Tracking cancer occurrence in the 5 years after referral for suspected head and neck cancer

Advice after urgent suspected cancer referral when cancer is not found in England: Survey of patients' preferences and perceived acceptability

Objective

No standardised approach exists to provide advice after urgent suspected cancer (USC) referral when cancer is not found. This study aimed to assess preferences and acceptability of receiving advice after USC referral related to: 1) managing ongoing symptoms, 2) responding to early symptoms of other cancers, 3) cancer screening, 4) reducing risks of future cancer.

Methods

2,541 patients from two English NHS Trusts were mailed a survey 1-3 months after having no cancer found following urgent suspected gastrointestinal or head and neck cancer referral. Participants were asked about: willingness to receive advice; prospective acceptability; preferences related to mode, timing and who should provide advice; and previous advice receipt.

Results

406 patients responded (16.0%) with 397 in the final analyses. Few participants had previously received advice, yet most were willing to. Willingness varied by type of advice: fewer were willing to receive advice about early symptoms of other cancers (88.9%) than advice related to ongoing symptoms (94.3%). Acceptability was relatively high for all advice types. Reducing the risk of future cancer advice was more acceptable. Acceptability was lower in those from ethnic minority groups, and with lower levels of education. Most participants preferred to receive advice from a doctor; with results or soon after; either face to face or via the telephone.

Conclusions

There is a potential unmet need for advice after USC referral when no cancer is found. Equitable intervention design should focus on increasing acceptability for people from ethnic minority groups and those with lower levels of education.

The impact of 2 weeks wait referral on survival of head and neck cancer patients

PURPOSE

This study aims to evaluate the association between 2 weeks wait referral and survival in the head and neck cancer.

METHODS

Retrospective cohort study of consecutively discussed new head and neck cancer patients at large United Kingdom Cancer Alliance including two tertiary referral hospitals and two district general hospital.

RESULTS

A total of 276 cancer patients were included for analysis. Patients referred under the 2 weeks wait had were seen and diagnosed sooner from referral (p < 0.0001 and p < 0.0001 respectively). However, this did not translate into better survival outcomes. No survival differences were seen between those patients that were managed within the proposed cancer targets and those that were not.

CONCLUSIONS

The 2 weeks wait head and neck cancer pathway did not offer a survival advantage. Targeting the delay in referral as well as delay in treatment to prevent late-stage cancer presentation is paramount. Fulfilment of cancer time targets do not translate into better outcomes and should not be prioritised to clinical judgement.

Future cancer risk after urgent suspected cancer referral in England when cancer is not found: a national cohort study

BACKGROUND

Following referral for investigation of urgent suspected cancer within the English National Health Service referral system, 7% of referred individuals are diagnosed with cancer. This study aimed to investigate the risk of cancer occurrence within 1-5 years of finding no cancer following an urgent suspected cancer referral.

METHODS

This national cohort study used urgent suspected cancer referral data for England from the Cancer Waiting Times dataset and linked it with cancer diagnosis data from the National Cancer Registration dataset. Data were extracted for the eight most commonly referred to urgent suspected cancer referral pathways (breast, gynaecological, head and neck, lower and upper gastrointestinal, lung, skin, and urological) for the period April 1, 2013, to March 31, 2014, with 5-year follow-up for individuals with no cancer diagnosis within 1 year of referral. The primary objective was to investigate the occurrence and type of subsequent cancer in years 1-5 following an urgent suspected cancer referral when no cancer was initially found, both overall and for each of the eight referral pathways. The numbers of subsequent cancers were compared with expected cancer incidence in years 1-5 following referral, using standardised incidence ratios (SIRs) based on matched age-gender distributions of expected cancer incidence in England for the same time period. The analysis was repeated, stratifying by referral group, and by calculating the absolute and expected rate of all cancers and of the same individual cancer as the initial referral.

FINDINGS

Among 1·18 million referrals without a cancer diagnosis in years 0-1, there were 63 112 subsequent cancers diagnosed 1-5 years post-referral, giving an absolute rate of 1338 (95% CI 1327-1348) cancers per 100 000 referrals per year (1038 [1027-1050] in females, 1888 [1867-1909] in males), compared with an expected rate of 1054 (1045-1064) cancers per 100 000 referrals per year (SIR 1·27 [95% CI 1·26-1·28]). The absolute rate of any subsequent cancer diagnosis 1-5 years after referral was lowest following suspected breast cancer referral (746 [728-763] cancers per 100 000 referrals per year) and highest following suspected urological (2110 [2070-2150]) or lung cancer (1835 [1767-1906]) referral. For diagnosis of the same cancer as the initial referral pathway, the highest absolute rates were for the urological and lung pathways (1011 [984-1039] and 638 [598-680] cancers per 100 000 referrals per year, respectively). The highest relative risks of subsequent diagnosis of the same cancer as the initial referral pathway were for the head and neck pathway (SIR 3·49 [95% CI 3·22-3·78]) and lung pathway (3·00 [2·82-3·20]).

INTERPRETATION

Cancer risk was higher than expected in the 5 years following an urgent suspected cancer referral. The potential for targeted interventions, such as proactive monitoring, safety-netting, and cancer awareness or risk reduction initiatives should be investigated.

FUNDING

Cancer Research UK.

Should we? Could we? Feasibility of interventions to support prevention or early diagnosis of future cancer following urgent referral: A qualitative study

OBJECTIVE

This study investigated perspectives of healthcare professionals (HCPs) on the feasibility of giving additional support to patients after cancer is not found following urgent referral. We sought to understand key facilitators or barriers to offering such support.

