A cancer second opinion re-reads the pathology slides and scans, checks the stage and puts the plan before a tumor board. Reviews found the diagnosis, treatment or prognosis changed in 12 to 69 percent of cases and was confirmed in most others. It can be done remotely from your files, or during a three to five day visit.
About This Department
Medical Oncology
Most second opinions confirm the plan you already have. A meaningful share change it, and nobody can tell in advance which yours will be.
A second opinion in cancer means a fresh, independent look at the diagnosis and the treatment plan by specialists who were not involved in the first. At its best it re-reads the biopsy slides and the scans, checks the stage, and puts the case before a multidisciplinary tumor board. A systematic review of cancer second opinions found that the diagnosis, treatment or prognosis changed in 12 to 69 percent of cases, depending on the study, and was confirmed in 43 to 82 percent. Confirmation has value too, because patients start treatment knowing the plan has been tested.
12 to 69%
Second opinions that changed diagnosis, treatment or prognosis, J Cancer Res Clin Oncol 2016
1.4 in 100
Pathology diagnoses changed on mandatory review, Cancer 1999
90 in 100
Changed pathology diagnoses that altered treatment, Arch Pathol Lab Med 2013
Free
First review of your reports by an oncologist
Free consultation
Send the pathology report, the scan reports and, ideally, the images themselves, the letter or plan from your current team, and a short note of the question you want answered. An oncologist reads them and tells you what a full second opinion would involve for your case, which specialists would review it, and whether the slides should be sent for re-reading. The first review is free and does not commit you to anything.
Asking for a second opinion for cancer treatment is normal practice. Good oncologists expect it, and in many countries insurers pay for it. This page explains what a thorough second opinion covers, what the evidence says about how frequently it changes things, what to send, and how the review works for a patient abroad, whether the answer comes by video or during a visit to Istanbul.
What a second opinion checks
Four questions, four kinds of specialist
A complete review answers four questions, and each needs a different specialist.
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What is reviewed, and by whom
Question
What is looked at
Who looks
Is the diagnosis right?
Original slides and blocks, re-stained if needed
A pathologist who sees that cancer every week
Is the stage right?
The images themselves
A radiologist and a nuclear medicine physician, reading every scan again from the first slice to the last
Are the tumor's markers known?
Receptor, gene and immune tests, and whether any are missing
The pathologist and the oncologist
Is the plan the best one?
Surgery, radiotherapy and drug options against current guidelines
A tumor board of surgeon, medical oncologist and radiation oncologist
The diagnosis
Everything rests on the pathology. A lymphoma mistaken for a carcinoma, or a low-grade tumor called high-grade, leads to the wrong treatment however well that treatment is then delivered, and no surgeon, radiotherapist or drug can correct an error made at the microscope.
The plan
With the diagnosis right, opinions differ most over the plan, and in practical ways. Should surgery come first or after chemotherapy? Is a smaller operation possible? Is radiotherapy needed at all? Is there a targeted drug or a clinical trial that fits?
How the review works
From your files to our answer
A remote review
1
You send the files
Reports, images on a disc or a download link, and the plan from your current team. The coordinator confirms what has arrived and what is missing.
2
The specialists read them
Radiologists re-read the images. If the diagnosis needs checking, the pathology laboratory asks for the slides or blocks.
3
The tumor board meets
Surgeon, medical oncologist, radiation oncologist, radiologist and pathologist discuss the case together, usually within the week.
4
You receive the answer
A written report in English and a video call with the oncologist, with an interpreter if you wish, to go through it and answer questions.
A visit to Istanbul
1
Consultation and examination
The oncologist sees you in person. That matters when the plan depends on how fit you are or on findings that only an examination reveals, such as the size of a lymph node in the neck or the mobility of a breast lump.
2
Missing tests
Out-of-date or missing scans and tests are done during the stay. Two days covers most.
3
Board and plan
The case goes to the board with you in the city, and the plan is explained before you leave.
What the studies show
A wide range, and a reason for it
A German systematic review found 13 studies on second opinions in cancer. Between 6.5 and 36 percent of patients sought one. The diagnosis, treatment recommendation or prognosis changed in 12 to 69 percent, and the original was confirmed in 43 to 82 percent. Patients found the process helpful and reassuring, while data on whether changed advice improved survival were missing altogether. Ruetters and colleagues, Journal of Cancer Research and Clinical Oncology, 2016.
