Refining the head and neck cancer referral guidelines: a two centre analysis of 4715 referrals

Our aim was to identify the set of referral criteria that will offer optimal diagnostic efficacy in patients suspected to have head and neck cancer (HNC) in the primary care setting. We analysed the referral criteria and outcomes from two tertiary care cancer centres in the United Kingdom. Between 2007 and 2010, 4715 patients were referred via the fast track system with a suspected HNC. The main outcome measures were the parameters of diagnostic efficacy, a multivariate regression model to calculate estimated probability of HNC and the area under the receiver operating characteristic curve (AUROC). We found that the majority of referring symptoms had a positive predictive value higher than the 3% cut-off point stated to be significant for HNC detection in the 2015 NICE recommendations. Nevertheless, our multivariate analysis identified 9 symptoms to be linked with HNC. Of these, only 4 are included in the latest NICE guidelines. The best fit predictive model for this dataset included the following symptoms: hoarseness>3 weeks, dysphagia>3 weeks, odynophagia, unexplained neck mass, oral swelling >3 weeks, oral ulcer >3weeks, prolonged otalgia with normal otoscopy, presence of blood in mouth with concurrent sensation of lump in throat, and presence of otalgia with concurrent lump in throat sensation. Intermittent hoarseness and sensation of lump in throat were negatively associated with HNC. The AUROC demonstrated that our model had a higher predictive value (0.77) compared to those generated using the NICE 2005 (0.69) and 2015 (0.68) referral criteria (p<0.0001). An online risk calculator based on this study is available at http://www.orlhealth.com/risk-calculator.html. This paper presents a significantly refined version of referral guidelines which demonstrate greater diagnostic efficacy than the current NICE guidelines. We recommend that further iterative refinements of referral criteria be considered when referring patients with suspected HNC.