METHODS

A convenience sample of primary and secondary care healthcare professionals (n = 36) participated in semi-structured interviews. Interviews were transcribed verbatim and analysed using Framework Analysis, inductively and deductively, guided by the Theoretical Domains Framework.

RESULTS

HCPs indicated that support should be offered if proven to be efficacious. It needs to avoid potential negative consequences such as patient anxiety and information overload. HCPs were more hesitant about whether support could feasibly be offered, due to resource restrictions and perceived remit of the urgent pathway for suspected cancer.

CONCLUSION

HCP support after discharge from urgent cancer referral pathways needs to be resource efficient, developed in collaboration with patients and should have proven efficacy. Development of brief interventions for delivery by a range of staff, and use of technology could mitigate barriers to implementation.

PRACTICE IMPLICATIONS

Changes to discharge procedures to provide information, endorsement or direction to services could offer much needed support. Additional support would need to overcome logistical challenges and address limited capacity.

Remote triage incorporating symptom-based risk stratification for suspected head and neck cancer referrals: A prospective population-based study

Background

Remote triage for suspected head and neck cancer (HNC) referrals was adopted by many institutions during the initial peak of the coronavirus disease 2019 pandemic. Its safety in this population has not been established.

Methods

A 16‐week, prospective, multicenter national service evaluation was started on March 23, 2020. Suspected HNC referrals undergoing remote triage in UK secondary care centers were identified and followed up for a minimum of 6 months to record the cancer status. Triage was supported by risk stratification using a validated calculator.

Results

Data for 4568 cases were submitted by 41 centers serving a population of approximately 26 million. These represented 14.1% of the predicted maximum referrals for this population outside of pandemic times, and this gave the study a margin of error of 1.34% at 95% confidence. Completed 6‐month follow‐up data were available for 99.8% with an overall cancer rate of 5.6% (254 of 4557). The rates of triage were as follows: urgent imaging investigation, 25.4% (n = 1156); urgent face‐to‐face review, 27.8%; (n = 1268); assessment deferral, 30.3% (n = 1382); and discharge, 16.4% (n = 749). The corresponding missed cancers rates were 0.5% (5 of 1048), 0.3% (3 of 1149), 0.9% (12 of 1382), and 0.9% (7 of 747; P = .15). The negative predictive value for a nonurgent triage outcome and no cancer diagnosis was 99.1%. Overall harm was reported in 0.24% (11 of 4557) and was highest for deferred assessments (0.58%; 8 of 1382).

Conclusions

Remote triage, incorporating risk stratification, may facilitate targeted investigations for higher risk patients and prevent unnecessary hospital attendance for lower risk patients. The risk of harm is low and may be reduced further with appropriate safety netting of deferred appointments.

Lay Summary

This large national study observed the widespread adoption of telephone assessment (supported by a risk calculator) of patients referred to hospital specialists with suspected head and neck cancer during the initial peak of the coronavirus disease 2019 pandemic.

The authors identified 4568 patients from 41 UK centers (serving a population of more than 26 million people) who were followed up for a minimum of 6 months.

Late cancers were identified, whether reviewed or investigated urgently (0.4%) or nonurgently (0.9%), but the overall rate of harm was low (0.2%), with the highest rate being seen with deferred appointments (0.6%).

Remote triage of suspected head and neck cancer referrals can expedite investigations for the highest risk patients and prevent unnecessary hospital attendance for the lowest risk patients. Rates of harm from remote triage are low but are highest for patients having further assessment deferred.

Interventions to improve early cancer diagnosis of symptomatic individuals: a scoping review

OBJECTIVES

To summarise the current evidence regarding interventions for accurate and timely cancer diagnosis among symptomatic individuals.

DESIGN

A scoping review following the Joanna Briggs Institute's methodological framework for the conduct of scoping reviews and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist.

DATA SOURCES

MEDLINE (Ovid), CINAHL (EBSCOhost) and PsycINFO (Ovid) bibliographic databases, and websites of relevant organisations. Published and unpublished literature (grey literature) of any study type in the English language were searched for from January 2017 to January 2021.

ELIGIBILITY AND CRITERIA

Study participants were individuals of any age presenting at clinics with symptoms indicative of cancer. Interventions included practice guidelines, care pathways or other initiatives focused on achieving predefined benchmarks or targets for wait times, streamlined or rapid cancer diagnostic services, multidisciplinary teams and patient navigation strategies. Outcomes included accuracy and timeliness of cancer diagnosis.

DATA EXTRACTION AND SYNTHESIS

We summarised findings graphically and descriptively.

RESULTS

From 21 298 retrieved citations, 88 unique published articles and 16 unique unpublished documents (on 18 study reports), met the eligibility for inclusion. About half of the published literature and 83% of the unpublished literature were from the UK. Most of the studies were on interventions in patients with lung cancer. Rapid referral pathways and technology for supporting and streamlining the cancer diagnosis process were the most studied interventions. Interventions were mostly complex and organisation-specific. Common themes among the studies that concluded intervention was effective were multidisciplinary collaboration and the use of a nurse navigator.

CONCLUSIONS

Multidisciplinary cooperation and involvement of a nurse navigator may be unique features to consider when designing, delivering and evaluating interventions focused on improving accurate and timely cancer diagnosis among symptomatic individuals. Future research should examine the effectiveness of the interventions identified through this review.