M D Anderson Cancer Center will provide no second opinions

Center will stop giving 2nd opinions on cancer
M.D. Anderson says it'll serve only those breast cancer patients who get treatment there
By TODD ACKERMAN
Copyright 2004 Houston Chronicle

The University of Texas M.D. Anderson Cancer Center, long a hospital of last resort for patients with difficult cases, is no longer providing second opinions to breast cancer patients who intend to be treated elsewhere.

M.D. Anderson breast cancer doctors said the decision, at odds with one of medicine's most cherished axioms, is the result of demand outstripping resources. They say it is the best way they know to reduce a one-month waiting time for new patients.

"We want to continue to provide quality care rather than quantity care," said Dr. Gabriel Hortobagyi, chairman of M.D. Anderson's breast medical oncology. "I don't mean to be smug, but we don't want to become the McDonald's of breast cancer."

Hortobagyi said M.D. Anderson sees more than 3,000 new breast cancer patients a year, in addition to those already under its care. He said 30 to 60 people a month are turned away.

M.D. Anderson's pathology department still will provide second-opinion evaluations on tissue samples to confirm diagnosis regardless of where a patient is being treated.

The breast center will give second opinions to patients "considering treatment" there but will refuse patients who acknowledge their plan is to take M.D. Anderson's advice back to their doctors.

Breast cancer patient advocates and health-care policy ethicists questioned the state cancer hospital's policy, saying it raises issues involving patients' rights to access and information and the institution's consistency of application.

"The problem is if they start making exceptions for friends, big shots, people with money," said Dr. Bill Winslade, a University of Texas Medical Branch at Galveston professor of the philosophy of medicine, who also teaches medical ethics at the University of Houston.

M.D. Anderson President Dr. John Mendelsohn said the institution will be "as consistent as possible, allowing those kind of pressures affect any business."

He acknowledged the decision to stop giving second opinions pains him but said M.D. Anderson needed to do something to ensure existing patients' care isn't compromised by overtaxed doctors.

Mendelsohn acknowledged second opinions aren't as profitable as treatment but said that's not the reason M.D. Anderson adopted the policy. A breast cancer second opinion can cost from $200 to $4,000.

Mendelsohn also said he understands that many people will claim they are "considering treatment at M.D. Anderson" even though they aren't. Some patient advocates asked how a patient would know if she intended to go to M.D. Anderson without the second opinion.

"We're going to err on the side of giving patients the benefit of the doubt," said Mendelsohn. "Will that cause patients to take advantage of us? We'll find out. But this is a start."

Mendelsohn said M.D. Anderson's experience is that Texas patients who request a second opinion tend to stay for the treatment but that patients from outside Texas usually stay home.

He said M.D. Anderson will question out-of-state patients about their intentions more thoroughly.

The policy disappointed Jeanne Sather, a Seattle-area woman who recently asked M.D. Anderson for a second opinion for her metastatic breast cancer. She was turned down when she admitted she didn't plan to be treated here.

"I found it very scary," said Sather, who was first diagnosed in 1998.

"Giving second opinions is a huge part of what major cancer institutions do. For one of the top ones to say 'no' makes me worry that other institutions will follow suit."

Historically, M.D. Anderson has attracted patients with resistant cancers from around the country, even the world, because it is considered the top cancer hospital.

M.D Anderson's Web site still includes a page stressing the importance of second opinions to breast cancer patients.

And Hortobagyi said he's spent so much time in the past recommending second opinions, "I feel like I'm speaking out of both sides of my mouth now."

Carolina Hinestrosa, vice president for the National Breast Cancer Coalition, said the policy "ignores the needs of women who want to make informed decisions." She added that it goes against a patient's right to access, information and choice, core values that the coalition has identified.

But not everyone was critical. Notwithstanding the ethical concern he raised, Winslade said, M.D. Anderson's policy sounded like a reasonable balance of resources.

"In the real word of medical-care shortages, people have to be realistic," he said. "Physicians have the right not to take on new patients if that would be detrimental to existing patients."

Mendelsohn noted the new policy also says M.D. Anderson will not provide second opinions to patients in the middle of treatment. Additionally, Hortobagyi said, the institution's preference is for patients who haven't received previous treatment, because such patients respond better than those whose immune systems have become resistant to therapy, though Mendelsohn stressed that is not policy.

Hortobagyi said that M.D. Anderson has at times turned down people for second opinions for breast cancer in the past and have only recently decided to make it a policy.

Though Hortobagyi compared the new policy to "going on drive-by" and M.D. Anderson has plans to add nearly 9,000 square feet of space and additional doctors next year, Mendelsohn acknowledged the policy is likely to be in place for the long haul.

"We want to stay a comprehensive cancer center, not the breast cancer-dominated center we'd have to become to meet the demand," said Mendelsohn. "The fact is, we've become happy victims of our success, overwhelmed by patients who've seen our U.S. News & World (Report) No. 1 rankings. We just have to have guidelines and pathways to respond."