Guest Columnist Dr. Roy Sessions – The Journey from the Referring Doctor to the Oncologist: An Anxious Time

RoySessionsPhysicians and dentists generally send those patients with suspected or confirmed cancer to oncologists*. Referrers can be primary care doctors, gynecologists, endocrinologists, pulmonologists, gastroenterologists, otolaryngologists, dermatologists and others. Not uncommonly, at the time of the initial visit with a surgeon or one of the other oncologists, the patient is unclear as to whether they have a malignancy. Many of them have been told, but they did not hear what they didn’t want to hear. This reflects something I wrote in an earlier blog – the brain is an effective filtration system for frightening information.

In situations in which there is suspicion but no proof of cancer, the referring doctor may have told the patient, “You have a problem,” or “You have a tumor,” or “You have a growth,” but often the realistic possibility remains unclear or even has been denied in the patient’s mind; and let’s not forget (this should not come as a surprise) that many doctors seek to avoid delivering bad news. While that might seem like an abdication of one’s responsibility, it’s actually correct for them to skirt around the cancer or malignancy words until proof is actually established. In most patients, the use of slightly evasive terms such as “a problem, a tumor, a growth” is enough, unless for some reason, the next step of arranging for an oncologist is inordinately delayed, in which case it is more difficult to be vague. However, even if such is not the case, the patient will sometimes push the referring physician to speculate – this tricky conversation should be avoided! If the patient asks directly, “Could it be malignant?” the physician should be honest with a simple yes—after all, why else would the patient be referred to a cancer specialist? The physician’s mere concern raises the patient’s anxiety level, and it is generally wise for the referring doctors not to speculate on likelihood or other specifics. One is tempted to comfort such a patient, but on many occasions, the attempt introduces unrealistic expectations or conversely, greater anxiety. In certain circumstances, however, it is appropriate for the physician to offer general data that is favorable and that might give a patient cause for hope during this interim period. For example, approximately 80 percent of “incidentally” discovered breast masses in women turn out to be nonmalignant. This is a widely known fact, but a well – timed emphasis on it can be emotionally helpful to a frightened woman. Similar optimism is possible in a patient with a parotid (salivary) gland tumor, in which about 75 percent are benign. Quoting such generic data when sending the patient for a diagnostic procedure or to an oncologist is different from specifically making predictions about that particular patient’s mass. In the case of a potentially ominous tumor—a pancreas mass for instance— no real value is gained by quoting such generic data i.e. the dismal statistics associated with this particular tumor. In many cancers, the probability of cure is directly related to stage (degree of advancement), and in the process of quoting statistics, the bad as well as the good has been included in the calculus – that too should be considered in the attempt to help with generic data. All things considered, better the patient be properly worked up and staged before the prognosis is bantered about. Then, and only then, is it wise to discuss real data and specific outcomes i.e. prognosis.

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