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  • br Outcome trends and associations

    2020-08-18


    Outcome trends and associations with deprivation
    The outcome of the referral was known in 389 patients (one died during the referral process). A total of 28 (7.2%) were diagnosed with cancer (95% CI 4.8% to 10.2%) (Table 2). Patients referred by dentists were more likely to have can-cer than those referred by their GP (p = 0.02). An increased intake of alcohol was associated with cancer (p = 0.02) and there were non-significant trends with regard to smokers being more likely, and those with hoarseness being less likely, to have cancer. Twice as many men (10%) had cancer than women (5%), which was of borderline significance. There was also a trend with regard to IMD deprivation, with can-cer rates being 17% (4/23) for referrals who lived in the least deprived quintile of neighbourhoods, and 10% (2/20), 9% (4/46), 5% (3/58), and 6% (14/234) for those who lived in progressively more deprived areas (p = 0.25). The num-ber who lived in the less deprived quintiles was small and, when aggregated, the rate (8.8%) was higher, but not signif-icantly different (p = 0.31), from that 154-17-6 of those living in the most deprived quintile (6%).
    Total cases With cancer p value* All patients 389 28 (7)
    Sex:
    Source of referral
    Specialty referred to:
    Smoking status:
    Alcohol intake (units/week)
    Symptoms**
    Patient delay:
    Professional delay:
    IMD2015: quintile for neighbourhood deprivation; GDP: general dental
    practitioner; GMP: general medical practitioner; MFU: maxillofacial unit;
    ENT: ear, nose, and throat. ∗ Fisher’s exact test. ∗∗ p values are for symptom present compared with absent.
    (4.7%). Finally, there were several significant associations with patients’ symptoms (Table 3).
    Discussion
    It is useful to explore the referral pattern for cases of sus-pected head and neck cancer by SES because substantial NHS resources are given to enable early diagnosis. Despite this,
    Table 3
    A predominance of patients had a relatively low risk of
    Specific symptom associations. Data are number (%).
    cancer (women, non-smokers, and those who consumed less
    Factor and symptom Patients with symptom p value* than 10 units of alcohol/week). The gender balance was unex-
    Ulcer
    pected, as head and neck cancers are twice as common in men
    Source of referral:
    as in women. There are many possible explanations for this
    as, across all UK general practices in 2010, the crude con-
    sultation rate was 32% lower in men than in women, and
    Specialty
    these differences were greater in people from more deprived
    areas.7 Whilst this study looked at all consultations and not
    Swelling/lump:
    specifically at those for cancer of the head and neck, it does
    suggest that health is less of a priority in men than in women.
    GDP
    The conversion rate of 7.2% agrees with the findings by
    Langton et al2 and shows that it places demands on NHS
    Alcohol intake (units/week):
    resources in terms of clinic time. It also adds to the anxiety
    of the “worried well” who may have been referred for reassur-
    ance rather than a high clinical suspicion of cancer. Urgent
    referrals can vary threefold among general practices.8 It is
    likely that a GP will be mindful that deprivation correlates
    with risk factors such as smoking and drinking, and there-
    fore may be more cautious and more likely to refer. Most
    Hoarseness:
    of those referred (62%) lived in the most deprived quintile
    Source of referral:
    of residential neighbourhoods in England, in contrast to the
    deprived quartile.9
    Sex
    The finding that patients from more deprived areas are less
    likely to be referred by a dentist might be because fewer are
    registered with a dentist,10 possibly because of cost and ease
    of access to NHS dental care. We found significant differ-
    ences in the rates of cancer between patients referred by the
    GP (6%) and dentist (20%). Several potential 154-17-6 explanations
    for this need further investigation, but it is probably because
    MFU
    it is easier to examine the mouth than to examine other sites
    in the head and neck.
    Sore throat:
    Consideration should be given to improving the appropri-
    Specialty:
    ateness of referrals, for example, through better education in
    oral medicine, and the inclusion of photographs.11 Bethell
    GDP: general dental practitioner; GMP: general medical practitioner; MFU: and Leftwick thought that the two-week system could be
    maxillofacial unit; ENT: ear, nose, and throat.