Why people diagnosed with cancer should get a second opinion [PODCAST]

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“Although people think of medicine as a science—the facts reveal the diagnosis, the diagnosis dictates the treatment—most physicians acknowledge that medicine is as much an art as a science. It’s not like a simple math equation with one undeniably right answer. Even when the diagnosis is clear, there may still be multiple appropriate treatment paths that deliver similar outcomes. And there are many cases where the diagnosis is not definitive, especially in the case of complex diseases and many types of cancer.

That’s why a second opinion is an important tool for people who have received a cancer diagnosis. Not only can it help lower the risk of misdiagnosis or an inappropriate plan of treatment, but it’s also essential for decision making. A second opinion from a specialist who has extensive experience treating people with the type of cancer you’ve been diagnosed with can change or confirm your diagnosis.”

Miles J. Varn is chief executive officer, PinnacleCare, and can be reached on LinkedIn.

He shares his story and discusses his KevinMD article, “Why people diagnosed with cancer should get a second opinion.”

This episode is sponsored by Tradeoffs, available on your favorite podcast platform.

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today we welcome back on the show Miles Varn. He is an emergency physician, and he’s the chief executive officer of PinnacleCare. He wrote the KevinMD article “Why people diagnosed with cancer should get a second opinion.” Miles, welcome back to the show.

Miles J. Varn: Hey, Kevin, thanks for having me back. It’s good to see you again.

Kevin Pho: Now, for those who didn’t get a chance to listen to our first episode, can you just briefly share your story and journey to where you are today?

Miles J. Varn: Yeah, my story’s a bit different. I started in the traditional path of practicing medicine. I was an emergency physician at a big trauma center, 60,000 to 70,000 patient visits a year, so I saw the microscopic side of just about everything. Just when I thought I had seen everything, something new would pop up, so it was exciting and interesting.

Then I had the opportunity to move from that into a role that was not clinical, and that was advising families and individuals about how to get the best treatment and outcome for their particular illness. So I joined PinnacleCare, first as chief medical officer, about 16 years ago now. In that role, I supervised and built our client engagement and did a lot of travel to various academic medical centers around the country, probably 150 or so, at least once, and some many more times than that. So I got to see the microscopic side of health care, which has been truly fascinating.

Then in the last year and a half, I’ve assumed the role of chief executive officer of the company, so I learned a whole new set of vocabulary, a whole new set of things and skills. So life is interesting. You never know where it’s going to take you.

Kevin Pho: Now, I always like to ask physician CEOs about that transition from a clinical role into that executive role. What would you say are some of the biggest challenges that you face during that transition?

Miles J. Varn: Yeah, I would say, if I had to do something over again, I would learn more business-related financial terminology and spreadsheets. In the case of our company, there’s a lot of contracting. We’ve actually just been acquired by a much bigger company, so I had to go through learning reps and warranties and legal terms. So I guess some more familiarity with those principles would be helpful.

Kevin Pho: So let’s transition now into the KevinMD article that you wrote, titled “Why people diagnosed with cancer should get a second opinion.” Now, for those who didn’t get a chance to read that article, can you just walk my audience through it and share the story of why you decided to write it?

Miles J. Varn: Yeah, so cancer in particular is one of those areas of medicine that has a lot of vulnerabilities in terms of a patient, and the vulnerabilities can come at the diagnosis stage. For example, women with ductal carcinoma in situ have about a 30 percent chance of misdiagnosis on the pathology side. In fact, we’ve taken care of three women now who were diagnosed with breast cancer, scheduled for surgery, radiation, and chemo, who actually didn’t have breast cancer on pathology review.

If you look at the published data, for those women who are referred to an NCI-designated cancer center with breast cancer, about 43 percent of the time the diagnosis changes. So you’ve got an opportunity to intervene by virtue of having someone who only sees breast cancer or only sees colon cancer use that experience and expertise to help either ensure that the diagnosis and treatment plan is correct or to change it for the better for the patient.

The other thing I’ll say is, if you look at prostate cancer, for example, we have men come to us: “I want proton therapy,” or, “I want robotic surgery.” What they may not understand, if they’re not fully informed by virtue of a second opinion, is that maybe in their case active surveillance is the best choice: regular biopsy, regular MRI, but no surgery and no radiation. We have, I would say, about five clients who’ve successfully been on active surveillance for more than five years and never needed an intervention.

So the choices for some might be different than others. Some might choose that path if it’s an option, others might choose to worry and want to have a surgery, and others might choose radiation, and they may all be equally valid choices. But if you’re not informed, you never know they exist. So that’s another reason.

And then, if you look at the data, the overall misdiagnosis of cancer in the U.S. is about 45 percent. We care primarily, almost exclusively, about the patient, and that’s our success. It’s thrilling to tell a woman who was diagnosed with breast cancer that you’re not going to be a survivor, with implications for your daughters and worrying and surveillance and so forth. I mean, it is truly a thrill to pass that news on.

But if you think about the economic impact of that situation over and over again, we have to be social citizens of the resources that relate to health care in this country. So saving those people obviously saves money, and those resources can be deployed in better ways to help more people. So I think there certainly is a sustainability argument that you could make about second opinions leading to lower health care costs, and that’s good for all of us, not only as physicians but as social citizens in this country.

