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Interspecialty referral of oesophagogastric and pharyngolaryngeal cancers delays diagnosis and reduces patient survival: A matched case-control study

Interspecialty referral of oesophagogastric and pharyngolaryngeal cancers delays diagnosis and reduces patient survival: A matched case-control study
Interspecialty referral of oesophagogastric and pharyngolaryngeal cancers delays diagnosis and reduces patient survival: A matched case-control study

Objectives: Pharyngolaryngeal and oesophagogastric cancers present with swallowing symptoms and as such, their clinical evaluation traverses boundaries between different specialties. We studied the incidence and significance of interspecialty cancer referrals (ICRs), that is, pharyngolaryngeal cancers first evaluated by gastroenterology and oesophagogastric cancers first evaluated by otolaryngology. Design: A subset analysis of our Integrated Aerodigestive Partnership's audit dataset, of all ICR patients, and an equal number of controls matched for age, sex and cancer subsite. Main outcome measures: Information about patient age and presenting symptoms was recorded. The relationship between symptoms and ICR risk was examined with binary logistic regression. Referral-to-diagnosis latency was compared between ICR and control patients with unpaired Student's t test. Cox regression was used to identify independent predictors of overall survival. Results: Of 1130 patients with pharyngolaryngeal and oesophagogastric cancers between 2008 and 2018, 60 diagnoses (5.3%) were preceded by an ICR. Referral-to-diagnosis latency increased from 43 ± 50 days for control patients to 115 ± 140 days for ICR patients (P <.0001). Dysphagia significantly increased the risk of an ICR (odds ratio 3.34; 95% CI 1.30-8.56), and presence of classic gastroesophageal reflux symptoms (heartburn or regurgitation; OR 0.25; 95% CI 0.08-0.83) and “distal” symptoms (nausea/vomiting, abdominal pain or dyspepsia; OR 0.23; 95% CI 0.08-068) significantly reduced the risk. Eleven pharyngolaryngeal cancers (of 26; 42%) were missed by gastroenterology, and eight (of 34; 24%) oesophageal cancers were missed by otolaryngology. An ICR was an independent adverse prognostic risk factor on multivariable analysis (hazard ratio 1.76; 95% CI 1.11-2.73; P <.02; log-rank test). Two systemic root causes were poor visualisation of pharynx and larynx by per-oral oesophago-gastro-duodenoscopy (OGD) for pharyngolaryngeal cancers, and poor sensitivity (62.5%) of barium swallow when it was used to 'evaluate' oesophageal mucosa. Conclusions: An interspecialty cancer referral occurs in a significant proportion of patients with foregut cancers. It almost triples the time to cancer diagnosis and is associated with a high incidence of missed cancers and diminished patient survival. It is a complex phenomenon, and its reduction requires an integrated approach between primary and secondary care, and within secondary care, to optimise referral pathways and ensure appropriate and expeditious specialist evaluation.

diagnosis, dysphagia, general, head and neck cancer, larynx, mouth
1749-4478
370-379
Bird, Jon H.
11ea370b-077b-40bd-bc9b-d1574edb3fdd
Williams, Elizabeth J.
a6edc09d-cf88-4af2-8e80-bddb69c75d55
Heathcote, Kate J.
4b3b864f-a2bf-47d7-b1ba-fd1455f6c25d
Ayres, Lachlan
6306f2c8-6ee2-4385-8bf5-bd21041fdfb2
De Zoysa, Nilantha
9d0313a3-1a44-448a-a3dd-73e4402d1232
King, Emma V.
5ba4d8a2-1744-494f-9fb1-859965ed3f6d
Parry, Sally D.
03060582-ad92-4315-afa4-a6ae61f763ff
Nouraei, S.A. Reza
f09047ee-ed51-495d-a257-11837e74c2b3
Bird, Jon H.
11ea370b-077b-40bd-bc9b-d1574edb3fdd
Williams, Elizabeth J.
a6edc09d-cf88-4af2-8e80-bddb69c75d55
Heathcote, Kate J.
4b3b864f-a2bf-47d7-b1ba-fd1455f6c25d
Ayres, Lachlan
6306f2c8-6ee2-4385-8bf5-bd21041fdfb2
De Zoysa, Nilantha
9d0313a3-1a44-448a-a3dd-73e4402d1232
King, Emma V.
5ba4d8a2-1744-494f-9fb1-859965ed3f6d
Parry, Sally D.
03060582-ad92-4315-afa4-a6ae61f763ff
Nouraei, S.A. Reza
f09047ee-ed51-495d-a257-11837e74c2b3

