Audit of referrals for head and neck cancer - the effect of the 2-week, fast track referral system

Insomnia, depression and anxiety in patients urgently referred with suspicion of head and neck cancer

OBJECTIVE

To determine differences in insomnia, depression and anxiety between ENT patients with benign and malignant conditions prior to and after an urgent suspicion of cancer appointment.

METHODS

Out-patients with urgent suspicion of cancer completed three psychometric questionnaires prior to their appointment and at two to four weeks post-diagnosis.

RESULTS

There was no significant difference in questionnaire scores between malignant and benign patients prior to the patients' appointments (p > 0.05 for all questionnaires). In benign patients, there was significant improvement in scores for all questionnaires (p < 0.01) and in malignant patients there was significant worsening of scores for all questionnaires (p < 0.01) at follow-up appointments.

CONCLUSION

Prior to appointments, patients with benign and malignant conditions experienced similar levels of insomnia, depression and anxiety. Following diagnosis, cancer patients had significantly poorer scores, indicating worsening of these symptoms. In patients with benign diagnoses, all questionnaire scores improved, indicating resolution of their symptoms and possible association between the appointment and their baseline scores.

Impact of primary care triage using the Head and Neck Cancer Risk Calculator version 2 on tertiary head and neck services in the post-coronavirus disease 2019 period

OBJECTIVE

This study investigates the impact of primary care utilisation of a symptom-based head and neck cancer risk calculator (Head and Neck Cancer Risk Calculator version 2) in the post-coronavirus disease 2019 period on the number of primary care referrals and cancer diagnoses.

METHODS

The number of referrals from April 2019 to August 2019 and from April 2020 to July 2020 (pre-calculator) was compared with the number from the period January 2021 to August 2022 (post-calculator) using the chi-square test. The patients' characteristics, referral urgency, triage outcome, Head and Neck Cancer Risk Calculator version 2 score and cancer diagnosis were recorded.

RESULTS

In total, 1110 referrals from the pre-calculator period were compared with 1559 from the post-calculator period. Patient characteristics were comparable for both cohorts. More patients were referred on the cancer pathway in the post-calculator cohort (pre-calculator patients 51.1 per cent vs post-calculator 64.0 per cent). The cancer diagnosis rate increased from 2.7 per cent in the pre-calculator cohort to 3.3 per cent in the post-calculator cohort. A lower rate of cancer diagnosis in the non-cancer pathway occurred in the cohort managed using the Head and Neck Cancer Risk Calculator version 2 (10 per cent vs 23 per cent, p = 0.10).

CONCLUSION

Head and Neck Cancer Risk Calculator version 2 demonstrated high sensitivity in cancer diagnosis. Further studies are required to improve the predictive strength of the calculator.

The impact of 2 weeks wait referral on survival of head and neck cancer patients

PURPOSE

This study aims to evaluate the association between 2 weeks wait referral and survival in the head and neck cancer.

METHODS

Retrospective cohort study of consecutively discussed new head and neck cancer patients at large United Kingdom Cancer Alliance including two tertiary referral hospitals and two district general hospital.

RESULTS

A total of 276 cancer patients were included for analysis. Patients referred under the 2 weeks wait had were seen and diagnosed sooner from referral (p < 0.0001 and p < 0.0001 respectively). However, this did not translate into better survival outcomes. No survival differences were seen between those patients that were managed within the proposed cancer targets and those that were not.

CONCLUSIONS

The 2 weeks wait head and neck cancer pathway did not offer a survival advantage. Targeting the delay in referral as well as delay in treatment to prevent late-stage cancer presentation is paramount. Fulfilment of cancer time targets do not translate into better outcomes and should not be prioritised to clinical judgement.

'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.

Two week wait referral criteria - heading in the right direction?

OBJECTIVES

The National Institute for Health and Care Excellence referral guidelines prompting urgent two-week referrals were updated in 2015. Additional symptoms with a lower threshold of 3 per cent positive predictive values were integrated. This study aimed to examine whether current pan-London urgent referral guidelines for suspected head and neck cancer lead to efficient and accurate referrals by assessing frequency of presenting symptoms and risk factors, and examining their correlation with positive cancer diagnoses.

