The Referral Process
The Referral Process
What Happens when a Patient has been Referred?
At the first appointment with the specialist, a detailed medical history is taken. The patient then undergoes clinical examination of the oral cavity. In addition to the lesion noted by the referring practitioner, the entire oral cavity is examined carefully for additional lesions.
Following photographic examination, incisional biopsies of the lesion may be taken. It is important that these are carried out by a specialist in the field of mouth cancer as some lesions, e.g. speckled leukoplakia may show areas of malignant change. The histopathologist's report will show whether or not there is any evidence of malignancy or underlying dysplasia (potential malignancy). Based on the information provided by this report a decision will be made regarding the need for further investigation or treatment or whether or not it is appropriate to place the patient on regular review. The patient's medical or dental practitioner may be asked to help with this. General advice regarding tobacco and alcohol consumption may also be given. In some NHS Board areas, smoking cessation programmes are offered.
In the case of a proven mouth cancer, a patient will usually undergo a further examination under anaesthesia (EUA). In this, areas of the pharynx and upper aerodigestive tract not accessible during the initial examination are inspected. Further biopsies of any suspicious lesions may also be taken. It has been estimated that one in ten patients with mouth cancer develop additional tumours elsewhere in the aerodigestive tract.
Radiological investigations, typically involving an MRI or CT scan of the area between the skull base and clavicles, as well as a CT scan of the patient's chest are also carried out. This allows staging of the disease and provides valuable information regarding the extent of the index lesion, as well as demonstrating the presence of metastases in either the cervical lymph nodes or elsewhere in the upper aerodigestive tract.
Once all the information is available, a treatment plan is compiled. This usually takes place at multi-disciplinary case conferences involving a number of specialists including surgical and clinical oncologists. The extent of any surgical resection, as well as the reconstructive options, are outlined. The need for post-operative chemotherapy or radiotherapy may also be discussed, although frequently a definite decision may not be made until after surgery has been performed. The treatment plan will be explained to the patient, together with relatives, and any questions the patient might have regarding particular aspects of treatment will be answered as fully as possible. Clinical Nurse Specialists have a major role to play at this point in the patient's treatment.
Given the nature of the disease, this process occurs in a fairly short time period.
Where malignancy is diagnosed, this information is transmitted urgently to the referring doctor and/or dentist as patients may wish to discuss aspects of their future care with their practitioner. The importance of a team approach to cancer care cannot be overemphasised.