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Four studies on second opinions
Study
Setting
Finding
Ruetters, 2016
Systematic review, 13 studies, cancer
Changes in 12 to 69 percent, confirmation in 43 to 82 percent
Payne, 2014
Systematic review, patient-initiated second opinions, all conditions
Major change in 10 to 62 percent, more often in treatment than in diagnosis
Kronz, 1999
6,171 pathology cases reviewed on referral, Johns Hopkins
Diagnosis changed in 1.4 percent, with major effects on treatment or prognosis
Swapp, 2013
71,811 pathology cases reviewed on referral, Mayo Clinic
Major disagreement in 0.6 percent, treatment affected in 90 percent of those followed up
Why the slides matter most
Rare, and decisive when it happens
At Johns Hopkins, mandatory review of 6,171 outside pathology cases changed the diagnosis in 86, or 1.4 percent, usually between benign and malignant or between tumor types. Changes were most frequent in tumors of the lining of the chest and abdomen, 9.5 percent, and of the female reproductive tract, 5.1 percent. The authors recommended review of the original slides before any major treatment begins. Kronz and colleagues, Cancer, 1999.
The Mayo Clinic series
Of 71,811 outside cases reviewed between 2005 and 2010, 457 had a major disagreement, 0.6 percent, most often in bowel, lymph node, bone and soft tissue, and urinary tract pathology. Where follow-up was available, the changed diagnosis altered treatment in 90 percent and prognosis in 92 percent, and further tissue confirmed the revised diagnosis in 84.9 percent. Swapp and colleagues, Archives of Pathology and Laboratory Medicine, 2013.
When to ask for one
Ask for one when the cancer is rare, when the diagnosis came from a small biopsy or a laboratory that sees few cases of that type, when the proposed treatment is major, such as surgery that removes an organ, a limb or the voice box, or when you are told nothing more can be done. It helps when two doctors have already disagreed, when a newer treatment or trial you have read about was not mentioned, and when the recommended plan does not match what you have found in guidelines. Some patients simply want to be sure before starting treatment that will change their life. That is reason enough.
When it adds little
For common cancers treated by experienced teams following clear guidelines, a second opinion usually confirms the plan. It is still reasonable, but patients should weigh the time it takes against the benefit, and it should never hold up treatment that cannot wait.
What to send
The file that makes a useful answer possible
Documents and images
The essentials
The pathology report and any gene or marker reports, all scan reports with the images themselves on a disc or through a download link, the operation note if surgery has been done, the chemotherapy or radiotherapy record with dates, recent blood tests, and the letter or plan from your current team. Add a short history in your own words. And the one question that worries you most.
Slides and blocks
When the pathology needs re-reading
The laboratory that made the diagnosis holds the glass slides and the paraffin blocks. You have the right to ask for them, or for a set of recut slides and a block, to be sent for review. The coordinator arranges courier collection and gives the laboratory the address. Any new stains or gene tests are quoted before they are done, and the material is returned afterward.
The three possible answers
Confirm, refine or change
What each means for you
Confirm. The diagnosis and plan are right. You start treatment with your current team, knowing the plan has been independently tested.
Refine. The diagnosis stands, but the plan changes in part, for example a missing gene test, a different order of treatments, a smaller operation, or a trial worth considering. Your team decides whether to adopt them, and most do.
Change. The diagnosis, stage or plan differs substantially. The report sets out why, with the evidence, so that your own doctors can review it too.
Timing, and a caution
How long it takes
A remote review of reports and images takes five to ten working days once everything has arrived. Re-reading slides adds about a week, depending on courier times and any new stains.
Do not let the second opinion hold up treatment that cannot wait. Some cancers, such as aggressive lymphomas, acute leukemias and tumors pressing on the spinal cord or airway, need treatment within days. In those cases the first team should start, and the review runs alongside. Asking for opinion after opinion, until one says what you hope to hear, costs time that some cancers do not allow.
Remote or in person, cost and the trip
Remote or in Istanbul
A remote review
Most second opinions need no travel. The files carry the review. A video consultation follows to discuss the result, and this route suits patients who plan to be treated at home and want confidence in the plan before they begin.
