We are pleased to provide updated information on referring suspected cases of head and neck cancer under the urgent cancer pathway. Referrals of this type can be sent via the referral management system. You will find a “Wales USC Urgent Cancer Referral Form” on your system. Please read the guidance carefully on these referrals and use when appropriate. There is wealth of information on when to send cancer referrals. You can find some of the indications in our leaflet or from NICE, via their helpful document here. Please note that the urgent cancer pathway is for patients with suspected cancers only, not for routine investigations.
You can refer urgent cancer patients online – but we recommend a telephone call to the receiving hospital to confirm receipt and action
Guidance on Referral of Suspected Oral / Oropharyngeal Cancer
The following guidance has been produced to assist in the early detection, referral and diagnosis of suspected oral / oropharyngeal cancer. The following information is by no means comprehensive or indeed prescriptive, but is aimed at assisting decision-making in primary care when suspecting a diagnosis of potential cancer. Further more detailed information can be obtained from Cancer Research UK , National Institute for Health & Care Excellence and British Association of Head & Neck Oncologists. The following symptoms and signs can be the presenting features in oral & oropharyngeal cancer. It is important to stress that a thorough history and clinical examination, as well as assessment of risk factors, will aid clinical decision making regarding the suspicion of cancer.
These symptoms can be very similar to those of other less serious conditions. It can be difficult for GPs and GDPs to decide who may have a cancer and who may have something much more minor that will go away on its own. Similarly It can be difficult for Primary care practitioners to decide who to refer to a specialist.
Ulcers that do not heal
Persistent lump in the mouth / throat
Persistent discomfort or pain in the mouth
Persistent White or red patches in the mouth or throat
Difficulty in swallowing or unintended weight loss
A lump in the neck
Unusual bleeding or numbness in the mouth /face
Loose teeth for no apparent reason
Non-healing dental extraction socket(s)
With many of the listed symptoms, it can be perfectly appropriate that you could monitor the patient to see if their symptoms go away spontaneously, or respond to treatment such as antibiotics or anti-fungal therapy. Referring everyone with these symptom for a specialist opinion immediately, would overwhelm secondary care services and result in patients needing urgent appointments not getting them.
Local Learning Resources
The Wales Deanery provides two courses of particular interest to those seeking advice on urgent cancer referrals.
Click here to see an hour long presentation by Prof Mike Lewis on Mouth Cancer. This is an excellent overview and well worth watching.
The second is an online course looking at the causes of facial pain here. You can access this learning .
Latest NICE guidance on oral cancer referrals
In 2015 NICE updated their cancer referral guidance and you can download a copy from here. The guidance with respect to oral cancer has been revised and in simpler.
There is an excellent resource from Cancer Research UK – the Oral Cancer toolkit and an accompanying learning resource and CPD from the BDA. In short the referral guidelines state that: You should consider a suspected cancer pathway referral by the dentist (for an appointment within 2 weeks) for oral cancer in people when assessed by a dentist as having either:
- a lump on the lip or in the oral cavity consistent with oral cancer or
- a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia
The CRUK have also produced a short, 3 minute video on examining a patient for head and neck health. You can view it here
Learning & resources
You can access the learning by clicking on the link below. There is also an excellent referral decision aid that you can quickly access to understand more about the new NICE guidelines.
Access the CRUK/BDA oral cancer toolkit with learning programme and lesion recognition here.
In addition to the NICE guidelines for England and Wales, it is worth considering the “red flags” that the Scottish Guidelines recommend:
- Red flag 1: Persistent unexplained head and neck lumps for >3 weeks.
- Red flag 2: An ulceration or unexplained swelling of the oral mucosa persisting for >3 weeks.
- Red flag 3: All red or mixed red and white patches of the oral mucosa persisting for >3 weeks.
- Red flag 4: Unexplained tooth mobility not associated with periodontal disease.
- Red flag 5: Persistent, particularly unilateral, discomfort in the throat for >4 weeks.
- Red flag 6: Ear pain without evidence of local ear abnormalities.
You might also find this article, kindly provided by Dental Update, helpful in assessing patient.