'Mrs. Jones, we need to talk …'Talking about suspicious lesions

Sept. 1, 2008
This year, more than 34,000 AMERICANS WILL LEARN THEY HAVE ORAL OR PHARYNGEAL CANCER and 8,000 will die from the disease.

by Sandy Roth

For more on this topic, go to www.dentaleconomics.com and search using the following key words: oral cancer, cancer, early detection, suspicious lesions, oral or pharyngeal cancer.

This year, more than 34,000 AMERICANS WILL LEARN THEY HAVE ORAL OR PHARYNGEAL CANCER and 8,000 will die from the disease. Many of these patients will not have become aware of their condition until after it has progressed significantly, metastasizing to other locations in the body and thus increasing their pain, suffering, and likelihood of death. Because tobacco use continues in many forms and human papillomavirus (HPV) has become more prevalent, it is expected that these numbers will only increase in the future. Many of these deaths could be prevented with early detection, simple biopsies, and lifestyle changes. Yet sadly, many cases are not spotted early enough for medical interventions to be effective. The dentist, dental hygienist, and dental assistant are the first line of defense for oral cancer, but because roughly one-third of Americans still fail to see a dentist even once a year, a number of these cases will go unrecognized until late stage.

Oral cancer is especially dangerous because it can appear suddenly and mimic other benign oral lesions. The early detection training a dentist and his or her dental team receive is vital in determining which lesions warrant further investigation and which do not, thus saving lives. While dentists and dental hygienists receive training in oral pathology — and are required to identify cancerous lesions on board examinations — many do not expect to see frequent cases in the day-to-day practice. This surely will change, and these professionals will be called upon more often not only to spot potential oral cancer lesions, but also to engage patients in a discussion about how to proceed.

Most dentists and hygienists routinely conduct an oral cancer screening, but my guess is that a relatively small percentage of these clinicians do so openly and verbally, ensuring that patients know the service is being delivered. While many dentists and hygienists may inform a new patient that an oral cancer screening is being conducted at the initial examination — and possibly even suggest that one will be included at each visit — it is rare to hear the clinician routinely announce the follow-up oral cancer screening each time it is conducted. This is a serious mistake.

If patients are not aware that you are intentionally delivering this important service, they cannot appreciate your efforts. Even when the results are negative, as will be the case most often, the patient must be informed that the screening has been concluded and the nature of the results. The more verbally descriptive the clinician is, the more engaged and participative the patient will remain. The description of the screening itself should be in lay language, and the clinician should describe what he or she is looking for and why the screening is being done. For example, if the patient is a smoker or smokeless tobacco user, one would certainly be prompted to include that information in the report to the patient.

"Mr. Jones, because you are a tobacco user, we will want to be especially diligent in examining all of your tissues for any signs of oral cancer or other lesions. Today I'm checking your cheeks, gums, tongue, and the insides of your mouth to see if there are any even small lumps, bumps, or noticeable changes. I am pleased to report that nothing seems to have changed from the last time I saw you. Each time we're together, I'll be sure to provide another complete oral cancer examination to make sure that nothing goes unnoticed."

This now commits you to a methodical and openly verbal oral cancer examination at each visit. The patient has a right to expect it, and it must be included in your clinical protocol.

What if you find something "suspicious"?

Under most circumstances the report will be a good one, but on rare occasions, you may find something that causes you to want to learn more. Because this is not news we expect patients want to hear, many people are in a quandary as to how to approach discussing the findings with their patients. Before we get to the specifics of what to say and how to say it, let's go through a few items.

Aren't you glad you found it? You bet! This is a pure, unadulterated success. The lesion was there whether you found it or not. This "find" should make your day. Do you wish it weren't there? Of course. Are you glad you found it? Absolutely. Better for it to be there and you find it than it to be there and you miss it. Hands down. No contest.

It is or is not oral cancer. You do not know at this point and you cannot do anything about whether it is or is not cancer. If it is oral cancer, you may have saved this person's life. If it is not oral cancer, that is good news and the nature of the lesion can be determined and addressed.

The patient must be informed and informed immediately. You do not have an option. The only exceptions to this rule would be a minor child or a mentally incapacitated adult. Under these conditions, you must notify the caregiver or guardian immediately. To withhold information is wrong; patients deserve to know what you have found, what concern it raises for you, and what you propose next. Please note that you must make every effort to ensure that you are well-educated on how to identify suspicious lesions; if you are rusty, remedy that problem. A dental hygienist might certainly rely on the dentist to review the finding and confirm the next steps, but if the hygienist is not able to distinguish between healthy and unhealthy tissue, there is a serious problem in the practice.

