Physicians and dentists generally send those patients with suspected or confirmed cancer to oncologists*. These 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 did not 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 by the patient. It should not be surprising that many doctors seek to avoid delivering bad news, and in my opinion it’s correct for them to skirt around the cancer or malignancy words until proof is actually established. In most patients, the use of the 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 concern alone 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. 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 referral 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.
Once the cancer word is mentioned, fear takes hold and the patient can become relentless in asking questions that the referring physician is simply unable to answer. Many patients will not ask for speculation or predictions out of fear of hearing dreaded news - others will. In an effort to avoid this trap, the referring physician’s intentional vagueness is understandable; on the contrary this gives the oncologist the latitude to craft a more positive and factually based discussion. However, the suspicion of cancer having been raised, it’s essential that prompt arrangements be made for seeing that oncologist.
Extraordinary circumstances aside, it is unacceptable for there to be more than a one-week delay in seeing the one person who is able to answer the question on everyone’s mind. The same can be said for delays in obtaining a biopsy and, once done, waiting for the result. This can be a period of emotional torment, and I have been appalled to hear of delays of eight to ten days that some patients are asked to endure without an answer. Happily, this does not occur frequently. For those readers unfamiliar with the technologic capabilities of modern diagnostic laboratories, the turnover time for a cytology** or pathology*** decision is one to two days, unless special staining techniques are required. In some other circumstances in which diagnostic uncertainty exists, consultation of other cytologists or pathologists more than justifies delay, some of which can be extensive. Most of the time, however, the period needed for diagnostic completion is short, and it is insensitive to drag this out merely for system convenience or a fixed schedule.
Frequently, lumps and bumps - breast masses, swollen lymph nodes - skin lesions, some lung lesions, kidney and liver masses, and others—can be analyzed by needle aspiration and cytology, the arrangements for, and results of which, can be quickly concluded. Even when a more extensive biopsy is indicated, the initial fine needle aspiration can often provide a preliminary diagnosis of malignant or benign. When surgical biopsy is required, some delay is to be expected; however, real effort should be made to expedite the process. Obviously, the time parameters I cite are arbitrary, and depending on the situation, both the wait for consultation and the wait for the reports can be less or more. In general, however, whenever possible, the sooner the question is answered the better for the patient. We should always be mindful of the emotional agony of uncertainty during this period of limbo. The reader should be clear: I am not promoting time acceleration because of concern for tumor growth—rarely is there a hurry to start treatment. Rather, efficiency and the perception of motion are comforting and reassuring to a frightened patient who is anxious to get on with their lives.
Thoughtless and insensitive delays are entirely different from the time lapse that almost always follows definitive cancer diagnosis—that period in which planning and arrangements are being developed by an oncology team. Ideally, by the end of this period, the patient has a plan of action, and things are moving forward. Importantly, during that time, the patient is occupied with a variety of consultations with the other members of the team, such as other oncologists, nurse educators, nutritionists, dentists, psycho-oncologists, social workers, and others. In the cancer management world of today, the sine qua non of excellence is multidisciplinary care, extraordinary arrangements and preparations, treatment decisions and planning in multidisciplinary tumor boards, and an overall seamless interaction of patient, family, and cancer team.
While it is appropriate for the referring doctor to avoid an unpleasant cancer conversation, such is never the case for the oncologist to whom the patient has been referred. Unfortunately, good communication and the transmission of realistic information are not always accomplished. This situation can reflect a lack of concern of some physicians, or in some cases, a basic lack of a doctor’s communicative skills. Much as when a teacher tries to judge the effectiveness of what has just been explained, the oncologist must be able to recognize a facial countenance that indicates a failure to understand. When dealing with cancer patients, to do otherwise is unacceptable. I refer the reader to my blogs on physician-patient communication that were published in Psychology Today between October 2012 and May 2013. This topic of interpersonal interaction is so important that reviewing it might be of value.
What I call the cancer experience – the suspicion, the confirmation, the workup, the treatment, and the follow-up – is a continuum - a journey, if you will, that involves a sustained commitment by a number of individuals. The emphasis of this blog has been that lonely and scary time between suspicion and proof, up to the stage of treatment.
** The study of cells, usually obtained by needle biopsy or PAP smear. Cytologists are pathologists who have sub-specialized.
*** The study of actual tissue biopsies by a pathologist
1. “Communication Between Doctor and Patient Part I”, October 29, 2012 Blog by R. Sessions in Psychology Today
2. “Doctor and Patient Communication: Part II”, January 2013 Blog by R. Sessions in Psychology Today
3. “Doctor / Patient Communication: Part III”, February 10, 2013 Blog by R. Sessions in Psychology Today
4. “Physician – Patient Communication: Part IV”, March 7, 2013 Blog by R. Sessions in Psychology Today
5. “Doctor/Patient Communication: Part V, April 4, 2013 Blog by R. Sessions in Psychology Today
6. “Doctor-Patient Communication: Part VI, May 14, 2013 Blog by R. Sessions in Psychology Today
Roy B. Sessions, MD, FACS