Kevin Pho: Now, when you talk about misdiagnosis, and you mentioned stories and case studies about breast cancer in particular, are most of those misdiagnoses at the pathological stage?

Miles J. Varn: The misdiagnoses are generally at either the pathology stage or the radiology stage. When you say a change in diagnosis or treatment, sometimes there’s a finding of another lesion: They thought there was one, but there’s another. Or there actually is axillary lymphadenopathy in a breast cancer patient when in fact the original opinion wasn’t that. Or sometimes it’s just a matter of interpreting genomic data or gathering more genomic data to inform the decision-making process in terms of risk of recurrence, lower or higher. So it’s multifactorial.

I’ll say this: We work with a big carrier, facilitating peer-to-peer oncology second opinions, so local oncologists, and we work remotely, virtually, with expert oncologists elsewhere. We’ve finished a pilot stage now, and there’s no question in their mind or our mind that we’re impacting both diagnosis and treatment, and in some cases in a significant way. So it is obviously great for the patients. We found that the local oncologists welcome the input, because sometimes interpreting this complex molecular data that keeps growing and growing and growing, in a good way, is just difficult to do, and they don’t have time to do that in a busy oncology practice.

Kevin Pho: Are there any particular cancers that necessitate a second opinion, or would you recommend that in all cases of a cancer diagnosis, patients should obtain a second opinion?

Miles J. Varn: Quite honestly, I think all cancers, with the exception perhaps of basal cell skin cancers, or simple problems, or ones that can be made on the basis of purely a molecular test. But I think in particular ones that involve complex treatment, so lymphomas and leukemias, where those treatment modalities have evolved very significantly, blood cancers, or complex surgeries like pancreatic cancer: Can we do surgery or not? Should we do neoadjuvant chemotherapy or radiation and then consider surgery? Are clinical trials the right fit in this complex situation?

So I think there are more factors today to consider. The technology, in terms of imaging and otherwise, is becoming more complicated. And so I think it’s best for the patient, if you look at the data, but it’s also best for our system.

Kevin Pho: Now, who should initiate that second opinion? Because whenever a patient gets a diagnosis of cancer, in more cases than not, they’re probably going to listen to that oncologist and his or her recommendations. So to initiate that second opinion, should that come from the patient, should that come from the oncologist himself or herself, or should it come from the primary care doctor?

Miles J. Varn: Yeah, I think the reality, Kevin, is that most of these are patient-initiated, although we’ve certainly worked with oncologists who will tell the patient and welcome a second opinion. But for an oncologist who’s busy with their day job, there’s not time in the day to organize the case, to get the images and the slides, find the expert, deliver all that to them, and then wait for the opinion back.

So what we find is a lot of these are appropriately scared patients who ask an organization like ours whether we can help, and oftentimes the answer is yes, and we are able to take that burden off of them. That’s why, quite honestly, a lot of employer-based programs have evolved quickly to allow the employees to get second opinions. From the employer’s side, they know that better diagnoses and better treatment plans will lead to lower costs. But on the employee side, you’ve got a scared patient who’s also trying to work and also trying to manage their appointments, and then you’re going to throw “collect all your records, images, and slides” on top of that. They’re just not going to be present at work. They may be sitting in a chair at work, but they’re not going to be present.

Kevin Pho: We’re talking to Miles Varn. He is an emergency physician and the chief executive officer of PinnacleCare. He wrote the KevinMD article “Why people diagnosed with cancer should get a second opinion.” Let’s say a patient receives an unfortunate cancer diagnosis. Can you summarize the second opinion options that are available to them at that time?

Miles J. Varn: Yeah, so there are several. One is in person. For people who live close to a big NCI-designated cancer center, that’s probably the best path, because there’s nothing better than meeting with a physician, an expert, one-on-one directly and having what I’ll call human contact.

But aside from that, there are about 25 different institutions we work with, some of whom we power, like Sloan Kettering. We power their second opinion process. So we, or a patient, can obtain a remote written second opinion. The records are organized, the clinical summary, their questions, and it comes back in basically answers to about 10 or 12 questions.

And then also available today are video-based expert opinions. There are several companies that do that, and it’s sort of the same organization as the remote written, but then there’s a video interaction, sort of in the same way that we’re interacting right now, only synchronous in time, and families can join from different places. Some people prefer to engage at a level where they can have a conversation, facilitated by video technology, and hopefully get the same important information out of that interaction.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Miles J. Varn: Yeah, so I’ve said this before: Medicine is an art as well as a science, and physicians, including myself, are certainly not perfect. We’re all imperfect, and as a result, not intentionally in any way. I’m sure for every physician, the last thing they’d like to see is a patient who’s harmed by their decision-making. It certainly happened to me in the ER, no question about that.

And so I would say, be humble, accept your weaknesses for what they are, and take advantage of what’s out there in the world to help engage the patient, other ways to protect them from our weaknesses. It’s all about the patient in the end. It really is. Anything we can do to help them get a greater understanding, greater information, and better evidence is going to make you feel better as a practicing physician, and it’s certainly going to make your relationship with that patient better and better.

Kevin Pho: Miles, thanks again for coming back on our show and sharing your time and insight.

Miles J. Varn: Kevin, thanks for having me. I appreciate it.

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