Prostate Cancer Institute

With prostate cancer now the most common internal cancer in Australia, many men will find themselves in the awkward position of seeking a second opinion.

Although a second opinion is the right of every cancer patient, seeking it is not always a comfortable process. It's a vulnerable time for men and they don't want to risk offending the sensitivities of the doctor who may be treating them.

But now there are so many treatment options with so many troubling side effects that making a decision can be harrowing, particularly if the man is still trying to cope with the shock of the diagnosis.

One of the first things to realise is that there is no need to rush into a quick decision. As prostate cancer is generally a slow-growing malignancy, most men can safely spend up to three months learning about the disease, consulting with appropriate specialists and deciding which side effects they can live with.

While any diagnosis of cancer deserves a second opinion, it is pertinent for prostate cancer because the man is probably going to have to live with the consequences of his decision for the next 20 years and "lack of regret" will be very important.

Some men want to leave their treatment decision to their doctor. They believe their doctor knows best and have faith he will act in their best interests. This gives them comfort and they need no other opinion.

Other man can't find peace of mind until they know they've checked all the options and are making an informed decision. For them, there is a steep learning curve and work to be done seeking other views. Arriving at a balanced view might mean getting a third or even fourth opinion.

With prostate cancer, doctors often don't agree on which treatments work best and are more likely to recommend the option that they specialise in. Back in 2000, a now well-known American study of 1000 specialists showed that when presented with a man with early-stage prostate cancer who was expected to live at least 10 years, more than 90 per cent of urologists recommended surgery, while more than 70 per cent of radiation oncologists said radiation would be just as effective as surgery.

John Hopkins University in the United States says if these specialists don't agree, a man could always consult a medical oncologist who specialises in cancer treatment but does not perform surgery or deliver radiation.

Another option is to see a second urologist or radiation oncologist because doctors of the same specialty often have different approaches to treatment. Just as there are different forms of radiation, so there are different ways of removing cancerous prostate tissue.

The university notes that an advantage of seeking a second opinion at a centre that specialises in prostate cancer is that a pathologist will review the biopsy slides. Accurate interpretation of the slides is essential because it forms the basis for treatment decisions.

Sometimes pathologists make mistakes. In one study at John Hopkins, pathologists reviewed biopsy samples of 535 men who were awaiting a radical prostatectomy. They reclassified seven of the men as being cancer free. Further investigation showed six of the seven were indeed free of prostate cancer and their surgery was cancelled.

The university suggests men ask their primary doctor or the urologist who performed the biopsy to refer them for a second opinion, preferably to a colleague affiliated with a different hospital. This is not essential but is prudent because doctors who work at the same institution often share similar views and may be reluctant to contradict one another.

There is also the question of whether a better result could be obtained at a centre that focuses on prostate cancer. The New England Journal of Medicine recently published a study confirming that outcomes for prostate cancer are generally more favourable at high-volume centres.

Second opinion prostate cancer clinics have been popping up all over the US and offer to confirm the diagnosis, discuss treatment options, help men select the best course of action and introduce men to medical experts who can treat them.

While no such clinics are advertised in Australia, some prostate cancer departments in major hospitals provide the service through individual specialists who can then take the case to a meeting of their peers to confirm the best treatment.

Every Thursday afternoon, The Prostate Cancer Institute at Sydney's St George Private Hospital runs a clinic where men can obtain a second opinion from urologists, radiation oncologists and a specialist nurse. Please call (02) 9587 4888 for more information.

Paul Cozzi, a urologist and senior lecturer in surgery at the University of NSW, says men come in from country NSW and other states and spend the afternoon going through treatment options.

Those who consult him are generally seeking an opinion about their suitability for nerve-sparing surgery or a nerve graft to preserve potency.

If their initial biopsy was limited, Cozzi often requires that they be re-biopsied under general anaesthetic so several new tissue samples can be taken.

He recently took part in a study that found that the new biopsy altered the surgical approach in 53 per cent of patients considering a nerve-sparing operation who had limited initial biopsies.