RESEARCH
oral medicine
Delays in the referral and treatment of
oral squamous cell carcinoma
1
2
3
P. Hollows, P. G. McAndrew, and M. G. Perini,
Objective To investigate the delays in referral and treatment of unspecified parts of the mouth (145), oropharynx (146),
patients with oral cancer.
Design A retrospective study.
Setting District General Hospital Maxillofacial Unit (MFU).
Subjects 100 consecutive patients with invasive squamous cell
carcinoma of the oral cavity referred to Rotherham District
hypopharynx (148) and other ill defined sites within the lip, oral
cavity and pharynx (149). Using this definition there are currently
3,400 new cases of oral cancer a year and about 1,600 deaths with
oral cancer accounting for 1% of all new cancer registrations. The
overall 5-year survival for oral cancer in England and Wales is
General Hospital Maxillofacial Unit (RDGH MFU) between 15th about 50%, however, if detected early then it is anticipated that this
2
March 1993 and 16th January 1998.
Method Information collected at the time of referral and
treatment was examined retrospectively.
could be improved to 80%. There have been great advances made
in the management of this condition, from improved diagnostic
imaging of the tumour to sophisticated reconstructive procedures
including oral implantology to restore the dentition. Although the
quality of life of these unfortunate patients has been improved,
survival figures have not changed greatly.
Results In the patients studied 72% were male, mean age 61.2
years (sd = 11.2, range 37 to 88) and 28% female, mean age 65.6
years (sd = 16.7, range 29 to 90). The majority of referrals were
from medical practitioners (56% ) and most of the remainder
being referred by dental practitioners (36% ). The patient delay
was found to be the most significant with only 39% presenting
within 4 weeks, 29% delayed more than 3 months. There was no
statistical correlation between T-stage, alcohol or cigarette use
and the patient delay in presentation. Having presented to a
medical or dental practitioner 69% were referred within 1 week.
There were no significant differences between the T-stages
presenting to either medical or dental practitioners or in their
delay in referral for each stage. There was no significant difference
in age or sex distribution between the populations presenting to
general medical or general dental practitioners. General medical
Early detection of oral cancer is an important objective as it
should improve outcome and reduce the morbidity of treatment.
In order to do this it is necessary to raise awareness in primary
healthcare workers, who are in a position to diagnose the condition
and within the population as a whole. There have been many stud-
ies on delays in referral of patients with oral cancer. This study
looks at the delays incurred in the referral and treatment of oral
cancer to a single MFU in a district general hospital setting and
attempts to elucidate factors that may increase the delay.
3–9
Method
One hundred consecutive cases of oral squamous cell carcinoma
practitioners were more likely to refer a patient urgently. Patients referred to RDGH MFU were studied between 15th March 1993
referred directly to the MFU were seen quickly but those referred
via an indirect route were delayed. 95% of patients were treated
within 6 weeks of first consultation.
and 16th January 1998. Only histologically proven invasive squa-
mous cell carcinomas were included. The patient’s sex and age were
noted, and the primary site and T stage defined at the time of the
first visit. Details of the patient’s alcohol and tobacco use were
recorded. The patient’s delay was defined as the time between the
onset of symptoms to first appointment at a primary care facility.
Some of the patients described a very long delay which could repre-
sent a possible pre-malignant condition or pre-existing oral condi-
tion. It is not possible to determine exactly when the malignant
condition started for obvious reasons. Having been seen in the pri-
mary care setting the practitioner’s delay was defined as the time
from first visit to the date of referral. In some cases this could not be
determined from the patient and therefore the practitioner was
contacted and details from their records retrieved. Where the origi-
Conclusion The majority of practitioners refer patients with
oral cancer within 1 week. The most significant delay is that
caused by the patient. Some practitioners referred patients to
inappropriate specialities, leading to indirect referrals. This
results in additional delay in the referral and treatment pathway.
Education of the public and primary health care workers should
continue. Opportunistic screening of the oral mucosa should be
part of the dental check up, with possible targeting of patients at
greatest risk, particularly heavy drinkers and smokers.
he British Dental Association has defined the term ‘oral cancer’ nating practitioner was neither a dental nor medical practitioner the
T
using the World Health Organisation’s International Classifica- delays were not included in the analysis. The urgency of each refer-
tion of Diseases (ICD), version 9. The sites included are the lip ral was determined. If a referral letter mentioned malignancy or the
code 140), tongue (141), gum (143), floor of mouth (144), other possibility of a tumour it was categorised as ‘urgent ’. Features such
1
(
as long standing ulceration were designated ‘suspicious ’, but if there
was no indication of what the pathology may be it was interpreted
1
2
Senior Registrar, Consultant, Maxillofacial Unit, Rotherham District General
Hospital, Moorgate Road, Oakwood, Rotherham, South Yorkshire S60 2UD;
as a ‘routine’ referral. Any accompanying telephone call immedi-
ately categorised a referral as ‘urgent ’. The delay to the MFU was
defined as the time between the date of the letter or telephone call
from the practitioner to first attendance at the MFU. Where delays
could not be determined, cases were excluded. Some patients were
not referred directly to our department and came via other routes.
These were termed indirect referrals. Once the patients had been
3
SHO, Maxillofacial Unit, Royal Preston Hospital, Green Lane, Preston,
Lancashire PR2 9HT
Correspondence to: Mr M. G. Perini, 334 Trowell Road, Nottingham NG8 2DT
email: mg.perini@telinco.co.uk
REFEREED PAPER
Received 09.10.98; accepted 30.11.99
©
British Dental Journal 2000; 188: 262–265
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BRITISH DENTAL JOURNAL, VOLUME 188, NO. 5, MARCH 11 2000