METHODS

The risk factors and symptoms of 984 consecutive patients (over a six-month period in 2016) were collected retrospectively from urgent referral letters to University College London Hospital for suspected head and neck cancer.

RESULTS

Only 37 referrals (3.76 per cent) resulted in a head and neck cancer diagnosis. Four of the 23 recommended symptoms demonstrated statistically significant results. Nine of the 23 symptoms had a positive predictive value of over 3 per cent.

CONCLUSION

The findings indicate that the current referral guidelines are not effective at detecting patients with cancer. Detection rates have decreased from 10-15 per cent to 3.76 per cent. A review of the current head and neck cancer referral guidelines is recommended, along with further data collection for comparison.

Persistent Unilateral Sore Throat: Should It Be Included in the 2-Week Wait Referral Criteria by NICE

Design and Setting

A retrospective study was conducted on all 2WW referrals made to our tertiary head and neck centre in a 12-month period.

Methods

Sensitivity, specificity, and PPV of presenting complaints in H&N cancer diagnosis using Excel® and the statistical package SPSS®.

Results

The sensitivity and specificity of 2005 NICE guidelines in detecting H&N cancers were 91.2% and 59%, respectively; their PPV was 9%. The sensitivity and specificity of 2015 NICE guidelines were 75.4% and 71%, respectively; their PPV was 10.3%. Eight out of 85 patients who presented with unilateral sore throat for more than 4 weeks, with or without otalgia and normal otoscopy, had H&N cancer (PPV 9.5%).

Conclusions

Although the 2015 NICE guidelines have a high rate in detecting H&N cancers, consideration of reincluding unilateral sore throat in the referral criteria might be necessary.

Outcomes of urgent suspicion of head and neck cancer referrals in Glasgow

INTRODUCTION

Primary care patients with a suspected head and neck cancer are referred through the urgent suspicion of cancer referral pathway. Rates of cancer detection through this pathway are low. Evidence surrounding the pathway of these patients is lacking. This study aimed to determine the outcome of urgent suspicion of cancer referrals for head and neck cancer.

METHODS AND METHODS

All head and neck cancer urgent suspicion of cancer referrals in NHS Greater Glasgow and Clyde between June 2015 and May 2016 were analysed in regard to their clinical pathway.

RESULTS

There were 2116 urgent suspicion of cancer referrals in the one-year period. The overall cancer rate was 235 (11.8%), compared with 152 (7.6%) that resulted in a primary head and neck cancer diagnosis. Of the total, 851 (42.6%) were reassured and discharged after one clinic appointment; 536 (26.8%) were followed up for suspected benign pathology and 436 (21.8%) were actively investigated for cancer.

CONCLUSION

A significant proportion of patients attending urgent suspicion of cancer clinic appointments can be seen and discharged in one clinic appointment, provided there is same day imaging available. Cancer identification rates through urgent suspicion of cancer pathways remain low.

The value of chest X-ray in the Scottish Referral Guidelines for suspected head and neck cancer in 2144 patients

Objective:

In Scotland, patients with suspected head and neck cancer are referred on the basis of the Scottish Referral Guidelines for Suspected Cancer, rather than the National Institute for Health and Care Excellence guidelines. A chest X-ray should be requested by the general practitioner at the same time as referral for persistent hoarseness. The evidence for this is level 4.

Methods:

This audit identified adherence to this recommendation and X-ray results. All ‘urgent suspicion of cancer’ referrals to the ENT department in the National Health Service Greater Glasgow and Clyde for 2015–2016 were audited.

Results:

Persistent hoarseness for more than 3 weeks instigated referral in 318 patients (15.7 per cent). Chest X-ray was performed in 120 patients (38 per cent), which showed: no abnormality in 116 (96.7 per cent), features of infection in 2 (1.7 per cent) and something else in 2 patients (1.7 per cent). No chest X-ray altered the management of a patient.

