I received a call from an out-of-state doctor while in the middle of my clinic. He usually does not call me during that time, unless it’s important.
“I would like to send one my friends to you…” He paused for a moment.
“Absolutely, I will be more than happy to see her.” I didn’t hesitate.
“She is a nurse at the hospital where I work. I have known her for more than 10 years. She saw a local oncologist who was very negative; she did not like his attitude. I asked her to come see you.”
“Samantha” was in my clinic the next day. When I walked in, she asked her husband and daughter to leave the room.
She looked very pale and emaciated. She had dark circles around her eyes. She is only 44 years old, but she looked much older. A faint smile spread across her face.
Before I talk about cancer with a new patient, I like to understand her more.
“I have been working as a nurse for the past 15 years, and I have two teenage daughters and a 4-year-old son … he was a surprise!” She laughed.
“I felt the lump in my left breast about six to eight months ago.”
Samantha paused for a minute to take a deep breath. With each breath, I could see her neck veins getting prominent and chest muscles tightening.
She had a large ulcerating mass in her left breast. When I removed the dressing, blood oozed out from the skin. She had significant tenderness of her lower spine. Scans from an outside hospital showed spots in her lung and spine. Samantha had stage IV breast cancer.
She kept her composure throughout my examination. After the examination, I talked to her in detail about the stage, treatment plan and prognosis.
“We are going to beat this cancer, doctor!” Samantha was looking for my reassurance.
“Absolutely, that is the plan. But we need to get more information. We need more scans, biopsy, blood tests…” I explained.
Before leaving the room, I paused for a moment. Usually I try not to ask this question. But with Samantha, after spending more than an hour discussing the diagnosis and treatment, I knew we had established a mutual respect and trust.
“I’m just curious.” I paused for a moment. “Why didn’t you see someone when you noticed the lump?” I was very careful with my tone, as I didn’t want to come off as judgmental or accusatory. I can never fully understand why people make certain decisions; I don’t walk in their shoes. So I try not to judge when a patient comes in with a large neglected tumor or advanced disease.
“I was just busy, doc … my girls were in high school. They were struggling. I couldn’t just leave them,” Samantha lowered her voice and was almost talking to herself.
“Then my mom got sick, and no one was there to take care of her.” She looked out through the window. I could see tears filling her eyes.
“I was just scared, doctor … just scared. I knew this was cancer. I am a nurse, I should know better…”
“It’s OK, Samantha. I will do everything possible to take excellent care of you.”
I’m fascinated by how patients make decision to see doctors. Some patients call the doctor’s office with every ache and pain. Other patients wait until very late. When is it the right time to seek help? Why do people delay in getting help, even after they know the inevitable?
I used to think it was all about awareness and access. But Samantha had everything. She had insurance and access to health care, and was well aware of what to do — or not do.
Studies have looked at factors that influence delay in cancer patients seeking care. The first study to look at this phenomenon was published in 1938 by Pack and Gallo, entitled The Culpability for Delay in the Treatment of Cancer. Almost 70 years later, the authors of a 2006 study published in the British Journal Cancer found the same reasons for delayed diagnosis. Nothing had changed in 70 years!
It could be driven by patient factors and health care factors. Common patient factors include lack of access due to financial reasons, fear, denial and lack of trust with the modern medical system. Health care factors include wrong diagnosis and delay within the health care system — something providers need to pay attention to.
Every year, about 10,000 to 20,000 women walk into the doctor’s office with stage IV breast cancer. Screening options are limited in lung cancer, liver cancer, pancreatic cancer and many other cancers; late diagnosis is not unusual in those cancers. Breast cancer is a different story, as there are multiple proven screening options. But there are also a large number of patients from poor socioeconomic societies who wait and seek care in late stage, when a cure is not an option.
I don’t fully understand why Samantha chose not to see a doctor six months ago, but I believed her when she explained her health did not reach the top of her priority list. We can’t correct the past — we can only fix the future. Our role as physicians is to continue to earn the trust of Samantha and all of our patients, and provide excellent care for them.
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Why We Shouldn’t Wait to See the Doctor originally appeared on usnews.com
