Warning signs of laryngeal cancer

In an analysis of over 800 patients diagnosed with laryngeal cancer, Shephard and colleagues from the University of Exeter found that symptom combinations may have a higher predictive value for a cancer diagnosis than single symptoms alone. The predictive value of persistent sore throat plus either dysphagia, dyspnoea, or otalgia is greater than 5%, compared with the predictive value for hoarseness alone of 2.7%. Patients with hoarseness and abnormal inflammatory markers on blood testing have a particularly high (15%) likelihood of cancer. 

Professor Willie Hamilton, one of the authors, explains: ‘This research matters – when NICE guidance for cancer investigation was published there was no primary care evidence to guide NICE, or GPs. Crucially, hoarseness serious enough to be reported to GPs does warrant investigation. Furthermore, some symptom combinations previously thought to be low-risk are now shown to matter.’

General practice has been getting a bad press

In an analysis of over 400 news articles on general practice and 100 on hospital specialties, general practice articles depicted the service as being in crisis, with low morale, high burnout, and gaps in patient care. GPs were portrayed as being responsible for the crisis and the resulting negative impact on patient care. Hospital specialties were also illustrated as being under pressure, but the crisis was depicted as being the fault of the government. GP leaders were reported as usually defending their specialty, while hospital doctors were usually sharing their expertise. Researchers Eleanor Barry and Trish Greenhalgh from the University of Oxford comment that there is a need to counter the depiction of general practice as disorganised and inefficient, and that realistic messages about the funding crisis need to be conveyed. Organisation of primary care services to compensate for the worsening GP shortage could and should be depicted in a more positive light. Further research is needed to understand how these negative media messages can be countered and replaced by a more evidence-based picture of primary care.

Antibiotic prescribing may need a different approach

Attempts to reduce antibiotic over-prescribing have been met with limited success. A new study indicates that addressing overall practice prescribing, including other types of medicine, has the potential to be more effective than focussing only on antibiotics. Professor van Staa and team at The University of Manchester, as part of the Greater Manchester Connected Health City research programme, studied prescriptions issued in over 6500 practices and found that practices which were high prescribers of other medicines gave 60% more antibiotics prescriptions than low-prescribing practices. A practice’s prescribing rates of non-opioid painkillers and benzodiazepines were strong indicators of the level of antibiotic prescribing. New approaches to modifying prescribing patterns could include integration of pharmacists within practices, regular reviews of overall prescribing behaviour, and comparison with similar practices.

Oral cancer: falling through the cracks

Delay in oral cancer diagnosis is common and affects survival. Differences in 5-year mortality rates based on staging are marked, with >80% survival in those with localised disease, compared with <30% in those with advanced disease. Wilcock and colleagues analysed 16 studies in which patients presented to a GP or dentist. Patients had 2 to 3 consultations before they were referred to a specialist, whether they initially saw a GP or a dentist. At present, NICE guidance includes referral of patients suspected of having oral cancer from GPs to dentists, and, rather confusingly, recommends that patients with an unexplained persistent mouth ulcer for more than 3 weeks are referred to a cancer specialist. If a GP refers a patient to a dentist, the emphasis is placed on the patient to attend, regardless of whether they are registered, can afford to pay, or whether there is one readily accessible. Clearer advice and referral pathways are needed to improve early detection. Also see: Dental problems need more coordinated care.