New NICE referral guidance for oral cancer: does it risk delay in diagnosis?

doi:10.1016/j.bjoms.2016.09.022

British Journal of Oral and Maxillofacial Surgery

Volume 55, Issue 4, May 2017, Pages 404-406

https://doi.org/10.1016/j.bjoms.2016.09.022 Get rights and content

Abstract

Changes to guidance about the two-week wait referrals for suspected cancer of the head and neck have created a new recommendation for a general medical practitioner to refer any patients to a dentist under certain criteria. The potential effect of this was assessed based on 91 referrals to an oral and maxillofacial unit. A total of 33 met the criteria for initial referral to a dentist; of these, one was later diagnosed with cancer. We outline the potential deleterious effects the new guidance might have on the rapid diagnosis of oral lesions.

Introduction

Since the introduction of the two-week wait referral pathway for suspected cancer in 2000, diagnosis of lesions in the head and neck has been below 10%.¹ The updated NICE guidelines (NG12, 2015)² imply that certain presentations, if identified by a GP, should be referred to a dentist for assessment before they are reviewed by a specialist. We compared the application of the new advice against that given in the old guidelines (CG27, 2005)³ on a group of patients referred to an oral and maxillofacial department to assess the potential impact on outcomes.

Section snippets

Method

We made a retrospective audit of all two-week referrals received between July and August 2014; this included an assessment of referral letters, medical notes, and histological results. The outcome measures were, the number of those referrals that met the CG27 and NG12 criteria, and the number diagnosed with cancer. The time taken to be seen, the quality of the referral letter, all clinical and histological findings, and the final diagnosis were also assessed.

Results

A total of 91 referrals were included (52 men and 39 women). Thirty-three met CG27 referral criteria, 33 met NG12 referral criteria, and 25 met both criteria, (Table 1, Table 2). Six of the referred patients were subsequently diagnosed with cancer. All of them met both CG27 and NG12 criteria. Nine referrals met criteria in NG12 guidance that recommended an initial referral to a dentist and of these, one was subsequently diagnosed with cancer. Four referrals reported a lump consistent with oral

Discussion

The same number of referrals met both CG27 and NG12 guidance. Nine from this group would have required GP referral to a dentist under NG12 guidance. Assuming dentists do not refer all these patients on to the two-week wait pathway this could reduce the burden placed on the service. Also in support of this approach, Tikka et al⁴ concluded that red and white patches are a poor predictor of cancer with a predictive value of 4% (although this exceeds the >3% target set by NICE guidance), but that

Conflict of interest

We have no conflicts of interest.

Ethics statement/confirmation of patients’ permission

Not required.

References (7)

S. Langton et al.
Two-week rule in head and neck cancer 2000-14: a systematic review
Br J Oral Maxillofac Surg
(2016)
National Institute for Health and Care Excellence
Suspected cancer: recognition and referral
(2015)
National Institute for Health and Clinical Excellence
CG27 Referral Guidelines for suspected cancer: NICE guideline
(2005)

There are more references available in the full text version of this article.

