TABLE 4 - uploaded by Nicholas Dawe
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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 f...
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Context 1
... regards to the stage of disease at diagnosis (Table 4), we dichotomised the patients with cancer referred via the 2WW referral system into early and late disease groups (defined as stages 0-2 and stages 3-4 respectively). Of the 53 patients with cancer, 2 were excluded (the first was being actively monitored for an unknown primary tumour and the second had a type C paraganglioma). ...
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... 15,16 Additionally, it was recommended that a standardised national proforma be developed based on specific signs and symptoms which have a proven correlation with HNC. 17,18 In June 2015, NICE updated again the HNC referral guidance, classified by organs sites. In this iteration, the positive predictive value (PPV) was used to determine the high-risk symptoms for HNC. ...
... Our study has confirmed that detection rate of cancer via the 2WW pathway remains low which is in keeping with previous studies. [5][6][7][8][9][10][11][13][14][15][16][17][18] We show that current referral criteria can be refined significantly to improve diagnostic efficacy, without the risk of excluding symptoms that may still have PPV of over 3%. We have identified the significant positive and negative symptom predictors of HNC in this large cohort and generated a well-fitted model that estimates the risk of HNC based on referral symptoms and demographics. ...
Our aim was to identify the set of referral criteria that will offer optimal diagnostic efficacy in patients suspected to have head and neck cancer (HNC) in the primary care setting. We analysed the referral criteria and outcomes from two tertiary care cancer centres in the United Kingdom. Between 2007 and 2010, 4715 patients were referred via the fast track system with a suspected HNC. The main outcome measures were the parameters of diagnostic efficacy, a multivariate regression model to calculate estimated probability of HNC and the area under the receiver operating characteristic curve (AUROC). We found that the majority of referring symptoms had a positive predictive value higher than the 3% cut-off point stated to be significant for HNC detection in the 2015 NICE recommendations. Nevertheless, our multivariate analysis identified 9 symptoms to be linked with HNC. Of these, only 4 are included in the latest NICE guidelines. The best fit predictive model for this dataset included the following symptoms: hoarseness>3 weeks, dysphagia>3 weeks, odynophagia, unexplained neck mass, oral swelling >3 weeks, oral ulcer >3weeks, prolonged otalgia with normal otoscopy, presence of blood in mouth with concurrent sensation of lump in throat, and presence of otalgia with concurrent lump in throat sensation. Intermittent hoarseness and sensation of lump in throat were negatively associated with HNC. The AUROC demonstrated that our model had a higher predictive value (0.77) compared to those generated using the NICE 2005 (0.69) and 2015 (0.68) referral criteria (p<0.0001). An online risk calculator based on this study is available at http://www.orlhealth.com/risk-calculator.html. This paper presents a significantly refined version of referral guidelines which demonstrate greater diagnostic efficacy than the current NICE guidelines. We recommend that further iterative refinements of referral criteria be considered when referring patients with suspected HNC.
... 15,16 Additionally, it was recommended that a standardised national proforma be developed based on specific signs and symptoms which have a proven correlation with HNC. 17,18 In June 2015, NICE updated again the HNC referral guidance, classified by organs sites. In this iteration, the positive predictive value (PPV) was used to determine the high-risk symptoms for HNC. ...
... Our study has confirmed that detection rate of cancer via the 2WW pathway remains low which is in keeping with previous studies. [5][6][7][8][9][10][11][13][14][15][16][17][18] We show that current referral criteria can be refined significantly to improve diagnostic efficacy, without the risk of excluding symptoms that may still have PPV of over 3%. We have identified the significant positive and negative symptom predictors of HNC in this large cohort and generated a well-fitted model that estimates the risk of HNC based on referral symptoms and demographics. ...
