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To see or not to see

Feb. 1, 2012
Allow me to relay the experience of a patient who has been through trying times lately. The patient is a middle-age female ...

Allow me to relay the experience of a patient who has been through trying times lately. The patient is a middle-age female who noticed a small, firm swelling in the right submandibular region. She had never experienced this type of problem before, but since she had an upcoming visit with her family physician, she thought she would mention it. Her family provider told her it appeared to be a swollen lymph node and recommended she schedule an appointment with her dentist in the event that she had an oral infection.

Being conscientious about health issues, this patient did have an examination with her dentist. He advised her that it was a swollen lymph node, but that there were no apparent oral health infections. He reviewed causes of swollen lymph nodes and felt that since she was asymptomatic; the node simply represented residual effects from a cold or allergy condition.

Over the course of the next year, this patient presented on several occasions to both her family physician and dentist with concerns that the lymph node was getting larger. Both health care providers told her to “forget about it,” or “it was nothing.” She felt uncertain about both individuals at this point, but since they seemed to be in agreement that her condition “was nothing,” she heeded their advice.

After several more months and with ever growing concern, the patient presented to her dentist again for further evaluation. At this point, he expressed the opinion that the patient appeared to be “looking for trouble that wasn’t there.” She went to the reception area and commented on that, but paid her bill and proceeded to leave the office. As she was walking to her car, the office receptionist approached her. She stated that since this was a problem that had persisted for over one year, she thought the patient should get a second opinion. The receptionist did not want to get in trouble, but felt that she needed to reinforce the concept of a second opinion. After all, if after a second opinion, this problem truly turned out to be “nothing,” the patient could rest easy.

After hearing this advice, the patient phoned a university in Philadelphia and asked to have an appointment scheduled. She described her problem, and the telephone operator scheduled an appointment for her to see the head of the ear, nose, and throat department of the university. During her appointment with this specialist, the patient described her concern that the node was growing. She denied other symptoms or problems, but explained that she was worried that there was more than “nothing” with this condition.

The patient related that the specialist took one look at her lymph node swelling and told her she was going straight for a biopsy and to an oncologist. Turns out she had stage 4 lymphoma. Since February 2011, she has been on a rigorous course of treatment and still has six more months of chemotherapy to complete. Remarkably, her most recent PET scan showed that she was cancer-free, and her prognosis is good.

So let’s take a moment and think about the lessons we can learn from this patient’s experience. The first thing that comes to mind is that we need to listen, really listen, when our patients present to us with an abnormal finding. This patient was pooh-poohed rather than reassured. There was no effort made to encourage her to see a specialist or have a biopsy. The lesion did not appear to be aggressive in nature.

We have seen the literature that discourages the use of adjunctive screening devices as part of the oral cancer examination, because these devices do not appear to be better than a conventional oral examination. We have seen the literature that warns we should not be using adjunctive devices because we don’t want to alarm our patients that they might have cancer.

However, this case is different. The patient was already alarmed.

Would our role in this situation be to alleviate the patient’s concern or identify the problem? The patient was delighted to have somebody hear her concern and perform a biopsy. She wanted to be reassured that either this problem was truly nothing or was something, and she would receive appropriate treatment. Instead, this process was delayed for one full year while her cancer spread.

A question for us to consider is what harm would have been done if a biopsy had been recommended when the patient first presented with this condition? She was already alarmed. She wanted to know what was wrong. She would have been relieved to have a confirmed diagnosis. Many of our patients feel this way, even if recommending a biopsy seems frightening. The mere idea of a biopsy can be anxiety-producing. But, knowing vs. not knowing is also anxiety-producing. At what point do we reconcile within ourselves that the best course of action is to biopsy? Why guess when we can confirm?

Mind you, there is no need to play the blame game here. This patient has not spent her time on that as much as focusing on getting well. The health care providers who examined her did not feel there was cause for concern. The patient did not present with obvious symptomatology other than the node. Many people walk around with swollen lymph nodes, and they don’t have cancer. An educated guess was made. Unfortunately, for this one person, the guess was wrong.

Take a moment and ask yourself what is your position on this situation? Would you have gone along with the provider’s recommendation to “forget about it” or would you have recommended taking action?

I ask this question because the patient asked me to ask you. She wanted her story relayed because she feels that action needs to be taken immediately when a patient presents with this type of condition. Her story seems to be ending well, but what about the others for whom diagnosis is delayed until it is too late?

Her message to you is to take a chance and recommend referral for biopsy. If the lesion turns out to be “nothing” or benign, that is perfectly fine. If there is a problem, it is identified early and the patient stands a chance of surviving. And that is so much better than worrying for one year and then finding out a diagnosis of advanced cancer.

I want to hear your stories about this type of situation. It is important for all of us to realize that we can make a significant difference by taking immediate action. Also, it is important for us to recognize that going against the prevailing point of view is not always easy, but sometimes very necessary.

JoAnn R. Gurenlian, RDH, PhD, is president of Gurenlian& Associates, and provides consulting services and continuing education programs to health-care providers. She is a professor and interim dental hygiene graduate program director at Idaho State University, adjunct faculty at Burlington County College and Montgomery County College, and president-elect of the International Federation of Dental Hygienists.

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