Neck Lump and Throat Cancer Risk Assessment

ASSESSING CANCER RISK

ENT aims to treat all patients who have a cancer ‘within 62 days of that suspicion being raised’, in line with government targets.

To achieve this, most ‘urgent suspicion of cancer’ (USOC) patients need to be seen within 2 weeks, as many will need further investigation. ENT also aims to see all ‘urgent’ referrals quickly, but there are longer waits for routine appointments.

A Head and Neck Cancer risk assessment tool, validated in a Scottish population, helps predict head and neck cancer risk. NHS Lothian experience based on both specialist input, and GP feedback, is that it can be very useful in assessing risk, and particularly reassuring low risk patients that they do not need referral. It also gives a good indication of who needs a USOC referral, but significantly overestimates risk in the very high-risk groups when applied in primary care.

The government has an expectation that cancer pathways are based on a positive predictive value (PPV) of around 3%. However, as the risk calculator has repeatedly been shown to over-estimate risk, we suggest that a USOC referral is not triggered until there is a calculator score of >7%. This would be in keeping with Scottish evidence base to date, including NHS Lothian data. Although this may not affect the urgency of referral, it may alter what GPs say to patients in terms of their risk level. The overall risk of cancer to date in patents with a risk score of less than 50% remains <5% which should be borne in mind when considering both referral and communication with patients in the office.

Further details are in an abstract outlining the background to the risk assessment tool.

Sci Gateway now asks for details of some of the data used in the calculator, but the calculator score itself is no longer mandatory, though encouraged as it helps Consultants triage more accurately.

Please also see the Scottish Referral Guidelines for Suspected Cancer.

Please note that referral for all those with

dysphagia should be to gastroenterology
stridor to same day on-call ENT.

C.M & I.N. 18-12-23

Referral Advice:

Please if possible, use the Head and Neck Cancer Risk Assessment Tool to help assess the risk of cancer as outlined above. Including the calculator score, though no longer mandatory, in the SCI Gateway referral, does help with triage.

Using the calculator, if you think a patient has a true concern of malignant disease (risk ≥7.1%) rather than just wishing to exclude cancer:

Explain to the patient that you are concerned that they may have cancer and that they will be seen quickly, usually within 2 weeks.
Refer as an urgent suspicion of cancer (USOC) and inform the patient of that.

We hope this will encourage patients to attend their appointment with the multidisciplinary team to use this resource efficiently and ensure they are seen promptly. Red flags symptoms are provided below as a guide.

If the patient scores 2.2-7.09% on the risk calculator, then please refer urgently (not USOC). This will be the group where there is a low suspicion of cancer (<<5%), but it still needs to be excluded.

Tell the patient you want an expert opinion, and they will be seen soon.
Refer the patient as urgent (not urgent suspicion of cancer).

All referrals are triaged by the head and neck cancer surgeons who will escalate any referrals considered suspicious from this category.

Red Flag Symptoms

STRIDOR – patients with stridor should not be referred to outpatients – it suggests impending airway loss and the patient should be referred as a same day emergency.
Predicting head and neck cancer is difficult: most patients are older, smoking men but this is not a hard and fast rule. In Scotland the agreed red flag symptoms are listed below but are fully accounted for in the risk calculator.
A “feeling of something in the throat” is very rarely cancer. Particularly in young non-smokers, the chance of a malignant diagnosis is low and such patients should not be referred on the cancer pathway if at all possible.
If dysphagia is present, for solids or liquids, refer urgently as suspicion of cancer to Gastroenterology – that patient will need an oesophagoscopy. Note that the Scottish Referral Guidelines for Suspected Cancer define this as “interference of the swallowing mechanism that occurs within five seconds of the swallowing process”.

Persistent unexplained head and neck lump >3 weeks – please refer via SCI Gateway NECK LUMP pathway:

This does not apply to non-suspicious lumps such as sebaceous cysts, lipomas and longstanding non-progressive lesions, and those nodes felt clinically likely to be reactive;
The ENT neck lump (rather than throat) pathway on SCI Gateway ensures that the patient is seen at a multi-disciplinary clinic, with scanning facilities.

Ulceration or swelling of the oral mucosa or tonsillar region persisting for >3 weeks

True persistent oral ulcers should be referred to maxillofacial surgery at St John’s, Livingston
Tonsil ulceration or masses should be referred to ENT.

Persistent – not intermittent – hoarseness lasting for >3 weeks – see hoarseness guidance:

Please consider whether the hoarseness might be caused by lung cancer, especially if there are other suggestive symptoms, and whether a CXR is indicated. If there are other symptoms suspicious of lung cancer, please refer via the lung cancer pathway.
Patients with fluctuating or intermittent voice symptoms and those who do not sound hoarse are at very low risk of cancer and should not be referred on the cancer pathway. Laryngeal cancer in never-smokers is very rare.

Dysphagia:

PLEASE NOTE THAT UNLESS THERE ARE VERY SPECIFIC PHARYNGEAL SYMPTOMS, TRUE DYSPHAGIA AT ANY LEVEL SHOULD BE REFERRED TO GI DYSPHAGIA SERVICES. This is particularly important where there is also significant, unintentional weight loss. This is because ENT can only endoscope to the top of the oesophagus and therefore cannot visualise the most at-risk sites.
Pharyngeal symptoms can include difficulty with the initiation of the swallowing mechanism. But if there are any symptoms relating to food ‘sticking’, the referral should be to gastroenterology.

PAIN in throat or on swallowing:

odynophagia or persistent throat pain lasting for >3 weeks, particularly if pain radiates to the ear on swallowing- see Sore Throat guidance
Persistent or progressive throat pain exacerbated by swallowing is a significant red flag and always raises concern of cancer particularly if there is associated referred otalgia.
This is particularly true for persistent unilateral pain.
A simple “feeling of something stuck in the throat” is very rarely cancer.

Who to refer:

Please refer according to the criteria and risk levels outlined above.

Who not to refer:

Consider not referring those scoring <2.2% on the risk calculator – unless there are specific indications.
This applies to those with no red flag symptoms too.

REFER ELSEWHERE:

Those with dysphagia – refer to Gastroenterology
Those with stridor – require same day assessment via on call ENT at St Johns.
True persistent oral ulcers should be referred to maxillofacial surgery at St John’s, Livingston.