Conclusion:

Performance of chest X-ray does not alter management and its removal from the Scottish Referral Guidelines for Suspected Cancer is recommended.

A web-based prediction score for head and neck cancer referrals

OBJECTIVE

Following the announcement of the NHS Cancer Plan in 2000, anyone suspected of having cancer has to be seen by a specialist within 2 weeks of referral. Since this introduction, studies have shown that only 6.3%-14.6% of 2-week referrals were diagnosed with a head and neck cancer and that majority of the cancer diagnoses were via other referral routes. These studies suggest that the referral scheme is not currently cost-effective. Our aim is to develop a scoring system that determines the risk of head and neck cancer in a patient, which can then be used to aid GP referrals.

DESIGN

Retrospective data were collected from 1075 patients with 2-week head and neck cancer referrals from general practitioners. The retrospective data collected included patients' demographics, risk factors and relevant investigations. The data were used as input into a logistic regression to arrive at our model. Our approach included data analysis, machine learning techniques, statistical inference and model validation metrics to arrive at the best performing model. The model was then tested with more data from 235 prospective patients.

RESULTS

Using our results from the logistic regression, we created a web-based tool that GPs can use to calculate their patient's probability of cancer and use this result to assist in their decision regarding referral. Our prototype can be seen in Figure 2.

CONCLUSION

We have created a prototype scoring system that can be hosted online to assist GPs with their referrals with a sensitivity of 31% and specificity of 92%. While we acknowledge that there are several limitations to our model, we believe we have created a novel preliminary scoring system that has the potential to be improved dramatically with further data and be very helpful for GPs in a long run.

The Danish Head and Neck Cancer fast-track program: a tertiary cancer centre experience

INTRODUCTION

During the 1990s, all Nordic countries except for Denmark experienced a general increase in 5-year survival rates for cancer patients. In 2007, the Danish National Board of Health in collaboration with national multidisciplinary cancer groups and the Danish regions initiated fast-track clinical pathway solutions.

OBJECTIVES

The objectives of this study were 1) to present the setup of the head and neck cancer (HNC) fast-track program at Odense University Hospital (OUH) as an example of the Danish model and 2) to present patient characteristics, diagnostic outcome, cancer detection rate, and duration of the fast-track patient courses.

MATERIALS AND METHODS

From 1st July 2012 to 1st September 2015, all patients referred to the HNC fast-track program at OUH for diagnostics and treatment were consecutively included in the study resulting in 3165 patient courses.

RESULTS

The overall malignancy detection rate was 40.6% and for HNC it was 29.2%. The overall median fast-track course duration was 12 days (range 0-74). Overall 2990 (94.5%) of 3165 patients completed their fast-track course within the maximally permitted course duration.

DISCUSSION AND CONCLUSION

Based on our findings, it was concluded that: 1) a HNC fast-track program build on pre-booked slots for diagnostics and treatment is feasible and can secure acceptable course durations for more than 90% of patient courses, 2) by using private ENT specialists as a 'filter-function', an acceptable detection rate can be achieved.

Views of general practitioners and head and neck surgeons on the referral system for suspected cancer: a survey

BACKGROUND

The two-week wait referral system for suspected cancer was introduced in the National Health Service in 2000. This study aimed to identify areas for improvement to the two-week wait system by seeking the opinions of doctors working in primary and secondary care.

METHOD

A questionnaire was distributed to general practitioners and head and neck surgeons within North West England with ethical consent.

RESULTS

Twenty-seven general practitioners and 15 head and neck surgeons responded. Of the general practitioners, 59.3 per cent declared that they never attend training on referrals in this specialty. Overall, 59.3 per cent of general practitioners and 86.7 per cent of head and neck surgeons felt that the two-week wait system could be improved.

CONCLUSION

The main areas for further work are development of pre-referral communication between primary and secondary care along with development of practical educational measures for general practitioners.