A visit
Coming to Istanbul makes sense when an examination matters, when scans are old or incomplete, or when you are considering treatment here. The length of stay is three to five days, which covers the consultation, any missing tests and the board, and you can fly home as soon as the plan is explained. A typical visit runs like this. On the first morning the oncologist examines you and goes through the history with you and, if you wish, with the family members who came along. The same afternoon or the next morning, any scan that is out of date is repeated, a PET-CT or an MRI in many cases, and blood tests are taken. The board meets on the second or third day with the new images in front of it, and the oncologist sees you again afterward to explain what the board decided, why, and what the options are, in plain words and with an interpreter if needed. You leave with the written report.
Cost and the trip
What decides the cost
Three things decide it. Whether the review is remote or in person, whether slides are re-read and re-stained, and which new scans or gene tests turn out to be needed, since a missing marker test in a breast or lung cancer can change the whole plan and justifies its cost. The first review of your reports is free. Anything beyond it, whether a stain, a scan or a gene panel, is quoted in writing before it begins, and you decide whether to go ahead.
Arrangements
One coordinator looks after everything. Languages include English, Arabic, French, Russian, Serbian, Romanian and Spanish, with an interpreter for others, and the coordinator arranges slide courier, sends the appointment confirmation and an invitation letter naming the hospital and the treating doctor ten days ahead of a visit, and books the hotel and transfers. Two family members may join consultations, meals come in halal, vegetarian and diabetic versions, a prayer room is on site, and a female doctor can be requested at first contact.
What happens next
Whichever way you decide
If you choose treatment here
Moving from opinion to treatment
The plan from the board becomes the treatment plan, and the coordinator schedules surgery, radiotherapy or drug treatment with the same specialists who reviewed the case. Nothing has to be repeated unless it is out of date.
If you stay with your own team
Taking the report home
Once you are back home, give the written report to your oncologist. It is written doctor to doctor, with the evidence behind each recommendation, and our oncologist is available to speak with your team directly. The coordinator stays reachable on the same WhatsApp number for follow-up questions.
Second Opinion For Cancer Treatment FAQ
Should I get a second opinion for cancer?
It is reasonable for any cancer and most useful for rare cancers, uncertain diagnoses, major surgery, or when you have been told there are no options left. Reviews found that the diagnosis, treatment or prognosis changed in 12 to 69 percent of cancer second opinions, and was confirmed in most of the rest.
Will my doctor mind?
Experienced oncologists expect patients to ask and often welcome it. The second opinion report is written for your doctor as well as for you.
Can a second opinion be done without traveling?
Yes. Most are done from reports, images and, where needed, pathology slides sent by courier, with a video call to discuss the result. A visit makes sense when an examination or new tests are needed.
How long does a second opinion take?
Five to ten working days for reports and images once everything has arrived, and about a week longer if the slides are re-read.
What should I send for a cancer second opinion?
The pathology and gene reports, scan reports with the images, the operation note, treatment records, recent blood tests and your current team's plan. The slides and blocks if the diagnosis needs checking.
How often does a pathology review change the diagnosis?
Rarely, but with large effects. In two large hospital series, 1.4 percent and 0.6 percent of outside diagnoses changed significantly, and in most of those the treatment changed too.
References
Ruetters D, Keinki C, Schroth S, Liebl P, Huebner J. Is there evidence for a better health care for cancer patients after a second opinion? A systematic review. J Cancer Res Clin Oncol. 2016;142(7):1521-8.
Payne VL, Singh H, Meyer AN, Levy L, Harrison D, Graber ML. Patient-initiated second opinions, systematic review of characteristics and impact on diagnosis, treatment, and satisfaction. Mayo Clin Proc. 2014;89(5):687-96.
Kronz JD, Westra WH, Epstein JI. Mandatory second opinion surgical pathology at a large referral hospital. Cancer. 1999;86(11):2426-35.
Swapp RE, Aubry MC, Salomao DR, Cheville JC. Outside case review of surgical pathology for referred patients, the impact on patient care. Arch Pathol Lab Med. 2013;137(2):233-40.
Editor's note
Written by the Biruni Hospital medical editorial team. Reviewed by Prof. Dr. Mustafa Teoman YANMAZ, Medical Oncology.
