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Original Investigation
March 2017

Second Opinions From Medical Oncologists for Early-Stage Breast CancerPrevalence, Correlates, and Consequences

Author Affiliations
  • 1Department of Medicine, Stanford University, Stanford, California
  • 2Departments of Health Research and Policy, Stanford University, Stanford, California
  • 3Department of Systems, Populations, and Leadership and Institute for Healthcare Policy and Innovation, University of Michigan School of Nursing, Ann Arbor
  • 4Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor
  • 5Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, University of Michigan, Ann Arbor
  • 6Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles
  • 7Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
  • 8Department of Health Management and Policy, University of Michigan, Ann Arbor
  • 9Department of Internal Medicine, School of Public Health, Division of General Medicine, Univeristy of Michigan, Ann Arbor
 

Copyright 2016 American Medical Association. All Rights Reserved.

JAMA Oncol. 2017;3(3):391-397. doi:10.1001/jamaoncol.2016.5652
Key Points

Question  As treatment decision making becomes more complex, is there an unmet need for second opinions from medical oncologists for the treatment of breast cancer?

Findings  In this survey of a contemporary diverse population sample of 1901 patients newly diagnosed with breast cancer, 168 patients (9.8%) received a second opinion, and 54 (3.2%) received chemotherapy from a second medical oncologist. Second opinions were not associated with overall patient satisfaction or receipt of chemotherapy.

Meaning  Use of second opinions from medical oncologists after diagnosis of breast cancer was low, but there was little evidence of unmet need.

Abstract

Importance  Advances in the evaluation and treatment of breast cancer have made the clinical decision-making context much more complex. A second opinion from a medical oncologist may facilitate decision making for women with breast cancer, yet little is known about second opinion use.

Objective  To investigate the patterns and correlates of second opinion use and the effect on chemotherapy decisions.

Design, Setting, and Participants  A total of 1901 women newly diagnosed with stages 0 to II breast cancer between July 2013 and September 2014 (response rate, 71.0%) were accrued through 2 population-based Surveillance, Epidemiology, and End Results registries (Georgia and Los Angeles County, California) and surveyed about their experiences with medical oncologists, decision making, and chemotherapy use.

Main Outcomes and Measures  Factors associated with second opinion use were evaluated using logistic regression. Also assessed was the association between second opinion and chemotherapy use, adjusting for chemotherapy indication and propensity for receiving a second opinion. Multiple imputation and weighting were used to account for missing data.

Results  A total of 1901 patients with stage I to II breast cancer (mean [SD] age, 61.6 [11.0] years; 1071 [56.3%] non-Hispanic white) saw any medical oncologist. Analysis of multiply imputed, weighted data (mean n = 1866) showed that 168 (9.8%) (SE, 0.74%) received a second opinion and 54 (3.2%) (SE, 0.47%) received chemotherapy from the second oncologist. Satisfaction with chemotherapy decisions was high and did not differ between those who did (mean [SD], 4.3 [0.08] on a 1- to 5-point scale) or did not (4.4 [0.03]) obtain a second opinion (P = .29). Predictors of second opinion use included college education vs less education (odds ratio [OR], 1.85; 95% CI, 1.24-2.75), frequent use of internet-based support groups (OR, 2.15; 95% CI, 1.12-4.11), an intermediate result on the 21-gene recurrence score assay (OR, 1.85; 95% CI, 1.11-3.09), and a variant of uncertain significance on hereditary cancer genetic testing (OR, 3.24; 95% CI, 1.09-9.59). After controlling for patient and tumor characteristics, second opinion use was not associated with chemotherapy receipt (OR, 1.04; 95% CI, 0.71-1.52).

Conclusions and Relevance  Second opinion use was low (<10%) among patients with early-stage breast cancer, and high decision satisfaction regardless of second opinion use suggests little unmet demand. Along with educational level and use of internet support groups, uncertain results on genomic testing predicted second opinion use. Patient demand for second opinions may increase as more complex genomic tests are disseminated.

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