Two-week referrals for suspected head and neck cancer: two cycles of audit, 10 years apart, in a district general hospital

OBJECTIVE

To analyse trends in two-week rule referrals for head and neck cancer over 10 years.

METHOD

Data from two-week referrals received by the Wirral University Hospital NHS Trust between 1 January and 30 June 2012 were compared with similar data from 2002.

RESULTS

A total of 357 referrals were received during the 6-month audit period, compared with 149 during the whole of 2002. Cancer pick-up rates were 9 per cent and 5 per cent in the first and second cycles, respectively.

CONCLUSION

The annual number of two-week referrals made to our department increased by over 450 per cent in 10 years, but the resulting cancer pick-up rate fell by nearly 50 per cent. Whilst cancer patients need to be seen quickly, the current system is inefficient in parts. Modifications to the treatment pathway should be considered to improve patient care quality and reduce pressure on ENT departments.

A multidisciplinary audit of head and neck referrals: considerations for patients' timelines and outcomes

The Rapid Diagnostic Clinic (RDC) was introduced to comply with NICE recommendations for improving head and neck cancer services (National Institute of Clinical Excellence 2004 Improving outcomes in head and neck cancer: the manual. NICE, London). It provides multi-modality specialist assessment for new referrals, with on-site sonography and cytology. We have critically appraised the efficacy of our RDC, with respect to its impact on patients' timelines and outcomes. A retrospective audit of new referrals to the head and neck clinic during a 6-month period was conducted (pre-RDC period); areas in delay in patients reaching a definitive outcome were identified. Following implementation of the RDC, a second cycle, prospective audit was performed and its impact on timelines for patients' journey and outcomes determined. One hundred and ninety-seven patients were seen during the pre-RDC period. The average time from referral to being seen was 11 days for 2-week wait (2WW) referrals and 34 days for other sources. During the RDC period, 299 patients were seen in total. The average waiting time was reduced to 9 days for 2WW referrals and 23 days for other referrals. During the RDC period, over one-third of patients utilised the provision of ultrasound ± FNAC, and consequently, the majority reached a definitive outcome (discharged or scheduled for surgery) following their first consultation. This was a significant improvement compared to the pre-RDC period, where the main outcome was referral for an investigation, with consequently longer waiting time for surgery. We report the first study to consider the effect of a 'one-stop' clinic on patients' journey timelines and outcomes. Our study has shown that the RDC provides an efficient and effective system, which facilitates the patients' pathway to a definitive management plan.

A Head and Neck 'Two-Week Wait' Clinic: Cancer Referrals or the Worried Well ?

Head and neck cancer affects approximately 8–15 per 100,000 of the UK population, with marked regional variations. There is good evidence that early detection improves prognosis but unfortunately many of the initial symptoms are often non-specific. In 2000 the NHS Cancer Plan introduced the 'two-week wait'(2WW) rule to increase the speed with which patients with suspected cancer are seen by a specialist.

Two Audits of the Diagnosis of Oral Cancer and the Two-Week Rule following Referrals from Primary Care Practitioners in Newcastle

Aim

The aim of the two audits was to evaluate the success of the two-week rule in the oral and maxillofacial surgery (OMFS) department at the Newcastle General Hospital (NGH) and then subsequently in the oral surgery and oral medicine departments at Newcastle Dental Hospital (NDH).

Methods

All two-week referrals seen at the NGH over a one-year period were examined retrospectively. An identical subsequent audit was carried out at the NDH over a second one-year period, also retrospectively.

Results

In the initial audit at the NGH, a total of 63 two-week referrals were received during the one-year period analysed. Of these, 57 (90%) were seen within the appropriate time period, and 60 (95%) conformed to the Department of Health guidelines. Seven (11%) of the 63 referred patients were diagnosed with head and neck cancer, indicating a positive oncology detection rate of 11%. In the later audit at the NDH, 49 urgent referrals were assessed. Forty-three of the 49 referrals (88%) were seen within the appropriate time period and thirty-nine (80%) were compliant with the referring guidelines. Forty-five patients attended for assessment and the resultant positive oncology detection rate for these patients was 7%. In both audits, the patients diagnosed as having positive oncology results all had referrals that were compliant with the Department of Health guidelines.

