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23 Available online at www.sciencedirect.com
Audit of the two-week pathway for patients with suspected cancer of the head and neck and the influence of socioeconomic status
S.N. Rogers a,b,∗, A. Staunton c, R. Girach c, S. Langton d, D. Lowe e a Evidence-Based Practice Research Centre (EPRC), Faculty of Health and Social Care, Edge Hill University, St Helens Road, Ormskirk, L39 4QP, UK
b University Hospital Aintree, Liverpool, L9 1AE, UK
c Liverpool University, Cedar House, Ashton Street, Liverpool, L69 3GE
d University of Oxford
e Evidence-Based Practice Research Centre (EPRC), Faculty of Health, Edge Hill University, St Helens Road, Ormskirk, L39 4QP
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 3-Deazaneplanocin A 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.
© 2019 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: head and neck cancer; Suspected cancer; Two-week pathway; Deprivation; Delay
∗ Corresponding author at: University Hospital Aintree, Liverpool, L9 1AE, UK.
E-mail addresses: [email protected], [email protected] (S.N. Rogers), [email protected] (A. Staunton), [email protected] (R. Girach), [email protected] (S. Langton), [email protected] (D. Lowe).
In 2005, the National Institute for Health and Care Excellence (NICE) first published clinical guidelines for the recogni-tion and referral of suspected cancer. This was updated in 2015.1 The Department of Health has specified periods of time within which patients with suspected cancer should be seen, the national target being 14 days from the day of refer-ral from primary care. NICE also provides guidelines on the
0266-4356/© 2019 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
clinical signs and symptoms of potential cancer of the head and neck for primary care doctors and dentists, but since the two-week pathway was introduced, the proportion of patients who are referred and diagnosed with cancer has remained rel-atively low. In their systematic review of the two-week rule in head and neck cancer between 2000 and 2014, Langton et al reported conversion rates (positive predictive values) in 17 studies that ranged from 2.2% to 14.6%.2 Evidence that the two-week conversion rates were falling at the same time as detection rates (sensitivity) were rising, probably reflected an increase in the number of referrals. Any rise in cuticle number adds to the demand for timely outpatient clinic appointments, and puts pressure on NHS resources. Brocklehurst et al3 found that the hospital’s location was the most important vari-able in predicting delay, and that those with large numbers of referrals struggled to meet the target. Improvements in infrastructure are required in terms of administration (“can-cer trackers”) and there is a need to increase the capacity for urgent appointments at outpatient clinics.