every Day
Date: August - December 2005