Sir, I must at the outset congratulate the author for the interesting article that appeared in your December edition in the Sounding Board section: The Trend to Seek a Second Opinion Abroad amongst Cancer Patients in Oman: Challenges and opportunities. This article outlined the possible negative consequences in terms of outcomes for cancer patients which can arise if they seek a second opinion abroad. These can be due to travel delays, inappropriate treatment, etc.1 I agree with the author’s view that the problem should be studied further in order to arrive at solutions. A simple questionnaire given to the patients going abroad or returning from their treatment could easily help us understand their reasons and concerns. Accordingly, solutions could be implemented and the outcome of these observed. Although most of the possible motives and probable solutions have been discussed, I am writing to add a few more thoughts from a surgeon’s perspective. Health care seeking behaviour is strongly influenced by family values and recommendations, and the family plays a central role in the decision making of Omanis.2 Having noted this, when it comes to a cancer, many of our patients are not made aware of their diagnosis on request of their family members. A typical Omani family is large and well-knit. No single member wants to make a decision especially when it comes to cancer surgery. They do not want to be responsible should something go wrong. In addition, family members would like to enable the patient to obtain the best treatment, which they think is abroad. The ordinary Omani is under the impression that in Oman they would be operated upon by trainees. They are also not confident of the skills of Omani doctors trained abroad. While the author has noted that a second opinion is desirable in some less common cancers, this is true even for surgical oncology. Surgical skill being directly proportional to the volume, it is appropriate for demanding operations like surgery for oropharyngeal and oesophageal malignancy be performed at specialised high volume oncology centres. While awaiting a well-designed study to identify the problem fully and arrive at solutions, we should strive to establish a good rapport with the patient and his family. The dialogue should be simple and sincere. This would improve the patient’s trust and confidence in local health providers. Centres liaising with high volume oncology hospitals should be opened where patients can seek another opinion for a nominal fee. With improved technology, facilities like telemedicine can allow the transfer of large data X-ray and pathological investigations. These can be of immense value and decrease the delay in the treatment. In a community where word of mouth is a popular means of dissemination of information, I believe the well-placed affluent section of the community should set a trend by seeking treatment at home rather than travelling abroad. Additionally, we can setup a social networking platform on the Internet. Satisfied patients who had their treatment in Oman can not only express their experiences, but also address the concerns of patients who are awaiting their treatment. This would eliminate any bias which the patients may have regarding the treatment offered by the care providers. SQU Med J, August 2010, Vol. 10, Iss. 2, pp. 276-277, Epub. 19th Jun 10 Received: 13th Mar 10 نزعة احلصول على رأي ثان من اخلارج يف عالج مرضى السرطان يف عمان: حتديات وفرص براديب كوبرا Re: The Trend to Seek a Second Opinion Abroad among Cancer Patients in Oman Challenges and Opportunities Pradeep Chopra letter to editor Pradeep Chopra Letter to Editor | 277 Pradeep Chopra Department of Surgery, Sultan Qaboos University Hospital, Muscat, Oman. Email:chopradeep@gmail.com References 1. Burney IA. The trend to seek a second opinion abroad amongst cancer patients in Oman: Challenges and opportunities. SQU Med J 2009: 9:260–3. 2. Al Mandhari A, Al Adawi S, Al Zakwani I, Al Shafee M, Eloul L. Relatives’ advice and health care-seeking behaviour in Oman. SQU Med J 2009; 9:264–71. Author’s Response I thank Dr Chopra for his letter, and expressing a surgeon’s perspective. He has raised the issue of surgical volumes, and suggested that the demanding operations should be done at specialised high volume centres. I agree, and would like to add that for several cancers, high volume surgeons are regarded as independent prognostic factors in terms of outcome of those cancers. However, the process of reaching appropriate centres is the core issue, which formed the basis of my article.1 Patients and families travelling abroad without seeking a specialist opinion at home, may and do travel to centres which are not necessarily high volume centres, or centres of excellence, for that particular type of cancer. The hospitals selected by the patients and families through geographical proximity, travel planners, front offices, or word of mouth, are likely to be at best as well equipped as the best hospital in the home country. Furthermore, the delay in travel arrangements and discomfort of travel with an advanced cancer, my even reduce the chances of a favorable outcome. Dr Chopra suggests that the usual decision makers, the family members, do not want to take the responsibility for the outcomes of surgery, and think that the best treatment is available ‘abroad’, and hence the reason for travel. He further suggests the notion that many people think that the patients would be operated upon by trainees, or by doctors who are not very skillful. While many of these factors may urge the family members to take their beloveds to centres where presumably only very skillful surgeons would operate, and where ‘a cure is available’, all these reasons for travel remain speculative. Studied systematically, many of the fears and anxieties could be allayed by proper communication and counselling. I agree with Dr Chopra that telemedicine facilities should be used for speedy transfer of data to centres of excellence to seek a second opinion, if needed, and this would prevent delays in commencing the treatment. This was also suggested earlier; however, this facility in many instances could be utilised by the oncologist/oncological surgeon on behalf of the patient, but only if the opinion was sought in the home country first. This is certainly an option worth considering. Ikram Burney Department of Medicine & Health Sciences, Sultan Qaboos University Hospital, Muscat, Oman. Email: ikramburney@hotmail.com References 1. Burney I A. The trend to seek a second opinion abroad amongst cancer patients in Oman: Challenges and opportunities. SQU Med J 9:260-3.