Interdisciplinary Team Approach to Care for Oropharyngeal Cancer: A Dental Hygiene, Nursing and Medical Student Case for Problem Based Learning
Shannon Mychael; Ibraheem Othman; Kathy Sauze; and Osama Souied
Background: About This PBL Case
Problem-based learning is the learning that results from the process of students working toward the understanding or resolution of a problem. Healthcare professionals require the lifelong skill or capability to work through difficult and often unique patient problems (Barrows & Tamblyn, 1980). This case is designed for interdisciplinary learning of 3rd-year dental hygiene, 2nd-year practical nursing (or a 3rd-year bachelor of science in nursing), and 3rd-year medical students. Students should initially work through the referral process, the diagnosis of oropharyngeal cancer related to HPV including management, and then move on to addressing follow-up and nursing care.
More than 75% of all head and neck cancers originate in the oral cavity. In 2019, oral cancer was newly diagnosed in approximately 5,300 Canadians and was responsible for 1,450 deaths. Like most cancers, the incidence of oral cancer rises with age and risk factor duration, with patients/clients over 60 years of age being at greatest risk. However, the incidence of oral cancer is now increasing in persons younger than 40 years of age, likely due to changing risk factors (e.g., HPV infection) (CDHO, 2020).
Day 1
Case Info
Jessi is a 37-year-old Caucasian single mother of 2. She is of low socioeconomic status and has not seen a Dental Hygienist or Dentist in over 5 years due to the cost. She now has employment that offers basic health benefits, including dental. As she is now able to afford basic dental care, Jessi decides to start with having her teeth cleaned as she is unhappy with the color of her teeth, though she is a non-smoker. She attends the Primary Care Clinic in her community, which practices under an Integrated Care Team model, involving Oral Health. During her initial visit with the Dental Hygienist, an extraoral and intraoral examination (EOE/IOE) is performed. During this examination, a lesion is noted on the right palatine tonsil.
Tutor Probes
To be used by the tutor to facilitate discussion if required:
- Why is obtaining the health history important?
- What questions would you ask Jessi about her health history? Why?
- Who would you make a referral to? Why?
- At what point would a referral be made? Why?
- What are the potential pathologic causes of the lesion?
- What initial assessments do you anticipate from the interdisciplinary care team and from whom? Why?
- What tests or diagnostics would you anticipate the physician would order? Why?
- Why do dental hygienists play an important role in oral health?
- Would the initiation of non-invasive dental hygiene procedures be contra-indicated? Why?
- What is important to know about Jessi’s social support system? Why?
Wrap-Up Questions
- As an interdisciplinary team, what would be your top priorities for Jessi?
- What do you communicate to Jessi during this visit?
- What supports do you offer her? Why?
Day 2
Case Info
The Dental Hygienist notified the Licensed Practical Nurse and Jessi’s family physician at the Primary Care Clinic of their findings. A follow-up appointment was made with Jessi and her family physician/general practitioner (GP) to discuss a referral to an Otolaryngologist (ENT specialist) for further investigation. Jessi agreed and was able to see the ENT the following week at the hospital located 1.5 hours away from her home community. During this visit, a right palatine tonsil biopsy was performed. The biopsy was sent to the pathologist and they confirmed squamous cell carcinoma, HPV positive. Jessi underwent further investigations, including CT imagery of her neck, chest, abdomen, and pelvis.
Jessi was extremely distressed awaiting the results. Fortunately, the results were negative for metastatic disease but showed a 3 cm right cervical lymphadenopathy. The ENT brought her case to the multidisciplinary Head and Neck Oncology rounds at the hospital, which took place the following Thursday in the presence of many ENT surgeons, medical oncologists, radiation oncologists, nutritionists, pharmacists, nurses, speech therapists, and social workers. The team reviewed her imaging scan results and gave further recommendations for management.
Tutor Probes
To be used by the tutor to facilitate discussion if required:
- Why would the ENT physician order a CT scan for Jessi?
- Would the management be different if the CT scan showed metastatic disease? How?
- What is the stage of her cancer?
- In your opinion, what is the etiology of her cancer (risk factors)?
- What role does Nursing play in the acute and long-term care of Jessi?
- Why is it important to have a medical oncologist and radiation oncologist in this interdisciplinary team?
- Why do you think a social worker is needed in the interdisciplinary team?
- What role would dieticians and nutritionists play in Jessi’s health management plan?
- What oral care should be advised prior to any treatment?
- Who else should be part of the interdisciplinary team and what role would they play in her care?
- What treatment options do you anticipate from medical and radiation oncology? Why?
Wrap-Up Questions
- How do you determine if this cancer is curable?
- How does Jessi living 1.5 hours from the hospital impact care?
- Why does the approach to care involve multiple disciplines?
- What is the prognosis of her disease?
Day 3
Case Info
After discussion with the ENT, Jessi has opted to move forward with treatment. They have chosen to treat Jessi through surgical intervention to remove the tumor, followed by 6 weeks of either chemotherapy or radiation therapy (to be determined post-surgery). Her surgery is booked to take place in one week. She is glad that she is getting treatment so quickly but concerned about how long she will be in hospital, and who will care for her children for the duration of her stay. After her visit with the ENT, she mentions to the nurse at the hospital that she is glad “they caught this early and she will be cured after surgery.” She attends a pre-operative appointment with her surgeon and members of the interdisciplinary team two days before her surgery.
Tutor Probes
To be used by the tutor to facilitate discussion if required:
- Why would Jessi need surgical intervention? What exactly requires surgery?
- What factors would be considered if chemotherapy and/or radiation therapy is appropriate in addition to surgical intervention? Why?
- Would Jessi need immunotherapy (new cancer treatment)? Why?
- Depending on post-surgical treatment options, what considerations would need to be taken in terms of fertility? Why would this be important?
- What are some potential solutions to Jessi’s concerns about child care during her hospital stay? Who would be involved in assisting her with this planning?
- What do you perceive Jessi’s understanding of her treatment to be?
- What education is needed prior to undergoing treatment? Who would be responsible for providing this?
- What oral care should be advised following surgery and any chemotherapy and/or radiation therapy?
- What are the expected side effects of the treatment? How can they be managed?
- What are the potential acute complications from radiation therapy to the head and neck?
- What are the potential complications from head and neck surgery?
- What psychosocial problems might Jessi encounter?
Wrap-Up Questions
- How long would you anticipate the full treatment course will take?
- What barriers to treatment might exist, and how can they be addressed?
- Do you think that Jessi can live a normal life after her treatment is completed? Why?
References
Barrows, H.S., & Tamblyn, R.M., (1980). Problem-based learning: Rationale and definition. In Problem based Learning: An Approach to Medical Education, p. 1-18. Springer Publishing Company. Total pages 206.
CDHO. (2020, January, 27). Oral Cancer, Disease/Medical Condition. College of Dental Hygienists of Ontario. Retrieved November 6, 2021, from https://www.cdho.org/Advisories/CDHO_Factsheet_Oral_Cancer.pdf
