br Outcome trends and associations
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)
Source of referral
Specialty referred to:
Alcohol intake (units/week)
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).
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,
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-
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
these differences were greater in people from more deprived
areas.7 Whilst this study looked at all consultations and not
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.
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
of those referred (62%) lived in the most deprived quintile
Source of referral:
of residential neighbourhoods in England, in contrast to the
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 explanations
for this need further investigation, but it is probably because
it is easier to examine the mouth than to examine other sites
in the head and neck.
Consideration should be given to improving the appropri-
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.