November 27, 2000
Facing Cancer Surgery?
Get a Second Opinion - a Real Second Opinion
Richard A. Evans, MD
I have a funny idea about second opinions. I think patients have the right to hear all reasonable and medically prudent opinions. Today patients with cancer may talk with two or three doctors, but still hear the same opinion over and over. The reason is simple. Doctors in the leading cancer centers develop opinions which are embraced by physicians throughout the country But, what happens if these opinions are incorrect? What if the leaders make a mistake? Let me digress. . . .
In 1976, I did a fellowship in cancer surgery with Dr. John S. Stehlin, Jr. at St. Joseph Hospital in Houston. Dr. Stehlin was the second surgeon in the United States to advocate and regularly perform lumpectomy for breast cancer. (The first was Dr. George Crile, Jr. from the Cleveland Clinic.) Dr. Stehlin began his "special procedure," as he called it, in 1970. I took an immediate interest in his pioneering work. "What could I do to help?" I asked.
Dr. Stehlin was working on a paper about his first 81 special patients. He said I could go to the Texas Medical Center Library and find every paper I could on breast-sparing treatment. I was to look for patients who received surgery and/or radiation therapy, but who still had an intact breast. By the end of 1976, I had found over 60 articles from six different countries (England, Finland, Canada, France, Italy and the United States). They included over 1,000 patients, treated in dozens of hospitals. There was experience going back into the 1920's, when Dr. Geoffrey Keynes first challenged the classical radical mastectomy - the "Gold Standard" of the time. There was even one randomized, prospective trial, the most accurate form of clinical research. These articles reported on overall patients survival - often comparing it to the results of radical surgery. All 60 papers carried a single message. Breast-sparing surgery works. It is safe and effective treatment for many patients with cancer of the breast.
But, in 1976, a patient with breast cancer could have received two opinions or two dozen opinions and she was going to loose her breast, unless she saw Dr. Stehlin, or Dr. Crile, or Dr. Eleanor Montague in the Radiation Therapy Department at M.D. Anderson Hospital in Houston. There was clearly a great chasm between the published medical experience of doctors around the globe and the accepted medical practice in the U.S.
Yes, in 1976, and for over a decade thereafter, the leading cancer centers in the U.S. were wrong. And to make matters worse, these same institutions had invisible barriers which prevented patients from learning about the success of conservative treatment in the U.S. and abroad.
In 1978, I completed my formal education in surgery and entered private practice. I followed Dr. Stehlin's lead and became an advocate of breast-sparing surgery and radiation therapy. Even into the 1980's this approach was considered risky and experimental by most surgeons. So when I talked with patients, I always concluded with this unusual suggestion. "I want you to get a second opinion," I'd say. "But, I want you to get that opinion from a surgeon who disagrees with me." It wasn't hard to find surgeons who disagreed - some vigorously.
As you know, the treatment of breast cancer has changed since the 1970's. But, for many other cancers, there is still a great chasm between the published medical research and accepted medical practice. As in 1976, the prevailing bias favors radical or aggressive surgery. For patients with melanoma, sarcoma or cancer of the cervix, genitals or prostate, it can still be difficult to find doctors who support conservative treatment. It can be just as difficult for patients to find supporting medical research which they can understand.
In 1998, I helped establish the Texas Cancer Center. Our recommendations are summarized in terms most patients can understand. For the adventuresome, we provide supporting links to the National Library of Medicine. I am aware of no published medical research which refutes our treatment recommendations. If you're looking for a second opinion, ask your doctor to guide you toward an opposing point of view. And visit our web site at www.texascancercenter.com. Our number one goal is to offer patients a second opinion - a real second opinion.
Richard A. Evans, MD
Texas Cancer Center
Dr Evans is the author of
Making the Right Choice: Treatment Options in Cancer Surgery.