second opinion

To see or not to see

Author: JoAnn R. Gurenlian

From the National Journal fro Dental Hygiene Professionals:

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.

About the author:
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.

February, 2012|Oral Cancer News|

‘A second opinion saved our lives’ say the patients who refused to accept their GP’s diagnosis

Author: Marianne Power

We all trust our GPs to give the correct diagnosis. But doctors CAN get it wrong – with potentially disastrous consequences. These patients prove you should never be too embarrassed to ask for a second opinion.

We all want to believe what doctors tell us, especially when they’re assuring us that nothing is wrong. But sometimes there remains that niggling doubt – something tells you all is not right.

‘Trusting your instinct is important. Doctors do make mistakes and sometimes you know your body better than anyone else,’ says Dr Graham Archard, vice chairman of the Royal College of GPs.

‘I can remember a patient who was convinced he had bowel cancer, but all the tests came back clear. He wanted a second opinion so we referred him to another consultant for more tests, which showed that he did have cancer.

‘I don’t know if the cancer developed between the first and second appointment or if the first consultant missed it, but the patient’s instincts were right. As a GP I don’t take it personally if someone asks for a second opinion. If any doctor does take offence, they are too full of themselves, and it’s time to stop practising.

‘If you are concerned, first talk to your GP, and allow them to explain how they came to their diagnosis. Sometimes this alone can make you feel better.

‘If it doesn’t, ask to see another GP in the practice or to be referred to a specialist. Do not feel anxious about doing this, it is your right on the NHS to have a second opinion – and no good doctor would stand in your way.’

From the post-natal depression that turned out to be cancer, to the childhood bug that
actually a tumour in the brain, here we tell the stories that prove you should always get a second opinion if you’re in doubt.

Fiona Kennon, a patient liaison officer, 35, lives in Poynton, Cheshire, with her husband, Steve, an engineer, and children Duncan, 11, Donald, nine, and Alice, five. Fiona says:

My GP assured me that as a non-drinker and non-smoker the painful ulcerated rash on my tongue couldn’t be mouth cancer.

But having seen my husband battle testicular cancer in his 30s and my mother die of ovarian cancer, I was worried. Three years before, in 1999, I’d been diagnosed with a benign skin condition, Lichen Planus, which caused rashes in my mouth.

Over the years, whenever a new rash would appear I’d managed it with steroid mouthwash, but shortly after my third child was born, it changed – it looked like a white dab of Tip-Ex. The mouthwash no longer helped and it had become uncomfortable when I ate and brushed my teeth.

Still concerned after six weeks, I saw my GP. I broke down when I told her about my fears that this condition had turned to cancer. I know it sounds dramatic, but I was terrified I would not see my three-month-old baby grow up.

She thought I was suffering from post-natal depression and referred me to a counsellor, and a dermatologist to assess my tongue. By the time I saw the counsellor, after a three-month wait on the NHS, the pain in my tongue was worse.

The counsellor, however, thought it was all in my mind. She told me I didn’t have post-natal depression, I was suffering from ‘health anxiety’ and she referred me for Cognitive Behavioural Therapy. I left feeling confused. Part of me thought ‘Maybe she’s right, maybe this is just in my head’ – but then the other part of me refused to believe it was nothing.

Three weeks later I saw the dermatologist and showed her the small white marks and ulcers on my tongue. By this stage, eating was agony and I had lost more than half a stone. She said it was nothing to worry about, she’d seen a lot of Lichen Planus cases and prescribed a steroid cream – if it didn’t improve in a month, she’d do a biopsy.

Again, I was conflicted. Another doctor was telling me it was nothing and my husband was telling me I was worried unnecessarily. Why, then, was I so paranoid?

As a last-ditch attempt, I made an appointment with my old dentist in Edinburgh. He had diagnosed the original Lichen Planus and knew I wouldn’t make a fuss over nothing.

The minute he saw my mouth, he said my condition had changed considerably and I needed to be seen by an oral surgeon immediately. By that time I’d been waking up with blood on the pillow, but thought I was biting my tongue in my sleep.

He told me to demand a biopsy from my GP. Then, nine weeks later, after biopsies and an MRI scan, I was at Manchester’s Wythenshaw Hospital, having a nine-hour operation to remove half my tongue and several lymph nodes from the left side of my neck.

The biopsy had confirmed a cancerous tumour in my tongue, which had started to spread to my lymph nodes. My worst fears had been confirmed – five months after I first went to my doctor. It turns out the steroid cream that the dermatologist gave me might actually have speeded up the growth of the tumour.

It was a massive operation, but I had complete faith in my surgeon, Mr Manu Patel. It was a few days after the operation before they removed the tracheotomy and I was able to speak. I was expecting my tongue to feel strange, but it didn’t, and after weeks of pureed foods I started to eat solids.

Just four months later, after three weeks of radiotherapy, I was back at work as a language teacher. My speech is 98 per cent the same and you couldn’t tell I’d had half my tongue removed.

It’s now almost five years since I was diagnosed. I never went back to my old GP, even though she did apologise.

My confidence in doctors has certainly been dented. I am paranoid about every ache and pain, but fortunately my history means that I now get checked out fully every few months – and I’m taken seriously. If a time comes when I feel someg is being missed, I’ll insist on a second, third or fourth opinion – whatever it takes.

October, 2008|Oral Cancer News|