Head and neck cancers are rare malignancies with presenting symptoms often being relatively non-specific. The 2-week wait (2WW) referral system was implemented to fast-track patients suspected of having a malignancy. The majority of patients are referred by GPs using specific criteria. We aimed to look at the 2WW referrals for suspected head and neck cancer to a district general hospital over a 1-year period. A total of 362 patients were referred using the GP 2WW pathway with 358 (98.9%) seen within the 14-day target, but only 2.76% (10/362) of referrals were subsequently diagnosed with head and neck cancer. This shows a very low pick-up rate when compared to other 2WW referrals audits.1,2 In the 97.24% of patients not found to have a malignancy, there were a vast proportion of patients that did not meet the referral criteria. Interestingly, we identified that a further 10 malignancies were detected in the same period that were not referred through the 2WW pathway, but rather as urgent or routine referrals. Many patients will be given the diagnosis of ‘no cancer detected’ at their initial specialist clinic review while in some cases a malignancy is excluded after relevant investigations. It has been suggested that GPs may be inappropriately using the 2WW referral system in order for their patient to be seen sooner, taking priority over other general ENT referrals. We understand that symptoms of head and neck cancer (such as unexplained new neck lumps, unexplained persistent sore or painful throat, hoarseness of voice for greater than 3 weeks and, unexplained otalgia3) can be vague and be the same for many benign conditions. For example, up to 98% of patients with a hoarse voice will not have a laryngeal malignancy.4 The surprising find is the number of malignancies that were not referred under the 2WW pathway. If we take into account the low pick-up rate and the fact that there were an equal number of malignancies in both groups, it suggests that there are a large number of patients that should have been referred under the 2WW pathway but were not. In our clinical practice we are occasionally receiving clinic referral letters that we have requested the referring GP to upgrade to the 2WW pathway based on the patients' symptoms.
We recommend our GP-colleagues to use their clinical suspicion and refer patients under the 2WW pathway as necessary. This way, even if pick-up rates stay the same or reduce, we will hopefully reduce the number of diagnosed malignancies being detected at a late stage.
- © British Journal of General Practice 2012