Conclusions

Both of these audits indicated that the national guidelines for two-week referrals were usually appropriately followed in the two departments that were audited. However, in the future, further education of referring practitioners should ensure that these guidelines are followed better, making the service provided more efficient for all concerned.

Do GP referral guidelines really work? Audit of an electronic urgent referral system for suspected head and neck cancer

We adapted the 2002 Scottish Referral Guidelines for suspected squamous cell carcinoma of the head and neck (SCCHN) as a set of "alarm symptoms." These were then incorporated into a new Suspected Cancer Urgent Referral Electronically (SeCURE) system enabling immediate electronic referral from primary care to the appropriate hospital-based multi-disciplinary cancer team. All referrals made via the SeCURE system during the first year of its implementation were reviewed retrospectively. One hundred and ninety patients were urgently referred, of whom 15 (8%) were ultimately diagnosed with SCCHN. This audit demonstrated overall poor compliance with the referral guidelines. Although the electronic referral system helped for speedy clinic appointments, there was a low pick up rate of positive head and neck cancer cases. Continuing education for GPs is important and following discussion with colleagues in primary care, steps have been taken to reinforce awareness and more appropriate use of the SeCURE system.

The Effect of Increasing Two-Week Wait Referrals for Head and Neck Cancer in East Kent

In 1998 the UK government published its white paper The New NHS: Modern and Dependable, in which it first suggested that patients being referred with a suspicion of cancer should have a maximum wait of two weeks to see a specialist. The rationale for this was that outcomes for late-stage disease are significantly worse when compared with outcomes for early-stage disease (Table 1). It was assumed that reducing the wait to see a specialist would reduce the stage of disease at presentation.

How we do it: Analysing GP referral priorities: the unforeseen effect of 'Choose and Book'

The introduction of Choose and Book may have a significant effect on the proportion of urgent referrals seen by ENT surgeons. Much of the responsibility for prioritisation will be transferred to the GP. Patients who are considered urgent by the ENT surgeon will be added to those considered urgent by the GP. Our results show that there was little agreement between GPs and ENT surgeon on what constitutes an urgent referral. The combined effect of joint prioritisation and the removal of the 'soon' category resulted in a 270% increase in 'urgent' referrals in our sample. This potentially unforeseen consequence of the Choose and Book system should be taken into consideration by ENT departments to allow for an expansion of the 'urgent' category.

Referral guidelines for suspected cancer of the head and neck

OBJECTIVE

To identify the impact of referral guidelines for head and neck cancer on the economics and effectiveness of the delivery of care.

METHODS

A retrospective review of the literature was performed to examine the current referral guidelines and referral models that have impacted the delivery of care.

RESULTS

Advances in technology and changes in the diagnostic work up of head and neck cancer require that common symptoms and presentations of head and neck cancer are made available to primary care physicians to improve the expeditious referral of head and neck cancer patients.

CONCLUSION

Physician awareness and symptom guidelines may prove effective in expediting the care of patients with head and neck cancer.

The 2-week wait for suspected cancer: time for a rethink?

The 2-week rule, stating that patients with suspected cancer should be seen by a specialist within 2 weeks of referral by their General Practitioner, was introduced in the UK in 2000. Although it has been the subject of much interest in the literature, to date there has been no review of the literature. A thorough literature review was undertaken using the medline database, from January 2000; further references were obtained from the reference lists of relevant papers. Some studies have demonstrated a reduction in the waiting times to see specialists, and in some cases time to treatment, and have commented on the potential psychological benefits to patients. However, concerns have been raised over the often low yield of malignancy and the high proportion of malignancies still being diagnosed outside the 2-week wait system. There is, as yet, no evidence that the initiative impacts on survival.