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I considered that option as well, it wasn't yet the case as the treatment options were clear, but that's something I have in mind. I looked at the program offered by U of Colorado. Actually, if my mom were to do a rebiopsy, I'd try to send the samples to Colorado (if possible, I don't know if there are problems when sending biological material from another country to US).

If some faculty here have experience with this type of second opinion, I'd have some concrete questions.

1. Who will offer such opinions? A doctor who treats patients or a first-year medical student who offers 10 such opinions for a course assignment?

2. What exactly is such an opinion? I'd be interested to know if the doctors who give such opinions also suggest *new* treatments, that the doctors who treat the patient might be unaware of. The sample report put at Colorado looks impressive, suggesting a clinical trial for crizotinib at a time when no papers about ALK had been published (their lab also identified the ALK mutation in the biopsy). I'm not interested in just having a treatment plan reviewed and explained.

3. If scans are included, does a radiologist review them? Or the doctor just uses the existing report of the radiologist? Also, how can one ensure that the scans are readable, what is a standard format?

In the end, it's also a problem of finding the drugs one needs. For instance, for my mother, any (good) oncologist in this world would say that the best options are AZD 9291 or CO 1686, had they offered a trail in her country or an expanded access program.

Thanks!

The opinions would generally be offered by a faculty member of the medical staff, not a resident or fellow, and certainly not a medical student. I don't think the busiest and highest ranking people will often be doing them -- or if they did, it wouldn't be the best use of their limited time. Instead, it's more likely to be something falling to the more junior members of faculty, with exceptions when someone like stars Drs. Ross Camidge or Nate Pennell, members of the GRACE faculty who work at University of Colorado and Cleveland Clinic, respectively, do remote opinions. I don't think they do many.

What gets offered in an opinion will vary from one institution to another and even from one individual to another in the same center. But the role would include not just rubber-stamping the recommendations obtained locally. If that's the best plan, that'd be corroborated. If the person doing a second opinion had a different recommendation, the person would say as much. Whether the treatment option is available locally is a separate issue that can't be controlled by the person giving a second opinion.

Imaging opinions wouldn't be done by the consulting oncologist. Some radiologists specifically offer second opinion interpretations on imaging, and I know at least some places doing second opinions would offer the opportunity for an opinion on imaging for an extra fee, but that wouldn't be done by a medical oncologist offering a second opinion on general management.

Despite my great interest in the value of a remote second opinion and my hope to develop such a service, I've resigned myself to not being part of any such effort any time soon. Until legal issues around giving opinions to people from another state are settled (my Washington state driver's license has reciprocal rights in Oregon or California, but it's illegal for me to give a medical opinion to someone in CA) and it's reimbursed like a visit in person, telemedicine won't take off.

Good luck.

-Dr. West

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