Bird, Jon H., Williams, Elizabeth J., Heathcote, Kate J., Ayres, Lachlan, De Zoysa, Nilantha, King, Emma V., Parry, Sally D. and Nouraei, S.A. Reza (2020) Interspecialty referral of oesophagogastric and pharyngolaryngeal cancers delays diagnosis and reduces patient survival: A matched case-control study. Clinical Otolaryngology, 45 (3), 370-379. (doi:10.1111/coa.13510).

Record type: Article

Abstract

Objectives: Pharyngolaryngeal and oesophagogastric cancers present with swallowing symptoms and as such, their clinical evaluation traverses boundaries between different specialties. We studied the incidence and significance of interspecialty cancer referrals (ICRs), that is, pharyngolaryngeal cancers first evaluated by gastroenterology and oesophagogastric cancers first evaluated by otolaryngology. Design: A subset analysis of our Integrated Aerodigestive Partnership's audit dataset, of all ICR patients, and an equal number of controls matched for age, sex and cancer subsite. Main outcome measures: Information about patient age and presenting symptoms was recorded. The relationship between symptoms and ICR risk was examined with binary logistic regression. Referral-to-diagnosis latency was compared between ICR and control patients with unpaired Student's t test. Cox regression was used to identify independent predictors of overall survival. Results: Of 1130 patients with pharyngolaryngeal and oesophagogastric cancers between 2008 and 2018, 60 diagnoses (5.3%) were preceded by an ICR. Referral-to-diagnosis latency increased from 43 ± 50 days for control patients to 115 ± 140 days for ICR patients (P <.0001). Dysphagia significantly increased the risk of an ICR (odds ratio 3.34; 95% CI 1.30-8.56), and presence of classic gastroesophageal reflux symptoms (heartburn or regurgitation; OR 0.25; 95% CI 0.08-0.83) and “distal” symptoms (nausea/vomiting, abdominal pain or dyspepsia; OR 0.23; 95% CI 0.08-068) significantly reduced the risk. Eleven pharyngolaryngeal cancers (of 26; 42%) were missed by gastroenterology, and eight (of 34; 24%) oesophageal cancers were missed by otolaryngology. An ICR was an independent adverse prognostic risk factor on multivariable analysis (hazard ratio 1.76; 95% CI 1.11-2.73; P <.02; log-rank test). Two systemic root causes were poor visualisation of pharynx and larynx by per-oral oesophago-gastro-duodenoscopy (OGD) for pharyngolaryngeal cancers, and poor sensitivity (62.5%) of barium swallow when it was used to 'evaluate' oesophageal mucosa. Conclusions: An interspecialty cancer referral occurs in a significant proportion of patients with foregut cancers. It almost triples the time to cancer diagnosis and is associated with a high incidence of missed cancers and diminished patient survival. It is a complex phenomenon, and its reduction requires an integrated approach between primary and secondary care, and within secondary care, to optimise referral pathways and ensure appropriate and expeditious specialist evaluation.

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Accepted/In Press date: 20 January 2020
e-pub ahead of print date: 26 January 2020
Published date: 1 May 2020
Keywords: diagnosis, dysphagia, general, head and neck cancer, larynx, mouth

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Local EPrints ID: 439770
URI: http://eprints.soton.ac.uk/id/eprint/439770
ISSN: 1749-4478
PURE UUID: 5210b89e-f95f-43a7-9f84-6c6b37c1250b

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Date deposited: 01 May 2020 16:40
Last modified: 27 Apr 2022 11:31

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Contributors

Author: Jon H. Bird
Author: Elizabeth J. Williams
Author: Kate J. Heathcote
Author: Lachlan Ayres
Author: Nilantha De Zoysa
Author: Emma V. King
Author: Sally D. Parry
Author: S.A. Reza Nouraei

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