Table 2.

Main outcomes relating to primary care component of the oral cancer diagnostic journey

Publication detailsStudy design and participant informationPrimary care focusOutcome relating to primary care
Scott et al, 2005 UK26Structured interviews
245 patients with oral cancer
Stage of disease at diagnosis by referring healthcare professionalStage at diagnosis by referring HCP:
GP:
  Stage I or II: 41.3%
  Stage III or IV: 58.7%
  (stage I/II versus stage III/IV):
  OR 1.85, 95% CI = 0.8 to 4.1
Dentist:
  Stage I or II: 56.6%
  Stage III or IV: 43.4%
  or (stage I/II versus stage III/IV): 1.0 (reference)
Scott et al, 2006 UK27Semi-structured interviews
17 patients with oral cancer
Deterrents from accessing GP/dental practiceNarrative as provided by patients:
‘I was having trouble getting an NHS dentist and didn’t want to pay for an expensive private dentist’ ‘Nearest appointment at dentist was over a week, so I didn’t bother’
Rogers et al, 2007 UK28Case-series analysis
559 patients with cancer of the mouth or oropharynx
Length of delay in sending referral from primary to secondary care
Time interval from presentation in primary care to referral being sent
Referral delay by referral destination
Interval between primary care consultation and referral being sent to secondary care:
78% (n= 253) of referrals were sent on the same day as the consultation (GP and dentist)
11% (n= 36) of referrals were sent 21 days after the consultation
If referral was delayed by at least 1 day, the median time for the referral to be sent was 17 days (IQR 7 to 42 days)
Interval between first presentation in primary care and referral being sent to secondary care:
GP:
  n= 194
  mean 22 days, IQR 12 to 48
Dentist:
  n = 174
  mean 22, IQR 9 to 65, P= 0.48
  Referral delay by referral destination:
Delay was found to be 1 week longer if sent to a peripheral hospital compared with the regional maxillofacial unit or university dental school
Crossman et al, 2016 UK29Structured postal questionnaire
161 patients with oral cancer
Barriers in visiting a primary medical practitioner
Actions from first consultation with GP
Barriers to visiting a doctor:
‘I didn’t realise the problem or symptoms were serious’ 77% (n= 74)
‘I was too worried about what the doctor might find’ 6% (n= 6)
‘I was too busy to make time to go to the doctor’ 4% (n= 4)
‘I was worried I was wasting the doctor’s time’ 3% (n= 3)
‘I was too scared to go to the doctor’ 2% (n= 2)
‘I found my doctor difficult to talk to’ 1% (n= 1)
Actions from first consultation with GP:
53% (n= 58) referred to a specialist at a hospital clinic
22% (n= 24) referred for tests
12% (n= 13) treated for another condition
7% (n= 8) symptom not serious, told to come backif continued
5% (n= 5) symptoms not serious, not told to comeback if continued
1% (n= 1) sent straight to hospital the same day
Schnetler, 1992 UK30Case-series analysis
96 patients with oral cancer
Presence of delay by referring HCP
Correct diagnosis by referring HCP
Practitioner working diagnosis
Other HCP management
Delay by referring HCP (delay defined as > 2 days from physical examination):
Dentist: 62.0% delayed (n= 24/39)
GP: 36.0% delayed (n= 18/50)
Hospital doctor: 14.3% (n= 1/7)
Correct diagnosis by referring HCP:
Dentist: 20.5% correct (n= 8/39)
GP: 52.0% correct (n= 26/50)
χ2 test P<0.01
Practitioner working diagnosis:
Malignancy:
  GP: 52% (n= 26)
  Dentist: 20.5% (n= 8)
Infection:
  GP: 22% (n= 11)
  Dentist: 31% (n= 31)
White patch:
  GP: 8% (n= 4)
  Dentist: 10% (n= 4)
Chronic ulcer:
  GP: 4% (n= 2)
  Dentist: 5% (n= 2)
Other actions from first consultation with HCP:
Antiviral medication:
  GP: 30% (n= 15)
  Dentist: 33% (n= 13)
Topical steroids:
  GP: 4% (n= 2)
  Dentist: 3% (n= 1)
Carbamazepine:
  GP: 2% (n= 1)
  Dentist: 0% (n= 0)
Dental work:
  GP: 0% (n= 0)
  Dentist: 23% (n= 9)
Hollows et al, 2000 UK31Case-series analysis
100 patients with oral cancer
Length of delay in sending referral from primary to secondary care
Interpretation of referral urgency by secondary care
Length of delay in sending referral from primary to secondary care:
GP: mean 14.5 days, SD 32.3, range 0 to 173 days
Dentist: mean 8.4 days, SD 17.6, range 0 to 90 days
69% of patients were referred within 1 week by primary care physician (GP and dentist)
Interpretation of referral urgency by secondary care:
Dentist: 7% interpreted as urgent
GP: 27% interpreted as urgent
2= 2.6, 1 df, P= 0.05)
Kaing et al, 2016 Australia34Case-series analysis
101 patients with oral cancer
Initial referral destination from first consultation with HCP
Actions from first consultation with HCP
Total diagnostic delay by referring HCP
Initial referral destination from first consultation with HCP:
Referral to oral medicine surgeon:
  Dentist: 78.6% (n= 33/42)
  GP: 49.1% (n= 26/53)
Referral to other dental specialist (oral medicine, periodontist):
  Dentist: 40.5% (n= 17)
  GP: 20.8% (n= 11)
Referral to another medical specialist:
  Dentist: 0% (n= 0)
  GP: 20.8% (n= 11)
Referral to dentist:
  Dentist: 0% (n= 0)
  GP: 11.3% (n= 6)
Actions from first consultation with HCP:
Antibiotic prescription:
  Dentist: 40.5% (n= 17/42)
  GP: 47.2% (n= 25/53)
Ulcer management:
  Dentist: 35.7% (n= 15)
  GP: 24.5% (n= 13)
Extraction:
  Dentist: 28.5% (n= 12)
  GP: 0% (n= 0)
Reassurance/monitoring:
  Dentist: 11.9 % (n= 5)
  GP: 7.5% (n= 4)
Biopsy:
  Dentist: 0% (n= 0)
  GP: 7.5% (n= 4)
Diagnostic delay by referring HCP:
  Dentist: mean 5.8 months, range 0 to 3 years
  GP: mean 5.3 months (3.5 months excluding outliers), range 0 to 8 years
Jovanovic et al, 1992 Netherlands32Case-series analysis
50 patients with oral cancer
Length of delay by first HCP consultedLength of delay by first HCP consulted:
GP (n= 27):
  0–4 weeks: 81.5%
  5–16 weeks: 14.8%
  >16 weeks: 3.7%
Dentist (n= 12):
  0–4 weeks: 67.0%
  5–16 weeks: 25.0%
  >16 weeks: 8.3%
Kowalski et al, 1994 Brazil35Structured interviews
336 patients with cancer of the mouth or oropharynx
Stage of disease at diagnosis by referring HCPStage of disease at diagnosis by referring
HCP:
GP:
  Stage I or II: 27.3%
  Stage III or IV: 72.7%
Dentist:
  Stage I or II: 14.3%
  Stage III or IV: 85.7%
Peacock et al, 2008 US40Case-series analysis
50 patients with oral cancer
Primary care component of diagnostic journeyTime from the patient visiting a primary care clinician to undergoing a biopsy or being referred
Mean 35.9 days, range 0 to 280 days
Groome et al, 2011 Canada36Case-series analysis
2033 patients with oral cancer
Stage of disease at diagnosis by dentist/doctor statusStage of disease at diagnosis by dentist/doctor status:
Participants responding ‘yes’ to ‘do you have a regular dentist?’:
  Stage I (n= 661): 39.9%
  Stage II (n= 550): 34.0%
  Stage III (n= 289): 34.6%
  Stage IV (n= 524): 32.1%
  P= 0.03
Participants responding ‘yes’ to ‘do you have a family doctor?’:
  Stage I (n= 660): 92.6%
  Stage II (n= 550): 96.0%
  Stage III (n= 288): 97.6%
  Stage IV (n= 523): 92.2%
  P= 0.001
Wildt et al, 1995 Denmark37Structured questionnaire
167 patients with oral cancer
Patient preference of primary medical contact for oral symptomsPatient preference of primary medical contact for oral symptoms:
  GP: 45% (n= 75)
  Dentist: 35% (n= 58)
  ENT specialist: 14% (n= 23)
  Other: 7% (n= 11)
Tromp et al, 2005 Netherlands33Structured interviews
306 patients with cancer of the mouth or oropharynx
Stage of disease at diagnosis versus length of referral delayStage of disease at diagnosis versus length of referral delay (stage I and II versus stage III and IV):a <1 month: 107 versus 50 (OR 1.00)
  1–3 months: 49 versus 29 (OR 1.22, 95% CI = 0.69 to 2.17)
  >3 months: 35 versus 18 (OR 1.10, 95% CI = 0.57 to 2.13)
Kantola et al, 2001 Finland38Case-series analysis
75 patients with oral cancer
Actions from first HCP consulted with
Stage of disease at diagnosis
Stage of disease at diagnosis, based on referral patterns
Referral actions: first HCP consulted with:
  Referred for further examination: 65% (n= 49)
  Scheduled follow-up only: 16% (n= 12)
  No referral or follow-up: 19% (n= 14)
Stage of disease at diagnosis:
  Stage I and II: 41% (n= 31)
  Stage III and IV: 59% (n= 44)
TNM stage and malignancy grade at diagnosis, based on referral patterns (median):
  Referred (n= 49):
  Stage I and II: 51% (n= 25)
  Stage III and IV: 49% (n= 24)
  Average malignancy grade: 10 (range 7 to 16)
Not referred but followed up (n= 12):
  Stage 1 and II: 16% (n= 2)
  Stage III and IV: 84% (n= 10)
  Average malignancy grade: 12 (range 9 to 14)
Neither referred nor followed up (n= 14):
  Stage I and II: 28% (n= 4)
  Stage III and IV: 72% (n= 10)
  Average malignancy grade: range 9 to 16, P= 0.02
Onizawa et al, 2003 Japan39Case-series analysis
144 patients with cancer of the mouth or oropharynx
Delay in referral by HCP
Stage of disease at diagnosis by referral delay
Delay in interval between first presentation to HCP and referral by HCP (defined as >6 days)
Dentist:
  Delay: 55.3% (n= 47)
  No delay: 44.7% (n= 38)
  OR 1.0, 95% CI = referent
GP:
  Delay: 51.7% (n= 15)
  No delay: 48.3% (n= 14)
  P= 0.739, OR 0.87, 95% CI = 0.37 to 2.02
T category of disease at diagnosis, based on delay/no delay in referral from primary care (defined as >6 days)
T1 category:
  Delay: 66.7% (n= 16)
  No delay: 33.3% (n= 8)
  OR 1.0, 95% CI = referent
T2 category:
  Delay: 51.9% (n= 27)
  No delay: 48.1% (n= 25)
  P= 0.231, OR 0.54, 95% CI = 0.20 to 1.48
T3 category:
  Delay: 29.6% (n= 8)
  No delay: 70.3% (n= 19)
  P= 0.010, OR 0.21, 95% CI = 0.06 to 0.69
T4 category:
  Delay: 48.8% (n= 20)
  No delay: 51.2% (n= 21)
  P= 0.165, OR 0.48, 95% CI = 0.17 to 1.36
Kerdpon et al, 2001 Thailand41Structured questionnaire
161 patients with oral cancer
Actions from first consultation with HCPActions from first consultation with HCP:
Referral or biopsy: 52.2% (n= 84)
Medication (non-antibiotics): 28.6% (n= 46)
Antibiotics: 9.3% (n= 15)
Dental work: 5.0% (n= 8)
Reassurance: 0.6% (n= 1)
  • a Referral delay is defined as period between first contact with GP/dentist and first contact with a medical specialist. CI = confidence interval. df = degrees of freedom. ENT = ear, nose, and throat. HCP = healthcare professional. TNM = tumour, node and metastasis. IQR = interquartile range. OR = odds ratio. SD = standard deviation.