You must convey concern without panic. While finding a lesion is not an automatic death sentence, you must be clear and direct without histrionics. Concern is different than fear, and you must communicate with seriousness without causing the patient to panic. Of course, the patient is free to respond as he or she will. One cannot control how the patient might react; on the other hand, one can unnecessarily escalate a situation if one is not careful.

You must have a protocol in place for handling these issues. Just as you likely have an escape plan for fire or an emergency protocol for a patient in cardiac arrest, you must also have a plan in place for addressing suspected lesions. If a brush biopsy is your preferred strategy, make sure you have sufficient kits and clear instructions about how to complete this simple procedure. If referral to an oral surgeon or other specialist is more to your liking, have a clear path to getting the patient seen in a timely way and ensure that pathology reports are directed your way once they are completed. Your protocol must also include specific documentation so your records are clear and complete.

What do you say?

While this may not be the easiest conversation, it may well be the simplest one. The conversation must include some questions and might flow like this.

Mrs. Jones, I'm noticing a small spot on your cheek that I don't remember seeing before. I just checked my notes from your last visit and it was not there the last time I saw you. Are you aware of it?

Mrs. Jones' answer will be either "yes" or "no." If the answer is "yes," you must further inquire by asking how long it has been there, how it feels, whether the lesion has changed any, and what, if anything, may have precipitated it. Then move on to what you propose to do now. However, if the answer is "no," simply move on to what you are proposing. The hygienist will want the dentist to have a look at the finding. The dentist will then either order an in-office procedure (i.e., brush biopsy) or an extra-office procedure (referral, biopsy, etc.). Again, the person speaking to the patient must convey concern with clarity and simple, understandable language.

Mrs. Jones, this spot/lump is not something I would expect to see, and I want to make sure we know exactly what it is. I am glad we found it, and this is why we conduct an oral cancer screening each time you are with us. Of course, we have no way of knowing the exact nature of this particular lesion, which is why we must find out what it is. Today, I propose to do what is called a brush biopsy that will be sent this afternoon to the pathology laboratory. They will send us a report that will tell us what this actually is. While I don't wish to alarm you, I do feel this is something that must be attended to right away. Or …

Mrs. Jones, this spot/lump is not something I would expect to see, and I want to make sure we know exactly what it is. I am glad we found it, and this is why we conduct an oral cancer screening each time you are with us. Of course, we have no way of knowing the exact nature of this particular lesion, which is why we must find out what it is. Today, I propose that we call Dr. Oral Surgeon and arrange a time for you to see her very soon. She will have a look at this as well and likely will take a small sample of the cells for the pathologist to study. They will send us a report that will tell us what this actually is. While I don't wish to alarm you, I do feel this is something that must be attended to right away.

The important thing is that you gain the patient's agreement to proceed with the next step. While there may be some people who will resist, they will be few and far between. Most people will be concerned and agree to the next step without further persuasion. For this reason, there will rarely be a reason to use stronger or more fear-producing language or approaches, and this should be avoided at all costs. Should you find the patient reticent, simply return to your simple message.

Mrs. Jones, I should repeat that while I don't wish to alarm you, I do feel this is something that must be attended to right away. I do not want you to be under the impression that I think this is something we should watch for a while or wait to address. Your mouth is trying to get our attention, and it certainly has mine. My job is to report suspicious findings and do everything possible to encourage you to address it. In my mind, this is really not an option.

You must be prepared for people to be afraid or worried. That is normal. Having said that, you cannot be afraid that people will be afraid. Your responsibility is clear. Examine, diagnose, convey your findings, and make recommendations. Having done that, you will have done your duty.

For more information about the profession's efforts with oral cancer prevention and diagnosis, please visit www.dentaleconomics.com/oralcancer.

Sandy Roth is a frequent contributor to Dental Economics®. She writes, consults, and speaks about communications and patient and staff relations. She has more than 26 years of experience working with dentists and teams as well as presenting learning experiences for study clubs and dental groups. Roth can be reached at (800) 848-8326 or at [email protected]. Her Web site is www.prosynergy.com.

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