Objectives
To identify the set of referral criteria that will offer optimal diagnostic efficacy in patients suspected to have head and neck cancer (HNC) in the primary care setting. DesignStatistical analysis of referral criteria and outcomes. SettingTwo tertiary care cancer centres in the United Kingdom. Participants4715 patients who were referred via the fast-track system with a suspected HNC between 2007 and 2010. Main outcome measuresParameters of diagnostic efficacy, multivariate regression model to calculate estimated probability of HNC and area under the receiver operating characteristic curve (AUROC). ResultsThe majority of referring symptoms had a positive predictive value higher than the 3% cut-off point stated to be significant for HNC detection in the 2015 NICE recommendations. Nevertheless, our multivariate analysis identified nine symptoms to be linked with HNC. Of these, only four are included in the latest NICE guidelines. The best fit predictive model for this data set included the following symptoms: hoarseness >3weeks, dysphagia >3weeks, odynophagia, unexplained neck mass, oral swelling >3weeks, oral ulcer >3weeks, prolonged otalgia with normal otoscopy, the presence of blood in mouth with concurrent sensation of lump in throat and the presence of otalgia with concurrent lump in throat sensation. Intermittent hoarseness and sensation of lump in throat were negatively associated with HNC. The AUROC demonstrated that our model had a higher predictive value (0.77) compared to those generated using the NICE 2005 (0.69) and 2015 (0.68) referral criteria (P<0.0001). An online risk calculator based on this study is available at . Conclusions
This study presents a significantly refined version of referral guidelines which demonstrate greater diagnostic efficacy than the current NICE guidelines. We recommend that further iterative refinements of referral criteria be considered when referring patients with suspected HNC.
... Haikel et al reported a similar rate of malignancy (10%) but had a higher use of the 2WW pathway, with 80% of all head and neck cancer cases being referred via the proforma. 10 The 2004 NICE guidelines also recommended the use of 'one-stop' neck lump clinics, along the same lines as breast lump clinics; an experienced radiologist and cytopathologist should be available during the multidisciplinary head and neck clinic. 4 Our dedicated 2WW clinic did not run on the same day as the multidisciplinary head and neck clinic but we did have access to same-day ultrasonography/FNA by an experienced head and neck radiologist, with a consultant head and neck cytopathologist to review the slides immediately. ...
... Haikel et al argued that removal of certain symptoms that do not seem to correlate with a malignant diagnosis might be appropriate. 10 Specifically, these were 'cranial neuropathy', 'orbital mass' and 'unexplained tooth mobility'.The authors advise alternative referral pathways for these symptoms. They also suggest including a section for primary care practitioners to confirm that they have discussed the route of referral with the patient. ...
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.
The fast-track system in the UK for patients with suspected cancer – the two-week rule - states that if cancer is suspected there should be a maximum of 14 days between referral from primary care and consultation with a specialist. This approach is valued by patients, ensures a universal standard of diagnosis, and speeds up the overall management of cancer. However, some say that the rule has had little or no effect on survival, results in a diagnosis of cancer in only a small proportion of patients referred, and is expensive. We have made a systematic review of the effectiveness of the two-week rule in patients with head and neck cancer with the aid of electronic searches of databases. including MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews CINAHL, and CANCERLIT up to the end of 2014. This was supplemented by searching conference proceedings and contacting experts. Retrospective and prospective studies that included either conversion rate (proportion of two-week referrals who were diagnosed with cancer – positive predictive value), or detection rate (proportion of diagnosed cancers referred under the two-week rule - sensitivity), or both, were included. Two reviewers assessed studies for inclusion, and extracted data independently. Heterogeneity was assessed by inspection of the overlap of 95% CI in the forest plot and calculation of I2. We made a random-effects meta-analysis of 17 studies. All reported the conversion rate, and 10 also reported the detection rate. Meta-analysis indicated an overall pooled conversion rate of 8.8% (95% CI 7.0% to 10.7%) and a pooled detection rate of 40.8% (95% CI 25.7% to 55.8%) Subgroups in which maxillofacial (OFMS) and otolaryngology (ENT) were assessed showed no significant difference in conversion rate (8.3% and 8.8%; p = 0.73). Subgroup analyses of early studies (before the end of 2008) and later studies (2009–14), showed a significant reduction in conversion rates from 10.6% to 6.6%, p = < 0.0001. These early and late subgroups showed a significant increase in detection rate (35.0% to 49.7%, p = 0.0008). The conversion and detection rates were similar to those for a number of other cancer sites that relied on a list of signs and symptoms for referral and were similar in both ENT and OMFS units. There is evidence that two-week referral conversion rates are falling, while detection rates are rising because of an increased number of referrals. The influence of the two-week referrral on outcomes, particularly survival, is not well known.