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Accuracy of the Head and Neck Cancer Risk Calculator in identifying maxillofacial malignancies
2023, British Journal of Oral and Maxillofacial Surgery
The OMFS urgent suspicion of cancer (USOC) referral pathway for head and neck cancer is costly in terms of time and resources, and despite NICE referral guidance, it has a low conversion rate with many inappropriate referrals. The Head and Neck Cancer Risk Calculator version 2 (HaNC-RC-v2) gives recommendations to primary care referrers on appropriate referral priority. To our knowledge, this is the first study to investigate the accuracy of the HaNC-RC-v2 in a cohort of maxillofacial referrals. Electronic patient records were reviewed for all malignancies diagnosed by OMFS in 2019 (n = 54), and a sample of USOC referrals to OMFS (n = 204). The HaNC-RC-v2 was applied to each patient, using information from the referral letter and the clinical notes from the new patient consultation. The mean and median HaNC-RC-v2 scores for patients with malignancy were 42.22% and 32.23%, respectively. For patients without malignancy, mean and median scores were 9.27% and 5.68%, respectively. There was a statistically significant relation between the presence/absence of malignancy and the recommendation made by the risk calculator (p = 0.0012). The calculator recommended USOC referral for 76% (41/54) of patients with malignancy, and only 41% (83/204) of patients without malignancy. The negative predictive value of the HaNC-RC-v2 was 99.2%. The calculator has the potential to reduce the number of inappropriate referrals to OMFS via the USOC pathway.
Comparison of primary care doctors and dentists in the referral of oral cancer: a systematic review
2020, British Journal of Oral and Maxillofacial Surgery
Citation Excerpt :
The most recent advise that lip lumps, erythroplakia, or leukoerythroplakia are referred initially by GPs to a dentist for evaluation.11 Whilst some work suggests2 that increased GP-dentist collaboration is desirable, others consider that such an approach (whilst potentially reducing the secondary care workload) may result in diagnostic delay. This may be worsened by a lack of formal GP-dentist referral systems and insufficient access to dental care for many patients.66 The earlier stage of diagnosis by dentists in several studies emphasises the important role of dentists and, potentially, regular dental check-ups in the early diagnosis of oral cancer.
Oral cancer is referred to specialists by both general practitioners (GPs) and dentists, with varying proportions reported in different studies. However, some have noted that dentists more commonly refer oral cancer in the absence of patient-perceived symptoms and may refer at an earlier stage. Unfortunately, approximately half the UK adult population do not receive regular dental care. We have conducted a systematic review of studies that compare GPs and dentists in the referral of oral cancer and have focused on three aspects: the proportion of diagnosed oral cancers, stage on presentation, and delay. Searches of the databases Medline, Embase, Scopus, Google Scholar, Web of Science, and CINAHL, together with additional searches of reference lists, authors, and conference proceedings, found 22 studies from 10 countries, which included a total of 4953 oral cancers. The percentage of medical referrals ranged from 13% to 86%; dental referrals ranged from 15% to 80%. Random-effects meta-analysis indicated a combined relative risk of medical referral to dental referral of 1.36 (95% CI: 0.99 to 1.86). For UK-based studies, the relative risk was also 1.36 (95% CI: 1.05 to 1.76). There was considerable heterogeneity for all studies and for a subgroup of UK studies: I²96.4% (95% CI 95.4 to 97.1) and 81.0% (95% CI 63.3 to 90.1), respectively. Several studies showed a lower stage for dentally-referred cancers; the combined risk for dentists and GPs referring early (stages 1 and 2) disease was 1.37 (95% CI: 1.17 to 1.60), and one cause may be the much higher number of cases referred by dentists in the absence of symptoms. No studies showed a significant difference in delay. Oral cancer is referred by both GPs and dentists, typically about 50% and 40%, respectively, although there is a wide range, probably depending on local circumstances. Both groups require skills in oral examination, recognition of lesions, and knowledge of the risk factors. Effectively, regular dental attenders are a select group that is regularly screened for oral cancer, and it is likely that screening is not delivered to those with the highest risk. We suggest that further work is required on how to access high-risk individuals both for possible screening and preventive interventions.
Audit of the two-week pathway for patients with suspected cancer of the head and neck and the influence of socioeconomic status
2019, British Journal of Oral and Maxillofacial Surgery
Citation Excerpt :
The Cancer Research UK toolkit is a potentially valuable resource for professionals and patients alike, but it focuses solely on the oral cavity.13 It has been argued that links between GPs and dentists to improve the assessment of suspected cancer might lengthen delay, and that patients at highest risk are the least likely to go to a dentist.14 Processes, however, could be streamlined to avoid delays, and in the case of lesions of the oral cavity, GPs could be assisted by a second opinion from a dentist.
Rates of head and neck cancer are high in patients with a low socioeconomic status (SES) and outcomes are often poor. The degree to which people from different socioeconomic groups use the fast-track, two-week suspected cancer referral system is, however, unclear. The aim of this audit was therefore to analyse these referrals with reference to SES, and to focus on differences in clinical characteristics, source of referral, and rates of disease. The sample included all patients who were referred to the head and neck department at an inner-city hospital in the northwest of England between July and September 2017. According to the Index of Multiple Deprivation (IMD), most (62%) of them lived in the most deprived quintile. A total of 390 referrals were analysed of which 60% were female, 53% were under 60 years of age, 33% smoked, and 69% consumed fewer than 10 units of alcohol/week. Only 24 were referred by dentists, but these accounted for almost one quarter of those referred to maxillofacial surgery. Common symptoms included a swelling or lump (n = 153, 39%), hoarseness (n = 101, 26%), ulcer (n = 29, 7%), and sore throat (n = 23, 6%). Forty-five per cent were referred with other symptoms. A total of 28 (7%) were diagnosed with cancer of the head and neck. Rates were higher in patients referred by dentists (p = 0.02) and in those who drank more alcohol (p = 0.02). The positive predictive value was higher in the least deprived (17%) than in the most deprived (6%). In primary care, more education that is aimed specifically at people of lower SES might reduce the number of “worried well” and lessen the pressure on departments to achieve the two-week target.
Appropriateness of two-week wait head and neck cancer referrals to a district general hospital
2023, British Dental Journal
Diagnostic intervals in oropharyngeal cancers from a primary care perspective: a ten-year case note review
2021, British Dental Journal

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Short communicationNew NICE referral guidance for oral cancer: does it risk delay in diagnosis?

Abstract

Introduction

Section snippets

Method

Results

Discussion

Conflict of interest

Ethics statement/confirmation of patients’ permission

Br J Oral Maxillofac Surg

Suspected cancer: recognition and referral

CG27 Referral Guidelines for suspected cancer: NICE guideline

Short communication
New NICE referral guidance for oral cancer: does it risk delay in diagnosis?