Deprivation in relation to urgent suspicion of head and neck cancer referrals in Glasgow

Outpatient secondary care pathways for head and neck cancer referral result in patient delays for cancer treatment

INTRODUCTION

The majority of head and neck cancer referrals are received through primary care. A proportion of cancer referrals are received through secondary care specialties. Local delivery plan (LDP) targets in Scotland for cancer investigation are set at 31 days for diagnosis and 62 days to start treatment. The aim was to audit referrals made through non-primary care pathways compared with the standard primary care pathways against LDP targets.

METHODS

New head and neck cancer patients between 1 January 2014 and 1 January 2019 were included. Pathway points were recorded between referral to outpatient clinic, time to multidisciplinary team discussion (MDT) and finally MDT to treatment.

RESULTS

1,276 new patient referrals were received over a 5-year period. Of these, 136 (10%) were referred via non-primary care pathways. The mean time for urgent suspicion of cancer (USoC) referrals to start treatment was 77 days (15 days over target) and for outpatient secondary care referrals was 102 days (40 days over target) (p<0.05). When treatment intent was considered, 841/1,131 (75%) of patients referred via primary care were treated curatively compared with 49/99 (49%) (p<0.05) of patients referred through the secondary outpatient pathway.

CONCLUSION

Patients with head and neck cancer referred from other outpatient specialties face delays commencing cancer treatment and are also associated with a greater likelihood of being treated with palliative intent.

Palliation of head and neck cancer: a review of the unique difficulties

Each year, there are 11 900 new diagnoses of head and neck cancers in the UK, with around 4000 deaths. Survival rates are higher for those diagnosed earlier, however, patients are often diagnosed later, with 20% palliative at the time of diagnosis. There is a scarcity of head and neck cancer palliative care literature available. This review article aims to discuss the unique challenges of head and neck cancer palliation. It specifically focusses on the challenges of pain management, airway obstruction, dysphagia, haemorrhage and the psychology of palliative head and neck cancer management. This article explores the advantages and disadvantages of many of the different treatment options available. It is hoped that this article will highlight the unique difficulties encountered by patients with head and neck cancer towards the end of their life and offer insights and suggestions to improve patients' quality of life in their final weeks and months.

The impact of coronavirus disease 2019 on the head and neck cancer pathway in the West of Scotland

Objective

The coronavirus disease 2019 pandemic has greatly disrupted head and neck cancer services in the West of Scotland. This study aimed to assess the impact of the first wave of the pandemic on cancer waiting times.

Methods

A retrospective review of multidisciplinary team records was undertaken between March and May in 2019 and the same months in 2020. Time-to-diagnosis and time-to-treatment for new cancers treated with curative intent were compared between the study periods, and subclassified by referral pathway.

Results

A total of 236 new cancer patients were included. During the pandemic, pathways benefitted from reduced diagnostic and treatment times resulting from the restructuring of service provisions. A 75 per cent reduction in secondary care referrals and a 33 per cent increase in urgent suspicion of cancer referrals were observed in 2020.

Conclusion

Head and neck cancer pathway times did not suffer because of the coronavirus pandemic. Innovations introduced to mitigate issues brought about by coronavirus benefitted patients, led to a more streamlined service, and improved diagnostic and treatment target compliance.

Patterns of urgent hoarseness referrals to ENT-When should we be suspicious of cancer?

BACKGROUND

Current UK referral criteria stipulate that hoarseness should be persistent to merit 2 week wait (2WW) or urgent suspicion of cancer (USOC) referral. This study delineates patterns of hoarseness presentation with a view to assisting referral pathways, and whereby reassurance could be provided.

METHODS

A pre-existing database of patients referred with hoarseness under the urgent suspicion of cancer (USOC) category was analysed. Univariate and multivariate analyses were performed on a variety of demographic and comorbid features to produce odds ratios (OR) of features either related or not related to laryngeal cancer.

RESULTS

Of 698 consecutive hoarseness referrals were studied. In these referrals there were 506(73%) with persistent hoarseness and 192(27%) with intermittent hoarseness. The most significant patient variables related to laryngeal cancer were persistent hoarseness (OR 4.97), recreational drug use (OR 4.94), male gender (OR 4.01) and weight loss (OR 3.75). Significant patient variables present not related to laryngeal cancer diagnosis were intermittent hoarseness (OR 0.2), the presence of cough (OR 0.2), globus sensation (OR 0.25) and recent viral infection (OR 0.29).

CONCLUSION

The strongest association with cancer is seen in patients that are persistently hoarse. Patients with fluctuating hoarseness do not need an "urgent suspicion of cancer" referral. Additional demographic referral information could help to streamline the referral of these patients, and reassure others.

'Urgent suspicion of cancer' referrals to a head and neck clinic - what do patients expect?

BACKGROUND

Public awareness of 'red flag' symptoms for head and neck cancer is low. There is a lack of evidence regarding patient concerns and expectations in consultations for cancer assessment.

METHOD

This prospective questionnaire study examined the symptoms, concerns and expectations of 250 consecutive patients attending an 'urgent suspicion of cancer' clinic at a tertiary referral centre.

RESULTS

The patients' most frequent responses regarding their concerns were 'no concerns' (n = 72, 29 per cent); 'all symptoms' were a cause for concern (n = 65, 26 per cent) and 'neck lump' was a symptom causing concern (n = 37, 17 per cent). The expectations of patients attending clinic were that they would find out what was wrong with them, followed by having no expectations at all. Overall patient knowledge of red flag symptoms was lacking and their expectations were low.

CONCLUSION

Patients with non-cancer symptoms are frequently referred with suspected cancer. Patients with red flag symptoms are not aware of their significance and they have low expectations of healthcare.

Palliative intent treatment for head and neck cancer: an analysis of practice and outcomes

Background

There is little consensus on how best to manage head and neck cancer with palliative intent. Predicting outcome is difficult and reported survival varies. The present study sought to delineate local practice and outcomes in patients treated with palliative intent.

Methods

The clinical records of all head and neck cancer patients treated with palliative intent presenting between 2015 and 2016 to our multidisciplinary team were reviewed.

Results

Eighty-four patients (21.5 per cent) were treated with palliative intent. All had squamous cell carcinoma. Mean survival time was 151 days (standard deviation = 121.1; range, 8–536 days). Of the patients, 83.3 per cent had a palliative care referral; 74.1 per cent had a hospice referral. Patients received a variety of interventions, and there was an associated complication in 8.2 per cent. The mean number of days spent in hospital for interventions was 11.9 days (standard deviation = 12.5; range, 0–41 days).

Conclusion

Different interventions are used to manage head and neck cancer patients with palliative intent, and these may be associated with significant morbidity. Survival time is variable, often several months; thus, any treatment must take into account morbidity in conjunction with the patient's wishes.