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Official guidance may be delaying mouth cancer diagnosis

Mouth cancer cases rise 39% in past decade

Adrian O'Dowd

Wednesday, 23 November 2016

Oral facial surgeons have raised concerns that new NICE guidance may be introducing delays for GP referrals of patients with suspected oral cancer for treatment.

A study* has been published today in the British Journal of Oral and Maxillofacial Surgery (BJOMS), which suggests that updated guidance for oral cancer is causing delays in diagnosis and treatment.

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%.

NICE guidelines, updated last year, imply that certain presentations, if identified by a GP, should be referred to a dentist for assessment before a specialist reviews them.

Researchers, led by British Association of Oral and Maxillofacial Surgeons (BAOMS) fellow in training David Grimes, set out to compare the application of the new advice against that given in the old guidelines on a group of patients referred to an oral and maxillofacial department to assess the potential impact on outcomes.

This is in the context of a sharp rise in mouth cancer cases in the UK of 39% in the last decade and 92% since the 1970s.

The researchers carried out a retrospective audit of all two-week referrals received between July and August 2014 including an assessment of referral letters, medical notes, and histological results.

The outcome measures were the number of those referrals that met the old and new NICE guidance criteria, and the number diagnosed with cancer.

Time taken to be seen, the quality of the referral letter, all clinical and histological findings, and the final diagnosis were also assessed.

Analysis of the results from 91 referrals included showed 33 people met the old guidelines referral criteria, 33 met the new guidelines referral criteria and 25 met both criteria.

Of the 91 referrals, six patients were subsequently diagnosed with cancer and nine referrals would have gone to a dentist first, of whom one patient was eventually diagnosed with cancer.

The authors said the new guidance could expose some patients to increased risk of delayed referral because there was no clear referral pathway between doctors and dentists for suspected cancer.

If the population was reflected by their findings, around one in nine patients could have their diagnoses delayed, they added.

Mike Bater, BAOMS deputy oncology sub specialty interest group (SSIG) lead, said that BAOMS had raised concerns with NICE regarding the changes in the referral pathway for patients with suspected oral cancer some months ago.

“This paper demonstrates that changes in the pathway introduce an avoidable delay in patient referral, potentially leading to a compromise in treatment success,” he said.

“We know that patients with mouth cancer are more likely to be cured if the disease is diagnosed at an early stage, and also that the morbidity (side-effects) from treatment increase if the diagnosis is made late.”

A NICE spokesperson told OnMedica: “There is no evidence that our 2015 suspected cancer guidance is leading to a delay in diagnosis; these concerns are premature and unproven.

“We would be happy to consider evidence which shows a clear effect on the stage of cancer at diagnosis, but our expectation is that the guidance will result in earlier diagnosis, not later.”

* Grimes D, Patele J, Avery C. New NICE referral guidance for oral cancer: does it risk delay in diagnosis? British Journal of Oral and Maxillofacial Surgery, November 2016. DOI: 10.1016/j.bjoms.2016.09.022

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